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2025 PACUPrep BCCCP Preparatory Course Initial Resuscitation and Fluid Management in Trauma Supportive Care and Management of Complications Post-Resuscitation

Lesson 96, Topic 4

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Supportive Care and Management of Complications Post-Resuscitation

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Learning Objective

Recommend supportive care and monitoring to prevent and manage complications following initial resuscitation and aggressive fluid therapy.

1. Mechanical Ventilation and Respiratory Support

Secure the airway and apply lung-protective strategies to prevent hypoxemia, aspiration, and ventilator-induced lung injury in trauma patients.

A. Indications for Endotracheal Intubation

Glasgow Coma Scale (GCS) ≤ 8
Airway compromise (e.g., facial/neck trauma, hematoma, edema)
Active hemorrhage impairing ventilation or airway protection
Refractory hypoxemia (PaO₂ < 60 mm Hg despite high-flow supplemental O₂)
Anticipated clinical deterioration or need for sedation for imaging/surgery

B. Lung-Protective Ventilation Strategy

Tidal Volume: Target 6 mL/kg of predicted body weight.
Plateau Pressure (Pplat): Maintain ≤ 30 cm H₂O to minimize barotrauma.
Driving Pressure (ΔP): Keep the difference between Pplat and PEEP at ≤ 15 cm H₂O.
PEEP/FiO₂ Titration: Use high PEEP–FiO₂ tables or decremental PEEP trials to optimize oxygenation while minimizing FiO₂.

C. ARDS Protocol Considerations

Prone Positioning: Implement for 12–16 hours per day if the PaO₂/FiO₂ ratio is ≤ 150.
Neuromuscular Blockade: Consider a continuous infusion for ≤ 48 hours for severe patient-ventilator dyssynchrony.
Liberation Trials: Perform daily spontaneous breathing trials paired with sedation interruption to assess readiness for extubation.

Clinical Pearls: Airway Management +

Preoxygenation is Key: Always preoxygenate with 100% FiO₂ using a non-rebreather mask or bag-valve-mask. Consider adding apneic oxygenation via nasal cannula during laryngoscopy to significantly extend the safe apnea time and prevent desaturation.

Avoid High Tidal Volumes: Even brief periods of high-volume ventilation can initiate an inflammatory cascade, contributing to ventilator-induced lung injury (VILI). Adherence to low tidal volumes from the outset is critical.

2. Vasoactive Hemodynamic Support

After adequate fluid resuscitation has been confirmed, maintain vital organ perfusion pressure using vasoactive agents tailored to the patient’s specific shock phenotype.

A. Indications for Vasoactive Agents

Sustained Mean Arterial Pressure (MAP) < 65 mm Hg.
In traumatic brain injury (TBI), a higher MAP goal (≥ 80 mm Hg) is often targeted to maintain adequate cerebral perfusion pressure.
Persistent signs of hypoperfusion despite fluid resuscitation (e.g., oliguria < 0.5 mL/kg/h, elevated or rising lactate, altered mentation).

B. Agent Selection and Titration

Point-of-care echocardiography is invaluable for differentiating shock states (e.g., vasodilatory vs. cardiogenic) and guiding agent selection. The following table outlines first-line and adjunct agents.

Vasoactive Agent Selection in Post-Resuscitation Shock
Agent & Mechanism	Dose & Titration	Key Monitoring & Pitfalls
Norepinephrine α₁ > β₁ Agonist	Start: 0.05–0.1 µg/kg/min Titrate: by 0.01–0.05 µg/kg/min q5-10min	Monitor MAP, ECG, and extremity perfusion. Pitfalls: Digital ischemia at high doses, tissue necrosis with extravasation.
Vasopressin V₁ Receptor Agonist	Dose: 0.03 units/min (fixed) Use: Adjunct for refractory shock (NE > 0.2 µg/kg/min)	Monitor for signs of gut ischemia. Pitfalls: Splanchnic and coronary vasoconstriction. Not titratable.
Epinephrine α₁ and β₁ Agonist	Start: 0.01–0.1 µg/kg/min Titrate: to MAP and cardiac output response	Monitor lactate, heart rate, and for arrhythmias. Pitfalls: Tachyarrhythmias, hyperglycemia, can increase lactate.

Clinical Pearls: Hemodynamic Support +

TBI is Different: In patients with traumatic brain injury, permissive hypotension is harmful. Target a MAP ≥ 80 mm Hg to ensure cerebral perfusion pressure (CPP = MAP – ICP) remains above 60-70 mm Hg.

Reassess the Tank: Before aggressively escalating vasopressor doses, always reassess volume status. Use dynamic measures like passive leg raise or pulse pressure variation if the patient is eligible, or POCUS to evaluate for fluid responsiveness.

3. Prevention of ICU-Related Complications

Proactive prophylaxis and strict adherence to evidence-based care bundles are essential to reduce the incidence of venous thromboembolism (VTE), stress ulcer bleeding, and device-related infections.

A. Venous Thromboembolism (VTE) Prophylaxis

LMWH (e.g., enoxaparin): Preferred agent (30 mg SC q12h or 40 mg SC q24h). Avoid if active bleeding, severe coagulopathy, or platelets < 50 × 10⁹/L.
Unfractionated Heparin (UFH): Use 5,000 units SC q8h. Reserved for patients with severe renal failure (CrCl < 30 mL/min) or those at very high risk of bleeding, due to its short half-life and reversibility.
Mechanical Prophylaxis: Sequential compression devices (SCDs) are crucial when pharmacologic prophylaxis is contraindicated.

B. Stress-Related Mucosal Bleeding Prophylaxis

Indications: Mechanical ventilation > 48 hours, coagulopathy (platelets < 50, INR > 1.5), or shock requiring vasopressors.
Proton Pump Inhibitors (PPIs): First-line agents (e.g., pantoprazole 40 mg IV daily).
Histamine-2 Receptor Antagonists (H₂RAs): An alternative (e.g., famotidine).
De-escalation: Discontinue prophylaxis once risk factors resolve to minimize risk of hospital-acquired pneumonia and C. difficile infection.

C. Nosocomial Infection Prevention Bundles

Central Line (CLABSI) Bundle: Strict hand hygiene, maximal barrier precautions during insertion, chlorhexidine skin prep, and daily review of line necessity.
Ventilator (VAP) Bundle: Head-of-bed elevation ≥ 30°, daily sedation interruption and readiness-to-extubate assessment, oral care with chlorhexidine, and use of endotracheal tubes with subglottic suctioning.

Clinical Pearls: Prophylaxis Timing +

VTE Prophylaxis Timing: In trauma patients, initiate pharmacologic VTE prophylaxis (typically LMWH) within 24 hours of injury, once major hemorrhage has been controlled and there is no evidence of ongoing bleeding.

Audit and Feedback: The most effective way to ensure low infection rates is not just having bundles, but actively auditing compliance and providing regular feedback to the clinical team. Daily checklists are highly effective.

4. Management of Iatrogenic Fluid Therapy Complications

Aggressive fluid resuscitation is life-saving but can lead to significant complications, including fluid overload, intra-abdominal hypertension, and ARDS, which require active management.

A. Fluid Overload and De-resuscitation

Diuretics: Once hemodynamically stable, initiate de-resuscitation with loop diuretics (e.g., furosemide 20–40 mg IV bolus or a 5–10 mg/h infusion).
Monitoring: Closely track urine output, daily weights, fluid balance, electrolytes (especially K⁺ and Mg²⁺), and renal function.
Renal Replacement Therapy: Consider ultrafiltration via continuous renal replacement therapy (CRRT) for diuretic-resistant fluid overload.

B. Abdominal Compartment Syndrome (ACS)

ACS is a life-threatening complication of massive resuscitation. Early recognition through bladder pressure monitoring is key.

Intra-abdominal Hypertension (IAH): Defined as a sustained intra-abdominal pressure (IAP) ≥ 12 mm Hg.
Abdominal Compartment Syndrome (ACS): Sustained IAP > 20 mm Hg associated with new-onset organ dysfunction.
Management: Medical management includes sedation, paralysis, and gastric decompression. If IAP continues to rise with worsening organ failure, urgent decompressive laparotomy is required.

Figure 1: The Spectrum of Intra-Abdominal Hypertension (IAH) and Abdominal Compartment Syndrome (ACS). Routine monitoring of intra-abdominal pressure (IAP) via the bladder in high-risk patients allows for early detection of IAH and intervention before progression to life-threatening ACS.

Clinical Pearls: Fluid Management +

Monitor Bladder Pressure Early: In any patient receiving massive transfusion (>10 units PRBCs) or with severe abdominal trauma and ongoing resuscitation, initiate IAP monitoring every 4-6 hours to detect IAH before it becomes ACS.

Transition to Conservative Fluids: After initial hemorrhage control is achieved (the “ebb” phase), promptly transition to a conservative fluid strategy (the “flow” phase). This means using fluids only to replace ongoing losses and avoiding “maintenance” IV fluids to limit iatrogenic organ edema.

5. Multidisciplinary Goals-of-Care Conversations

Early and structured communication with patients and their families is a critical component of high-quality critical care, ensuring that invasive interventions align with patient values and realistic prognoses.

A. Optimal Timing for Discussions

Within 24–48 hours of ICU admission and initial resuscitation.
Following the development of a major new complication (e.g., refractory ARDS, ACS, anoxic brain injury).
Before consideration of any new high-risk or life-sustaining invasive procedure (e.g., tracheostomy, feeding tube).

B. Ethical Framework and Team Composition

Core Principles: Discussions should be guided by the principles of patient autonomy, beneficence (acting in the patient’s best interest), and nonmaleficence (avoiding harm).
Team: Led by the critical care physician, the team should include the bedside nurse, respiratory therapist, and pharmacist. In complex cases, involve palliative care, ethics, and social work consultants early.

Clinical Pearls: Communication +

Palliative Care is Not Hospice: Early palliative care consultation in the ICU has been shown to improve symptom management, reduce family distress, and shorten ICU length of stay without negatively impacting survival. It is a layer of support, not an end-of-life discussion.

Use a Framework: For difficult conversations, use a structured communication tool like SPIKES (Setting, Perception, Invitation, Knowledge, Emotions, Strategy/Summary) to ensure all key components of the discussion are covered effectively and empathetically.

6. Pharmacotherapy Quick Reference

This table provides a consolidated overview of key prophylactic medications used in post-resuscitation care, emphasizing selection criteria and monitoring.

Summary of Prophylactic Pharmacotherapy
Indication	First-Line Agent	Alternative / Special Considerations	Key Considerations
VTE Prophylaxis	Enoxaparin	40 mg SC daily or 30 mg SC q12h	UFH 5,000 U SC q8h for CrCl < 30 mL/min or high bleeding risk.	Initiate within 24h post-injury once bleeding is controlled. Monitor platelets for HIT.
Stress Ulcer Prophylaxis	Pantoprazole (PPI)	40 mg IV daily	Famotidine (H₂RA) as a cost-saving or alternative agent.	Only for high-risk patients (mech. vent >48h, coagulopathy). Discontinue when risk resolves.
Nosocomial Infections	Care Bundles	N/A	Selective Digestive Decontamination (SDD) in specific high-risk units under stewardship.	Adherence to bundles is more effective than prophylactic antibiotics. Practice antibiotic stewardship.

References

Roberts KJ, Goodfellow LT, Battey-Muse CM, et al. AARC clinical practice guideline: spontaneous breathing trials for liberation from adult mechanical ventilation. Respir Care. 2024.
Fan E, Del Sorbo L, Goligher EC, et al. An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2017;195(9):1253-1263.
Callaway CW, Donnino MW, Fink EL, et al. Part 8: Post-Cardiac Arrest Care: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(18 Suppl 2):S465-S482.
Rappold JF, et al. Venous thromboembolism prophylaxis in the trauma patient. J Trauma Acute Care Surg. 2021;91(2S):S1-S10.
Krishna SG, et al. Guideline for the Prevention and Management of Stress-Related Mucosal Bleeding in Critically Ill Patients. Crit Care Med. 2024.
Guillamondegui OD, et al. Stress Ulcer Prophylaxis in the Trauma Patient: A Practice Management Guideline from the Eastern Association for the Surgery of Trauma. J Trauma. 2008;65(5):1174-1185.
Al-Zubeidi D, et al. ASPEN-FELANPE-FELANPE-Parenteral Nutrition Safety Committee. Prevention of complications for hospitalized adult patients receiving parenteral nutrition: An ASPEN-FELANPE-FELANPE clinical guideline. Nutr Clin Pract. 2024;39(1):43-73.
Soar J, Böttiger BW, Carli P, et al. European Resuscitation Council Guidelines 2021: Adult advanced life support. Resuscitation. 2021;161:115-151.

2025 PACUPrep BCCCP Preparatory Course

Pulmonary

Participants 432

Supportive Care and Management of Complications Post-Resuscitation

Supportive Care and Management of Complications Post-Resuscitation

Learning Objective

1. Mechanical Ventilation and Respiratory Support

A. Indications for Endotracheal Intubation

B. Lung-Protective Ventilation Strategy

C. ARDS Protocol Considerations

2. Vasoactive Hemodynamic Support

A. Indications for Vasoactive Agents

B. Agent Selection and Titration

3. Prevention of ICU-Related Complications

A. Venous Thromboembolism (VTE) Prophylaxis

B. Stress-Related Mucosal Bleeding Prophylaxis

C. Nosocomial Infection Prevention Bundles

4. Management of Iatrogenic Fluid Therapy Complications

A. Fluid Overload and De-resuscitation

B. Abdominal Compartment Syndrome (ACS)

5. Multidisciplinary Goals-of-Care Conversations

A. Optimal Timing for Discussions

B. Ethical Framework and Team Composition

6. Pharmacotherapy Quick Reference

References