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Permissive Hypotension/ Low-Volume Resus In Peds


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#1 TexRNmedic

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Posted 24 April 2011 - 05:02 AM

Howdy folks. I just sent off my registration to a pedi trauma symposium (Houston, TX. May 17th- PM if in the hood and interested). It got me thinking about the application of permissive hypotension/low-volume resus(PH) in the pediatric population. I know that the kiddos compensate quite differently to traumatic insult and hypovolemia when compared to adults. Consideration of the potential variability in the age/weight-based vital sign "norms" ;) and PH can be even more challenging for my feeble mind to process. Anybody have any evidence regarding resus other than the PALS 20mL/kg isotonic crystalloid x2-3 then PRBC 10mL/kg /c NS? 10kg may have almost their entire blood volume replaced by NS before blood admin. Any thoughts toward the 1:1:1 resus with RBC, FFP and PLTs (whole blood transfusion)? Come on pedi gurus! Help me out with a little pedi learnin'.

Thanks for letting me pick your brains!
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Wes Seale
Houston , TX

#2 Brian Gacioch

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Posted 24 April 2011 - 05:14 PM

Howdy folks. I just sent off my registration to a pedi trauma symposium (Houston, TX. May 17th- PM if in the hood and interested). It got me thinking about the application of permissive hypotension/low-volume resus(PH) in the pediatric population. I know that the kiddos compensate quite differently to traumatic insult and hypovolemia when compared to adults. Consideration of the potential variability in the age/weight-based vital sign "norms" ;) and PH can be even more challenging for my feeble mind to process. Anybody have any evidence regarding resus other than the PALS 20mL/kg isotonic crystalloid x2-3 then PRBC 10mL/kg /c NS? 10kg may have almost their entire blood volume replaced by NS before blood admin. Any thoughts toward the 1:1:1 resus with RBC, FFP and PLTs (whole blood transfusion)? Come on pedi gurus! Help me out with a little pedi learnin'.

Thanks for letting me pick your brains!



Hi Tex, I've got a tiny bit of material on this that may help to get you started with lit review. PM me and I'll forward it.

Brian
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#3 onearmwonder

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Posted 25 April 2011 - 05:29 PM

Hi Tex, I've got a tiny bit of material on this that may help to get you started with lit review. PM me and I'll forward it.

Brian


Hey now share the wealth please....

Matt
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#4 TexRNmedic

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Posted 25 April 2011 - 10:48 PM

I'll send a PM and see what info I can post here. I'm sure I'm not the only person interested in this info.
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Wes Seale
Houston , TX

#5 Mike Mims

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Posted 25 April 2011 - 11:19 PM

I'll send a PM and see what info I can post here. I'm sure I'm not the only person interested in this info.

Dunno, there are a lot of NON-members who look at the forums.

The "view" under the stats is misleading and not always accurate, I believe it's updated hourly......
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#6 onearmwonder

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Posted 26 April 2011 - 12:20 PM

Hey Wes are you asking questions like should we use the same ACS guidelines in regards to H&H values and Lactate levels for adults when it comes to a pediatric PT? If so how low in age can we use these adult H&H and Lactate levels in peds to dictate resuscitation? I've tried to find this stuff in Hazinskis pediatric critical care book, but no luck on any additional insight. Anyways I will look for your PM soon.
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#7 TexRNmedic

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Posted 26 April 2011 - 01:17 PM

Hey Wes are you asking questions like should we use the same ACS guidelines in regards to H&H values and Lactate levels for adults when it comes to a pediatric PT? If so how low in age can we use these adult H&H and Lactate levels in peds to dictate resuscitation? I've tried to find this stuff in Hazinskis pediatric critical care book, but no luck on any additional insight. Anyways I will look for your PM soon.


Matt, I just got off work and am heading back tonight so about to go to bed. I don't have time right now to go pull references, but will tomorrow if requested. I was talking about PMing Brian for his info and I'll post and share here with everyone.

There are a couple trauma docs here in Houston that are pretty well published regarding the adult resus.
http://utsurg.uth.tm...olcomb-cv.html.
http://www.debakeyde...fs/MattoxCV.pdf

Basically, by the time a bleeding patient's labs are back we are already way behind on the resus. In the prehospital setting there really isn't time to trend CBCs and lactates. Dr Ken Mattox (from Ben Taub General Hospital, one of our two primary trauma facilities) and Dr Holcomb (the shiznit Irag veteran trauma guru from wonderful Memorial Hermann. Nope no bias there at all B) ) et al have supported fluid resuscitation that keeps the systolic at about 90 mm Hg- in adults without a suspected neuro insult. The idea being the lower blood pressure maintains clot integrity and hemostasis. Low volume resus helps to limit the dilutional coagulopathies associated with large volume NS/LR infusion. We know how well saline carries oxygen and makes clots, right? Any idea of the pH of NS? Go take a look at a bag of it sometime and prepare to be shocked. Holcomb's camp (don't forget he is an Army combat doc) supports the early transfusion of the equivalent of whole blood to those with obvious major bleeding. Typically adults get 6 rbcs, 6 ffps and a 6pack of platelets. Scott Weingart MD from the EMCrit podcast has talked about this a bit.

Soooo, how can this translate over to the pediatric patient, has anybody done any research about it, and is anybody doing anything different for hemorrhagic resuscitation in kids then the previously mentioned PALS recommendations? It would be more difficult to pick a target SBP considering the variability in BP norms, dependant on age and weight. Depending on age, kiddos have a poor to amazing ability to vasoconstrict,thermoregulate, and compensate. So by the time the kiddo is symptomatically hypotensive (and really freaking tachycardic) we've already lost relatively quite a bit of volume. So how much (typically room temp) IV fluids should we put back in and should we start transfusing the equivalent of whole blood like we are doing with the adults? Especially with the consideration of clot stability, oxygen carrying capacity, the potential for significant coagulapathies and the serious badness of profound acidosis.

Am I making sense or am I totally lost in the woods and way off base here?
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Wes Seale
Houston , TX

#8 SerendepitySaki

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Posted 26 April 2011 - 02:10 PM

nope. you're not. (way off base) summed nicely. was being done regularly years ago in Sunni triangle, etc. has taken waaaaay too long to make to civ land in general, much less in pedes. we all know about keeping fresh valves and lungs dry, right out of the OR, but those each are different rationales, not based on coagulopathy....

other than that, you don't see this often enough....betting that since it has its roots in adults in combat, it has been very slow to trickle down to pedes...i do know some instances, but they are specialized applications, outside of trauma...few and far between and i can't provide enough hard data off the top of my head to discuss intelligently....

some of our trauma surgeons (vets) started really preaching 1:1:1 about 5+ years ago.

you'll also hear cost:risks of transfusions vs colloids...immunogenicity, etc..... glad to see the discussion.

slight sidebar....nothing to do w/ pathophys, but speaking of colloids, there are also logistics considerations...more of a tactical thing...interesting stuff done in tactical environs with hypertonics and colloids...YaY colloids! you might find some adult corollary reading on the TCCC page...

http://www.naemt.org...PHTLS/TCCC.aspx

pedi-wise... i'm up to my arse in alligators at the moment, and the bast*rds are getting a bit nippy....no time to run it to ground....

what pedi literature searches have you done....?
have you checked the PFCCS page?, etc etc....
i'm willing to bet it's out there somewhere...
hoping someone'll post some good pedi-specific papers/links....have a GREAT shift at work, big guy!
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LET THE WILD RUMPUS BEGIN !!!!!!
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#9 Ectopy

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Posted 26 April 2011 - 10:47 PM

Matt -

The evidence for using lactate to target fluid resus is in flux. There's a number of studies about to come out showing that lactate levels are pretty wildly all over especially in trauma.

The prevailing "trend" for a while was to target lactate, of course, as direct correlation with cellular hypoperfusion. However, one big study coming out of a number of trauma centers are a poor indication of fluid resus, especially in the elderly and KIDS.

A good friend ran a lactate study at UPenn (think its still in poster phase...) that showed that for moderately injured patients, lactate was a poor predictor of prognosis and fluid needs.

Just did a lit search, doesn't seem to be any data on pediatric trauma lactate levels. Hmmmm, anyone want to go in on the grant with me? :-)
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Matthew George - NREMT-P, FP-C, CCP, Instructor

#10 Ectopy

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Posted 26 April 2011 - 10:49 PM

Also - some of our european colleagues have gone back to early monitoring of invasive pressures, CVP, etc. Banging in a cordis etc in the bay before the unit... Will try to find this citation
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Matthew George - NREMT-P, FP-C, CCP, Instructor

#11 Ectopy

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Posted 26 April 2011 - 10:53 PM

http://www.ncbi.nlm....pubmed/16531858 - No such data exists for peds, but this is pretty interesting if you're looking at the fluid resus/lactate argument
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Matthew George - NREMT-P, FP-C, CCP, Instructor

#12 onearmwonder

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Posted 26 April 2011 - 11:19 PM

Cool thanks...
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#13 TexRNmedic

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Posted 28 April 2011 - 02:08 AM

what pedi literature searches have you done....?
have you checked the PFCCS page?, etc etc....
I'm willing to bet it's out there somewhere...
hoping someone'll post some good pedi-specific papers/links....have a GREAT shift at work, big guy!


Thanks Sean, it was a busy night but nothing crazy. I'm just getting fired up on this train of thought. I was hoping that someone around here had already come across some information about this that would give me a head start. As I said in my previous post, Dr Holcomb is the director for the Center for Translation Injury Research at the University of Texas Health Science Center. The nice thing is, they are closely associated with Memorial Hermann and the hospital and HEMS program gets to participate in a number of trials. You can find dozens of studies published by the CTIR folks here. Studies regarding tourniquet use, blood products transfusions, synthetic blood products and analogues, ultrasounds etc can be found through their website. They are currently working on the PROMMTT (PRospective, Observational, Multi-center Massive Transfusion sTudy). The pedi trauma symposium will have quite a few speakers from UTHSC. I'm hoping to go well armed with questions so that I can be pointed in the right direction by them. Unfortunately, if we are just now getting to the core of this subject in the adult population, I'm guessing there will not be much published on the subject in the peds population.

My best guess from the lit review in adults is, we will see changes in the volumes and types of fluid used. Sean, I too am interested in the use of hypertonics and colloids in resus. My biggest concern is they will need to be used carefully and in conjunction with adequate crystalloid use to prevent intracellular dehydration and dysfunction. I'll leave the chemistry implications of NS (pH around 5) versus loading a patient up with a significant serum anion (albumin), to those more versed in chem and physics.

Scott Weingart (EMCrit) has a couple of good podcasts on the subject of hemorrhagic shock management. Some pretty interesting info on clotting factor replacement and massive transfusion protocols.

http://emcrit.org/po...itation-dutton/
http://emcrit.org/le...emostasis-acep/

I hope everyone has a great week. I'm now off from work for a week, but have two classes worth of final papers to write. Gotta love distance learning degrees.
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Wes Seale
Houston , TX

#14 DartmouthDave

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Posted 30 April 2011 - 12:22 PM

Hello,

I think Weingart talked about Tranexamic Acid (TA) in his hemostasis podcast. The Lancet just published a large study (CRASH II) that showed a reduction in trauma related deaths due to bleeding if TA is given within the first three hours.

Off course, this is an adult study in a peds topic.......but sort of follows the trend of discussion.

Here is a link to the study:

http://www.thelancet.com/crash-2



Cheers
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#15 onearmwonder

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Posted 30 April 2011 - 10:34 PM

So if we use the parameters of roughly 70+2xage for a pediatric BP 1 year or greater, then what is considered permissive hypotension for our pediatric population < puberty age?

Matt

Hello,

I think Weingart talked about Tranexamic Acid (TA) in his hemostasis podcast. The Lancet just published a large study (CRASH II) that showed a reduction in trauma related deaths due to bleeding if TA is given within the first three hours.

Off course, this is an adult study in a peds topic.......but sort of follows the trend of discussion.

Here is a link to the study:

http://www.thelancet.com/crash-2



Cheers


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#16 SerendepitySaki

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Posted 30 April 2011 - 10:57 PM

don't forget PPV and SVV.....



Also - some of our european colleagues have gone back to early monitoring of invasive pressures, CVP, etc. Banging in a cordis etc in the bay before the unit... Will try to find this citation


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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#17 SerendepitySaki

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Posted 30 April 2011 - 10:58 PM

did we ever hear back from brian?

I'll send a PM and see what info I can post here. I'm sure I'm not the only person interested in this info.


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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#18 TexRNmedic

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Posted 01 May 2011 - 03:33 AM

did we ever hear back from brian?

Yep. I received a PM. I still need to read the references and I'll post up some stuff tomorrow. From a 2007 med student presentation.
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Wes Seale
Houston , TX

#19 BrianACNP

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Posted 01 May 2011 - 03:58 PM

don't forget PPV and SVV.....


Unfortunately, SVV has its limitations. Don't forget about ScvO2....we're just now getting IRB approval to study the utility of ScvO2 in trauma resuscitation.

Brian
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Brian, MSN, ACNP, CCRN

#20 SerendepitySaki

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Posted 01 May 2011 - 05:01 PM

Unfortunately, SVV has its limitations. Don't forget about ScvO2....we're just now getting IRB approval to study the utility of ScvO2 in trauma resuscitation.

Brian




1. oh, trust me... if Matt is NOT well familiar with basic calculus and integrating the area under a curve and its application to atrial fibrillation, etc..., he WILL be... B)


2. and, i haven't. i am sitting back and watching this thread develop... opportunity for a million and one hemodynamically relevant sidebars... waiting for some of the the basic, underlying concepts to get explored first... B)
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup