2005 OPEN FORUM Abstracts
Recruit, Retain, Protect: Very early intervention with high frequency oscillation in trauma patients on a fluid resuscitation protocol
Michael J Hewitt, RRT-NPS, RCP; Roman Kosir, MD; Bobbie Brasseaux, RRT, RCP, Nena Lopez, CRT, RCP; Patricia Harshfield, RRT, RCP: Memorial Hermann Hospital at The Texas Medical Center & The University of Texas at Houston School of Medicine
Introduction: Trauma patients who require massive fluid resuscitation often develop significant oxygenation problems and many develop ARDS. Historically, we have managed these patients ventilator course in a reactive manner, attempting to overcome the heavy, wet, leaky lung physiology with approaches such as Pressure Control and APRV. In this case, we placed the patient on the Sensormedics 3100B oscillator very early in his ventilator course in an effort to prevent the typical flooding of the lungs that occurs in these fluid resuscitation scenarios.
Summary: The patient is a 20 year old male who presented to our Trauma Center following a rollover MVC where he was ejected. His list of injuries included multiple bilateral rib fractures, significant right sided pulmonary contusion, left sided hemo-pneumothorax, C-7 anterior fracture, left scapular fracture, right adrenal hematoma, and several transverse process fractures. He was admitted to our STICU and placed on mechanical ventilation. Upon admission to the ICU, the patient was hemodynamically unstable and was placed on the Fluid Resuscitation Protocol. This protocol is part of a standardization study amongst several Level 1 Trauma Centers across the country (The NIH Glue Grant Group). During the 24 hours following implementation of the fluid resuscitation protocol, the patient received 19,800 cc's of fluid. 6 hours following admission and initiation of the fluid protocol, the patient began having significant oxygenation issues. His FIO2 was 100% with PEEP levels increased up to 15 in modes ranging from SIMV/PRVC to PC/AC to APRV. Repeat CXR revealed a worsening right sided contusion. The decision was made to place the patient in an aggressive regimen of HFOV in an attempt to recruit the lungs and improve oxygenation. After 9 hours of HFOV, the patient had a PO2 of 344 torr on 60% FIO2. At 00:30 hours the next morning, the patients ABG revealed a significant respiratory alkalosis as well as a PO2 of 260 on 45% FIO2. Repeat CXR yielded a much improved right side contusion, with markedly improved aeration, which went in hand with the ABG. We then weaned the oscillator steadily, but cautiously, now in the mindset of protecting the lungs from the 19,000 cc's of fluid. The patient was removed from the oscillator approximately 72 hours after initiation. He was then weaned from conventional ventilation, extubated, and ultimately discharged to the floor. On day 19 of his stay, the patient was discharged home, with no deficits.
Discussion: This is the 7th fluid resuscitation trauma patient who displayed significant oxygenation problems that we have placed on HFOV with the 3100B very early in their course. In the past, we did not employ HFOV until well into the fluid overloaded, ARDS picture. While some of the patients placed on HFOV later in the well defined process of fluid overload and ARDS responded, they did so very slowly and not without other issues, such as renal failure. In each of the cases where we have employed very early intervention with HFOV, the patients have responded quickly and dramatically. None has progressed to the typical whited out CXR associated with fluid overload and ARDS, nor has renal failure been an issue. We feel that a much earlier intervention with HFOV than in the past with this population of patients may prevent the development of the commonly seen ARDS scenario. Plans are being formulated to conduct a formal trial with this approach.