Contemporary hemodynamic monitoring, fluid responsiveness, volume optimization, and endpoints of resuscitation: an AAST critical care committee clinical consensus

Major liver resections, perioperative issues and posthepatectomy liver failure: A comprehensive update for the anesthesiologist

Significant advances in surgical techniques and relevant medium- and long-term outcomes over the past two decades have led to a substantial expansion in the indications for major liver resections. To support these outstanding results and to reduce perioperative complications, anesthesiologists must address and master key perioperative issues (preoperative assessment, proactive intraoperative anesthesia strategies, and implementation of the Enhanced Recovery After Surgery approach). Intensive care unit monitoring immediately following liver surgery remains a subject of active and often unresolved debate. Among postoperative complications, posthepatectomy liver failure (PHLF) occurs in different grades of severity (A-C) and frequency (9%-30%), and it is the main cause of 90-d postoperative mortality. PHLF, recently redefined with pragmatic clinical criteria and perioperative scores, can be predicted, prevented, or anticipated. This review highlights: (1) The systemic consequences of surgical manipulations anesthesiologists must respond to or prevent, to positively impact PHLF (a proactive approach); and (2) the maximal intensive treatment of PHLF, including artificial options, mainly based, so far, on Acute Liver Failure treatment(s), to buy time waiting for the recovery of the native liver or, when appropriate and in very selected cases, toward liver transplant. Such a clinical context requires a strong commitment to surgeons, anesthesiologists, and intensivists to work together, for a fruitful collaboration in a mandatory clinical continuum.

Fluids and Early Vasopressors in the Management of Septic Shock: Do We Have the Right Answers Yet?

Septic shock is a common condition associated with hypotension and organ dysfunction. It is associated with high mortality rates of up to 60% despite the best recommended resuscitation strategies in international guidelines. Patients with septic shock generally have a Mean Arterial Pressure below 65 mmHg and hypotension is the most important determinant of mortality among this group of patients. The extent and duration of hypotension are important. The two initial options that we have are 1) administration of intravenous (IV) fluids and 2) vasopressors, The current recommendation of the Surviving Sepsis Campaign guidelines to administer 30 ml/kg fluid cannot be applied to all patients. Complications of fluid over-resuscitation further delay organ recovery, prolong ICU and hospital length of stay, and increase mortality. The only reason for administering intravenous fluids in a patient with circulatory shock is to increase the mean systemic filling pressure in a patient who is volume-responsive, such that cardiac output also increases. The use of vasopressors seems to be a more appropriate strategy, the very early administration of vasopressors, preferably during the first hour after diagnosis of septic shock, may have a multimodal action and potential advantages, leading to lower morbidity and mortality in the management of septic patients. Vasopressor therapy should be initiated as soon as possible in patients with septic shock.

Management of Decompensated Cirrhosis in the Surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document

Management of decompensated cirrhosis (DC) can be challenging for the surgical intensivist. Management of DC is often complicated by ascites, coagulopathy, hepatic encephalopathy, gastrointestinal bleeding, hepatorenal syndrome, and difficulty assessing volume status. This Clinical Consensus Document created by the American Association for the Surgery of Trauma Critical Care Committee reviews practical clinical questions about the critical care management of patients with DC to facilitate best practices by the bedside provider.

Utilization and Efficacy of Resuscitation Endpoints in Trauma and Burn Patients: A Review Article

Shock is a sequelae in trauma and burn patients that substantially increases the risk for morbidity and mortality. The use of resuscitation endpoints allows for improved management of these patients, with the potential to prevent further morbidity/mortality. We conducted a review of the current literature on the efficacy of hemodynamic, metabolic, and regional resuscitation endpoints for use in trauma and burn patients. Hemodynamic endpoints included mean arterial pressure (MAP), heart rate (HR), urinary output (UO), compensatory reserve index (CRI), intrathoracic blood volume, and stroke volume variation (SVV). Metabolic endpoints measure cellular responses to decreased oxygen delivery and include serum lactic acid (LA), base deficit (BD), bicarbonate, anion gap, apparent strong ion difference, and serum pH. Mean arterial pressure, HR, UO, and LA are the most established markers of trauma and burn resuscitation. The evidence suggests LA is a superior metabolic endpoint marker. Newer resuscitation endpoint technologies such as point-of-care ultrasound (PoCUS), thromboelastography (TEG), and rotational thromboelastometry (ROTEM) may improve patient outcomes; however, additional research is needed to establish the efficacy in trauma and burn patients. The endpoints discussed have situational strengths and weaknesses and no single universal resuscitation endpoint has yet emerged. This review may increase knowledge and aid in guideline development. We recommend clinicians continue to integrate multiple endpoints with emphasis on MAP, HR, UO, LA, and BD. Future investigation should aim to standardize endpoints for each clinical presentation. The search for universal and novel resuscitation parameters in trauma and burns should also continue.

Critical Care Considerations for Damage Control in a Trauma Patient

Traumatic injury remains the leading cause of death among individuals younger than age 45 years. Hemorrhage is the primary preventable cause of death in trauma patients. Management of hemorrhage focuses on rapidly controlling bleeding and addressing the lethal triad of hypothermia, acidosis, and coagulopathy. The principles of damage control surgery are rapid control of hemorrhage, temporary control of contamination, resuscitation in the intensive care unit to restore normal physiology, and a planned, delayed definitive operative procedure. Damage control resuscitation focuses on 3 key components: fluid restriction, permissive hypotension, and fixed-ratio transfusion. Rapid recognition and control of hemorrhage and implementation of resuscitation strategies to control damage have significantly improved mortality and morbidity rates. In addition to describing the basic principles of damage control surgery and damage control resuscitation, this article explains specific management considerations for and potential complications in patients undergoing damage control interventions in an intensive care unit.

Dilemma of crystalloid resuscitation in non-exsanguinating polytrauma: what is too much?

Background

Aggressive crystalloid resuscitation increases morbidity and mortality in exsanguinating patients. Polytrauma patients with severe tissue injury and subsequent inflammatory response without major blood loss also need resuscitation. This study investigated crystalloid and blood product resuscitation in non-exsanguinating polytrauma patients and studied possible adverse outcomes.

Methods

A 6.5-year prospective cohort study included consecutive trauma patients admitted to a Level 1 Trauma Center intensive care unit (ICU) who survived 48 hours. Demographics, physiologic and resuscitation parameters in first 24 hours, Denver Multiple Organ Failure scores, adult respiratory distress syndrome (ARDS) data and infectious complications were prospectively collected. Patients were divided in 5 L crystalloid volume subgroups (0–5, 5–10, 10–15 and >15 L) to make clinically relevant comparisons. Data are presented as median (IQR); p value <0.05 was considered significant.

Results

367 patients (70% men) were included with median age of 46 (28–61) years, median Injury Severity Score was 29 (22–35) and 95% sustained blunt injuries. 17% developed multiple organ dysfunction syndrome (MODS), 4% ARDS and 14% died. Increasing injury severity, acidosis and coagulopathy were associated with more crystalloid administration. Increasing crystalloid volumes were associated with more blood products, increased ventilator days, ICU length of stay, hospital length of stay, MODS, infectious complications and mortality rates. Urgent laparotomy was found to be the most important independent predictor for crystalloid resuscitation in multinominal regression analysis. Further, fresh frozen plasma (FFP) <8 hours was less likely to be administered in patients >5 L compared with the group 0–5 L. With increasing crystalloid volume, the adjusted odds of MODS, ARDS and infectious complications increased 3–4-fold, although not statistically significant. Mortality increased 6-fold in patients who received >15 L crystalloids (p=0.03).

Discussion

Polytrauma patients received large amounts of crystalloids with few FFPs <24 hours. In patients with <10 L crystalloids, <24-hour mortality and MODS rates were not influenced by crystalloid resuscitation. Mortality increased 6-fold in patients who received >15 L crystalloids ≤24 hours. Efforts should be made to balance resuscitation with modest crystalloids and sufficient amount of FFPs.

Level of evidence

Level 3.

Study type

Population-based cohort study.