The failure of optimization to produce improved survival in some randomized controlled trials may be associated with delays in starting the attempt to reach optimal goals. Following definitive hemorrhage control, more traditional endpoints of resuscitation include blood pressure. Vigorous intravenous fluid resuscitation has become widely accepted as the optimum management of hemorrhagic shock in trauma. Finally, as urine output has been recognized as a poor resuscitation target, a resuscitation protocol is suggested in part two which includes new targets and endpoints that can be obtained with modern, less invasive. Additional resuscitation endpoints that more closely evaluate the adequacy of perfusion and oxygenation at the tissue level should also be used when managing the critically ill. In line with novel shock definitions and evidence of the lack of a correlation between macro and microcirculation in shock, we recommend that macrocirculatory resuscitation endpoints. Tisherman, md, facs philip barie, md, facs faran bokhari, md, facs john bonadies, md. The resuscitation endpoints that have been evaluated include both global restoration of blood pressure,heart rate and urine output,lactate,base deficit,mixed venous oxygen saturation,ventricular. Selected endpoints should include a variety of global and regional indicators to guide and evaluate the effectiveness of treatment. Fluid resuscitation is mandatory in shock from traumatic haemorrhage massive use of resuscitative fluids following injury is now being disputed adequate resuscitation is no longer judged by. Optimal endpoints of resuscitation and early goaldirected. To determine the endpoints for resuscitation that would predict survival without organ system dysfunction if a defined level is achieved within a certain time frame. Trauma resuscitation is a fastpaced, highrisk clinical process requiring accurate and timely sharing of patient and process information for performing rapid diagnostic and therapeutic interventions.
The quest for ideal endpoints of resuscitation after severe trauma is incomplete. Dec 20, 2002 the base excess be has become the standard endpoint of resuscitation in trauma patients. It is an attempt to keep a very sick patient alive until he can get to definitive treatment. Endpoints of resuscitation aacn advanced critical care. Although it has never been prospectively validated, the base excess be is regarded as the standard end point of resuscitation in trauma patients. Despite years of research, a single resuscitation end point to assess adequacy of resuscitation has yet to be found. Statement of the problem severely injured trauma victims are at high risk of development of the multiple organ dysfunction syndrome mods or death. The fluid resuscitation plan emergency medicine and. Trauma life support manual broadly defines shock as an abnormality of the circula. Several endpoints of resuscitation need to be set a priori and followed diligently as vital signs alone are poor indicators of endorgan perfusion. N2 hemodynamic optimization of surgical patients during and after surgery in the surgical intensive care unit is meant to improve outcomes. Monitoring every severely burned patients 20% tbsa in adults or 15% tbsa in children should be adequately monitored with regard to fluid status, fluid responsiveness and organ perfusion. Metabolic resuscitation is a reasonable consideration for anyone with septic shock who is sick enough to require icu admission. We will briefly describe these endpoints, and propose damage control resuscitation as an additional endpoint.
Resuscitation is the process of treating shock in an attempt to restore normal physiology. Remarkably, while the be has been demonstrated to be of prognostic value, it has never been assessed prospectively in trauma patients 9,10,11,12,14,15. Methods seventyfive consecutive severely injured patients with shock resulting from bleeding and without major intracranial or spinal cord trauma. If the aim of resuscitation is to restore life, as the above definition implies, the underlying pathophysiology which threatens existence must be understood. Contemporarily, there is no perfect endpoint of resuscitation, each with their limitations, and thus current practice involves an assimilation of multiple endpoints of resuscitation into an overall assessment. Intensive care practice is built around the prompt resuscitation of patients with critical illness. All content in this area was uploaded by md rabiul alam on aug 27, 2018. Endpoints of resuscitation of critically injured patients. The optimal endpoint of resuscitation has been debated since the early 20th century when cannon espoused his controversial viewpoints concerning limited volume resuscitation, and it continues to be a topic of tremendous discussion and study.
The use of the be is based on the principle that tissue hypoxia associated with poor perfusion. Endpoints of resuscitation for the victim of trauma. It has long been recongnised that clinical parameters are poor indicators of adequacy of resuscitation, and the search for laboratory or monitoring endpoints has raged. Twitter may remove this content at anytime, convert it as a pdf, save and print for later use. Resuscitation endpoints resuscitation endpoints must be delineated from clinical endpoints. Controlled resuscitation is not a substitute for definitive surgical control.
Resuscitation endpoints practice management guideline. Various endpoints of resuscitation are in clinical use and can be broadly. Endpoints for fluid resuscitation in hemorrhagic shock. Higherthannormal values traditionally called supranormal or optimal of global. Jun 01, 2000 these endpoints of resuscitation from shock are controversial. The majority of trauma patients arriving at hospitals in both civilian and military settings will not require transfusion and are not coagulopathic on arrival. Today we are fortunate to hear from one of our favorite speakers. The resuscitation endpoints that have been evaluated include both global restoration of blood pressure, heart rate and urine output, lactate, base deficit, mixed.
Faultless compressions80% of total compressions and mean compression rate between 90. Passive leg raise passive leg raising is a dynamic measurement used to assess if a patient will respond to a fluid bolus. Jul 01, 2006 additional resuscitation endpoints that more closely evaluate the adequacy of perfusion and oxygenation at the tissue level should also be used when managing the critically ill. Fluid resuscitation is initiated in adults with 20% tbsa and. Endpoints of resuscitation statement of the problem. Additional serum protein markers have been proposed to assess shock. In an attempt to effectively guide fluid resuscitation in burn patients in the future, whilst avoiding deleterious effects of over resuscitation, a multimodal protocol using a modified formula and multiple endpoints is suggested.
While under resuscitation often has grave consequences, over resuscitation also leads to worse outcomes. Resuscitation adequate resuscitation does not equal normal vital signs, i. Background optimal fluid resuscitation in children with major burns is crucial to prevent or minimise burn shock and prevent complications of over resuscitation. The proposed endpoints of resuscitation fall into 2 cate gories.
Request pdf endpoints of resuscitation despite the multiple causes of the shock state, all causes possess the common abnormality of oxygen supply not meeting tissue metabolic demands. The intention of these guidelines is to inform practitioners with practical clinical guidance. Recommendations regarding fluid resuscitation and resuscitation endpoints in severe burns patients fluids 1. Reliance on traditional endpoints of resuscitation heart rate hr, blood pressure bp appears insufficient in detection of ongoing tissue hypoxia in shock states. The addition of vitamin c and thiamine may be considered when using stressdose steroid as discussed above. Rethinking resuscitation endpoints to avoid blood pressure cosmetics and vasopressor overuse in shock, resuscitation endpoints need to be reconsidered. Resuscitation endpoints in trauma wiley online library. Shoemaker et al6, 68, 73 published several studies that show that groups of critically ill patients randomized to these high hemodynamic goals have improved outcome compared with patients treated in a standard manner. There are limited controlled data on trauma patients. Galvagno has fast become a world renowned expert in the field of shock resuscitation and today will be doing his best to summarize his vast knowledge over some of the most informative 40 minutes you will ever find. It is unclear whether supranormal optimal hemodynamic values should serve as endpoints of resuscitation or simply as markers of the physiologic reserve of critically injured patients. Commentary the optimal endpoint of resuscitation in trauma.
Galvagno has fast become a world renowned expert in the field of shock resuscitation and today will be doing his best to summarize his vast. In a rat hemorrhage model, in this edition of critical care, totapally and colleagues demonstrate that the be is an insensitive and slowly responsive indicator of changes in intravascular volume. Various hemodynamic, metabolic, and regional endpoints have been described to evaluate the degree of shock and guide resuscitation efforts. Process the committee agreed upon the potential endpoints to be considered. Definitions of shock and resuscitation endpoints traditionally focus on blood pressures and cardiac output. Shock occurs bsecause of a failure to deliver adequate oxygen to meet the metabolic demands of the body resulting in metabolic acidosis, inflammation, and coagulopathy.
This carries a high risk of overemphasizing systemic hemodynamics at the cost of tissue perfusion. Unlike other clinical settings in which patient management relies on existing information, trauma resuscitation primarily relies on emerging. To improve patient survival and morbidity organ system dysfunction by use of appropriate resuscitation endpoints. Useful resuscitation endpoints must serve both to diagnose the need for and to ensure the ongoing adequacy of resuscitation. Ideal resuscitation end points should assess the adequacy of. The ideal endpoint should be readily obtainable and easily interpretable.
Resuscitation goals for the patient with sepsis and septic shock are to return the patient to a physiologic state that promotes adequate endorgan perfusion along with matching metabolic supply and demand. Hypotensive or delayed resuscitation has been postulated as a means by which the mortality associated with treatment can be reduced. Using capnography to establish endpoints of resuscitation national teaching institute may 2015 san diego, ca nicole kupchik rn, mn, ccns, ccrn, pccn, cmc tuesday. Trauma resuscitation an overview sciencedirect topics. This article, on hemodynamic monitoring, fluid responsiveness, volume assessment, and endpoints of resuscitation, is part of a compendium of guidelines provided by the aast american association for the surgery of trauma critical care committee. Ideal resuscitation end points should assess the adequacy of tissue oxygen delivery and oxygen consumption. Resuscitation endpoints can be divided into three groups metabolic, hemodynamic, and regional perfusion endpoints. Pcu nti 2015 using capnography to establish endpoints of. However, specific endpoints of resuscitation to target in critically ill patients remain controversial. Hypoproteinemia in sepsis low plasma colloid osmotic pressure. Napolitano of these animal models differ with regard to the site of injury solid organ, arterial injury, duration of hemorrhage, and type of fluids infused for resuscitation crystalloid, hypertonic saline, blood, colloids. The optimal endpoint of resuscitation in trauma patients ncbi. Article information, pdf download for endpoints of resuscitation open epub for endpoints of resuscitation.
Bedside transthoracic echocardiography is a noninvasive adjunct in the assessment of shock and resuscitation. To evaluate the effect of early optimization in the survival of severely injured patients. Th e authors propose a threestep approach of resuscitation endpoints which is based on growing evidence and physiological considerations figure 3. To demonstrate that the proposed endpoints are useful for predicting risk of development of mods or death. The optimal endpoint of resuscitation in trauma patients critical care.
An overview on fluid resuscitation and resuscitation. Urine output diuresis is a poor endpoint that may lead to over or under estimation of fluid resuscitation and, as such. The optimal resuscitation endpoint in trauma is controversial, remains elusive, and is one of the most published topics in modern medical literature. Cestero rf, dent dl 2015 endpoints of resuscitation. Damage control resuscitation and hemostasis should be considered a fourth endpoint in resuscitation.
The optimal endpoint of resuscitation in trauma patients. Elevated lactate andor decreased mixed venous oxygen saturation. To demonstrate that the proposed endpoints are useful for stratifying the patients severity of physiologic derangement. Ideal resuscitation end points should assess the adequacy of tissue oxygen delivery and oxygen consumption, and be quantifiable and reproducible. This contrasts with changes in the esophagealarterial carbon dioxide.