Intraoperative Oxygen Status in Patients with Injuries of Abdominal Cavity Organs

Aim: to analyze the oxygen balance in patients with injuries of abdominal cavity organs and acute blood loss during surgery and arrest of bleeding.

Material and methods: the study group consisted of 50 patients (49 men and 1 woman, average age: 33 (25.75; 44.5) years) who experienced injuries of abdominal cavity organs complicated by acute massive blood loss requiring urgent surgical interventions. The severity of patients' state was 38 (27.75; 48) by ISS scoring. The study examined the following parameters: the blood loss volume, hemoglobin (Hg) level, hematocrit (HCT), blood gases, oxygen balance, acid-base balance, electrolyte levels, and the tissue metabolism status. A continuous minimally invasive monitoring of central hemodynamics parameters was performed. The statistical data processing was per- formed using the SPSS software (SPSS Inc., USA).

Results: the central hemodynamics parameters did not reflect the severity of patients' state at their admission into an operating room. The signs of hypovolemia were observed along with normal vascular tone and cardiac out- put. At the same time, such parameters of oxygen balance as high VO2I and О2ER, as well as low SvО2 indicated the severity of patients' state. These data demonstrated that patients experienced a severe episode of respiratory or circulatory hypoxia during trauma, which had been corrected during first aid treatment and transportation by patient's admission into the operating room, so patients presented lab test findings of «oxygen debt». The VO2I values remained high in addition to the increase in О2ER values by the end of the surgery. However, low CvO2, PvO2, and SvО2 values indicated the persisting circulatory hypoxia.

Conclusion: All patients with postoperative complications were admitted into the operating room with already existing impairment of oxygen delivery. The patients did not recover from shock, the low cardiac efficiency was the main reason for its persistence. The correlation between postoperative lethal outcomes and the value of cardiac index (CI) at the end of surgery in this group of patients was demonstrated. 

1. Valetova V.V., Ermolov A.S., Timerbaev V.Kh., Dragunov A.V. The influence of intraoperative infusion-transfusion therapy on massive blood loss patients lethality. Anesteziologiya i Reanimatologiya. 2012; 2: 23–27. PMID: 22834283. [In Russ.]

2. Yakovlev A.Yu., Yemelyanov N.V., Mukhina I.V., Dvornikov A.V., Snopova L.B., Kalentyev G.V., Ryabikov D.V., Mineyeva N.V. Choice of an infu- sion agent for the prevention of multiple organ dysfunction in acute massive blood loss (experimental study). Obshchaya Reanimatologiya = General Reanimatology. 2010; 6 (3): 48–51. http://dx.doi.org/ 10.15360/1813-9779-2010-3-48. [In Russ., In Engl.]

3. Gorodetsky V.M. Modern philosophy of transfusion therapy for traumatic massive blood loss. Gematologiya i Transfuziologiya. 2012; 57 (3): 3–5. [In Russ.]

4. Zyblev S.L., Dundarov Z.A. The state of metabolism in experimental acute massive blood loss depending on the conducted therapy. Novosti Khirurgii. 2013; 21 (5): 3–10. [In Russ.]

5. Akaraborworn O. Damage control resuscitation for massive hemorrhage. Chin. J. Traumatol. 2014; 17 (2): 108–111. PMID: 24698581

6. Shoemaker W.C., Appel P.L., Waxman K., Schwartz S., Chang P. Clinical trial of survivors’ cardiorespiratory patterns as therapeutic goals in critically ill postoperative patients. Crit. Care Med. 1982; 10 (6): 398–403. https://doi.org/10.1097/00003246-198206000-00015. PMID: 7042206

7. Adamczyk S., Robin E., Barreau O., Fleyfel M., Tavernier B., Lebuffe G., Vallet B. Contribution of central venous oxygen saturation in postop- erative blood transfusion decision. Ann. Fr. Anesth. Reanim. 2009; 28 (6): 522–530. http://dx.doi.org/10.1016/j.annfar.2009.03.013. PMID: 19467825

8. Ilyinsky A.A., Molchanov I.V. Effects of hydroxyethylated starch in dif- ferent concentrations on homeostasis during the perioperative period. Gematologiya i Transfuziologiya. 2011; 56 (2): 13–18. [In Russ.]

9. Stukanov M.M., Lukach V.N., Girsh A.O., Yudakova T.N., Gorin P.V., Chugulev I.A., Maksimishin S.V., Rybakov I.A. Comparative study of infu- sion therapy options in patients with hemorrhagic shock. Anesteziologiya i Reanimatologiya. 2011; 2: 27–30. PMID: 21692218. [In Russ.]

10. Gerasimov L.D., Moroz V.V., Isakova A.A. Microrheological disorders in critical conditions. Obshchaya Reanimatologiya = General Reanimatology. 2010; 6 (1): 74–78. http://dx.doi.org/10.15360/1813- 9779-2010-1-74. [In Russ., In Engl.]

11. Hébert P.C., Wells G., Blajchman M.A., Marshall J., Martin C., Pagliarello G., Tweeddale M., Schweitzer I., Yetisir E.A. Multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N. Engl. J. Med. 1999; 340 (6): 409–417. http://dx.doi.org/10.1056/NEJM199902113400601. PMID: 9971864

12. Yudakova T.N., Girsh A.O., Maksimishin S.V., Malkov O.A. Relations of cardiovascular system and endothelial dysfunction indicators in patients with hemorrhagic shock. Anesteziologiya i Reanimatologiya. 2013; 6: 11–14. PMID: 24749256. [In Russ.]

13. Gerecht R. The lethal triad. Hypothermia, acidosis - coagulopathy cre- ate a deadly cycle for trauma patients. JEMS. 2014; 39 (4): 56–60. PMID: 24779101

14. Nascimento B., Callum J., Rubenfeld G., Neto J.B., Lin Y., Rizoli S.Clinical review: fresh frozen plasma in massive bleedings — more questions than answers. Crit. Care. 2010; 14 (1): 202. http://dx.doi.org/10.1186/cc8205. PMID: 20156316

15. Borovkova N.B., Valetova V.V., Timerbaev V.Kh., Kazakov M.G., Nikitina O.V., Khvatov V.B. Leukocytic response and peripheral venous blood lymphocyte apoptosis as a marker of tissue ischemia in acute massive blood loss. Obshchaya Reanimatologiya = General Reanimatology. 2013; 9 (4): 18–22. http://dx.doi.org/10.15360/1813-9779-2013-4- 18. [In Russ., In Engl.]

16. Bunn F., Trivedi D., Ashraf S. Colloid solutions for fluid resuscitation. Cochrane Database Syst. Rev. 2011; 16 (3): CD001319. http://dx.doi.org/10.1002/14651858.CD001319.pub3. PMID: 21412871

17. Boldt J., Ince C. The impact of fluid therapy on microcirculation and tissue oxygenation in hypovolemic patients: a review. Intensive Care Med. 2010; 36 (8): 1299–1308. http://dx.doi.org/10.1007/s00134- 010-1912-7. PMID: 20502873

18. Kosovskikh A.A., Churlyaev Yu.A., Kan S.L., Lyzlov A.N., Kirsanov T.V., Vartanyan A.R. Central hemodynamics and microcirculation in critical conditions. Obshchaya Reanimatologiya = General Reanimatology. 2013; 9 (1): 18–22. http://dx.doi.org/10.15360/1813-9779-2013-1- 18. [In Russ., In Engl.]

19. De Backer D., Ortiz J.A., Salgado D. Coupling microcirculation to systemic hemodynamics. Curr. Opin. Crit. Care. 2010; 16 (3): 250–254. http://dx.doi.org/10.1097/MCC.0b013e3283383621. PMID: 20179590

20. Bekar L.K., Wei H.S., Nedergaard M. The locus coeruleus-norepinephrine network optimizes coupling of cerebral blood volume with oxygen demand. J. Cereb. Blood Flow Metab. 2012; 32 (12): 2135–2145. http://dx.doi.org/10.1038/jcbfm.2012.115. PMID: 22872230

21. Shoemaker W.C., Appel P.L., Kram H.B. Hemodynamic and oxygen transport responses in survivors and nonsurvivors of high-risk surgery. Crit. Care Med. 1993; 21 (7): 977–990. https://doi.org/10.1097/ 00003246-199307000-00010. PMID: 8319478

22. Epstein C.D., Henning R.J. Oxygen transport variables in the identification and treatment of tissue hypoxia. Heart Lung. 1993; 22 (4): 328–345. PMID: 8360067

23. Shoemaker W.C., Appel P.L., Kram H.B. Measurement of tissue perfusion by oxygen transport patterns in experimental shock and in high-risk sur- gical patients. Intensive Care Med. 1990; 16 (Suppl 2): S135–S144. https://doi.org/10.1007/BF01785243. PMID: 2289979

24. Bouglé A., Harrois A., Duranteau J. Resuscitative strategies in traumat- ic hemorrhagic shock. Ann. Intensive Care. 2013; 3 (1): 1. http://dx.doi.org/10.1186/2110-5820-3-1. PMID: 23311726

25. Lyuboshevsky P.A., Artamonova N.I., Ovechkin A.M. Haemostasis dis- turbances as the component of the surgical stress-response and possi- bilities of their correction. Anesteziologiya i Reanimatologiya. 2012; 3: 44–48. PMID: 22993923. [In Russ.]

26. Moroz V.V., Myagkova E.A., Sergunova V.A., Gudkova O.E., Ostapchenko D.A., Chernysh A.M., Reshetnyak V.I. Morphological fea- tures of red blood cells in patients with severe concomitant injury. Obshchaya Reanimatologiya = General Reanimatology. 2013; 9 (3): 14–23. http://dx.doi.org/10.15360/1813-9779-2013-3-14. [In Russ., In Engl.]

27. Yakovlev A.Yu., Kichin V.V., Nikolsky V.O., Kalentyev G.V., Ryabikov D.V., Ryabikova M.A., Protasov D.M., Galanina T.A., Smerkalov A. Yu., Evdokimova O.S. Efficacy of employment of isotonic sterofundin after experimental hemorrhagic shock. Obshchaya Reanimatologiya = General Reanimatology. 2013; 9 (3): 24–29. http://dx.doi.org/ 10.15360/1813-9779-2013-3-24. [In Russ., In Engl.]

28. Dawes R., Thomas G.O. Battlefield resuscitation. Curr. Opin. Crit. Care. 2009; 15 (6): 527–535. http://dx.doi.org/10.1097/MCC.0b013e3 2833190c3. PMID: 19812487

29. Alam H.B., Rhee P. New developments in fluid resuscitation. Surg. Clin. North Am. 2007; 87 (1): 55–72. http://dx.doi.org/10.1016/j.suc.2006. 09.015. PMID: 17127123

30. ATLS: Advanced Trauma Life Support program for doctors. Committee on Trauma, American College of Surgeons. 8th ed. Chicago: American College of Surgeons; 2008: 167.

31. Beekley A.C. Damage control resuscitation: a sensible approach to the exsanguinating surgical patient. Crit. Care Med. 2008; 36 (7 Suppl): S267–S274. http://dx.doi.org/10.1097/CCM.0b013e31817da7dc. PMID: 18594252

32. Bouillon B., Brohi K., Hess J.R., Holcomb J.B., Parr M.J., Hoyt D.B. Educational initiative on critical bleeding in trauma. J. Trauma. 2010; 68 (1): 225–230. http://dx.doi.org/10.1097/TA.0b013e3181c42815. PMID: 20065778

33. Amato M.B., Barbas C.S., Medeiros D.M., Magaldi R.B., Schettino G.P., Lorenzi-Filho G., Kairalla R.A., Deheinzelin D., Munoz C., Oliveira R., Takagaki T.Y., Carvalho C.R. Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N. Engl. J. Med. 1998; 338 (6): 347–354. http://dx.doi.org/10.1056/NEJM199802 053380602. PMID: 9449727

34. Boyd O., Grounds R.M., Bennett E.D. A randomized clinical trial of the effect of deliberate perioperative increase of oxygen delivery on mor- tality in high-risk surgical patients. JAMA. 1993; 270 (22): 2699–2707. https://doi.org/10.1001/jama.1993.03510220055034. PMID: 7907668

35. Callum J.L., Rizoli S. Plasma transfusion for patients with severe hemorrhage: what is the evidence? Transfusion. 2012; 52 (Suppl 1): 30S–37S. http://dx.doi.org/10.1111/j.1537-2995.2012.03621.x. PMID: 22578369

36. Spahn D.R., Leone B.J., Reves J.G., Pasch T. Cardiovascular and coronary physiology of acute isovolemichemodilution: a review of nonoxy- gen-carrying and oxygen-carrying solutions. Anesth. Analg. 1994; 78 (5): 1000–1021. PMID: 8160966

37. Carrico C.J., Canizaro P.C., Shires G.T. Fluid resuscitation following injury: rationale for the use of balanced salt solutions. Crit. Care Med. 1976; 4 (2): 46–54. https://doi.org/10.1097/00003246-197603000- 00002. PMID: 819213

38. Mitra B., Mori A., Cameron P.A., Fitzgerald M., Paul E., Street A. Fresh frozen plasma (FFP) use during massive blood transfusion in trauma resuscitation. Injury. 2010; 41 (1): 35–39. http://dx.doi.org/10.1016/ j.injury.2009.09.029. PMID: 19833331

39. Frith D., Brohi K. The acute coagulopathy of trauma shock: clinical relevance. Surgeon. 2010; 8 (3): 159–163. http://dx.doi.org/10.1016/ j.surge.2009.10.022. PMID: 20400026

40. Cherkas D. Traumatic hemorrhagic shock: advances in fluid management. Emerg. Med. Pract. 2011; 13 (11): 1–19. PMID: 22164397

41. British Committee for Standards in Haematology, Stainsby D., MacLennan S., Thomas D., Isaac J., Hamilton P.J. Guidelines on the management of massive blood loss. Br. J. Haematol. 2006; 135 (5): 634–641. http://dx.doi.org/10.1111/j.1365-2141.2006.06355.x. PMID: 17107347

42. Shoemaker W.C., Kvetan V., Fyodorov V., Kram H.B. Clinical algorithm for initial fluid resuscitation in disasters. Crit. Care Clin. 1991; 7 (2): 363–381. PMID: 2049644

43. Thorsen K., Ringdal K.G., Strand K., Søreide E., Hagemo J., Søreide K. Clinical and cellular effects of hypothermia, acidosis and coagulopathy in major injury. Br. J. Surg. 2011; 98 (7): 894–907. http://dx.doi.org/ 10.1002/bjs.7497. PMID: 21509749

44. Perestoronina M.V., Korpacheva O.V., Palyanov S.V., Dolgikh V.T. The parameters of the oxygen status in the assessment of prognosis of a hemodynamically significant patent ductus arteriosus preterm neonatal infants. Obshchaya Reanimatologiya = General Reanimatology. 2015; 11 (2): 35–41. http://dx.doi.org/10.15360/1813-9779-2015-2- 35-41. [In Russ., In Engl.]

45. Cohen M.J. Towards hemostatic resuscitation: the changing under- standing of acute traumatic biology, massive bleeding, and damage- control resuscitation. Surg. Clin. North Am. 2012; 92 (4): 877–891. http://dx.doi.org/10.1016/j.suc.2012.06.001. PMID: 22850152