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Resuscitation of a bleeding patient

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  • 1. RECENT PRINCIPLES IN RESUSCITATING A BLEEDING PATIENT Dr.Pradeep
  • 2. TRAUMA OR GENERAL SURGICAL BLEED???? SURGERY IS A CONTROLLED FORM OF TRAUMA!!
  • 3. A SURGICAL PATIENT WITH HYPOVOLEMIC SHOCK • In actively bleeding patient, large volume of iv fluids merely increases bleeding from the site • So main treatment is to control the bleeding. • Conversely in intestinal obstruction or perforation patient should be well resuscitated with fluid before surgery
  • 4. Dynamic fluid response • Fluid bolus of 250 – 500ml given over 15mins and response is assessed in terms of heart rate, bp and cvp – RESPONDERS – TRANSIENT RESPONDERS – NON RESPONDERS
  • 5. CONVENTIONAL RESUSCITATION Vs DAMAGE CONTROL RESUSCITATION
  • 6. Conventional Resuscitation • In all cases of shock, regardless of classification, hypovolaemia and inadequate preload must be addressed before other therapy is instituted. • Start iv line • Inotropic support if needed (only after increasing preload)
  • 7. • Blood and component therapy as and when required • Indications for whole blood or packed cell? • Indications for component therapy – FFP if prothrombin time (PT) or partial thromboplastin time (PTT) > 1.5 × normal; – cryoprecipitate if fibrinogen < 0.8 g l ; – platelets if platelet count < 50 × 10 ml . –1 9 –1
  • 8. Dynamic fluid response • Fluid bolus of 250 – 500ml given over 15mins and response is assessed in terms of heart rate, bp and cvp – RESPONDERS – TRANSIENT RESPONDERS – NON RESPONDERS Conventional resuscitation DCR
  • 9. KEY POINTS IN PATHOPHYSIOLOGY
  • 10. HAEMORRHAGE REDUCED TISSUE PERFUSION ISCHAEMIC ENDOTHILIAL CELLS ACTIVATE ANTI-COAG. ACIDOSIS REDUCES FUCTIONING OF COAGULATION PROTEASES COAGULOPATHY UNDER PERFUSED MUSCLE BEDS AND GUT HYPOTHERMIA
  • 11. The Deadly Triad PHSIOLOGICAL EXHAUSTION COAGULOPATHY HYOPTHERMIA ACIDOSIS RESUSCITATION MEASURES WORSEN THIS EFFECT!!!!
  • 12. What happens on fluid resuscitation????? • • • • If not warmed, worsens hypothermia Causes dilutional coagulopathy Ph of most fluids are acidic (ph of NS is 6.7) Flushes toxic materials to circulation on reperfusion which furthur worsens microvascular damage
  • 13. WHICH IS THE BEST RESUSCITATION METHOD?? ONE WHICH IS LESS HARMFUL!!!
  • 14. • Treatment of Haemorrhage is SURGICAL CONTROL OF HAEMORRHAGE and not iv fluids.
  • 15. DAMAGE CONTROLLED RESUSCITATION • Aimed at halting or preventing the DEADLY TRIAD. While conventional methods tries to treat lethal triad of acidosis, hypothermia and coagulopathy
  • 16. Coagulopathy of Trauma
  • 17. The Deadly Triad PHSIOLOGICAL EXHAUSTION COAGULOPATHY HYOPTHERMIA ACIDOSIS
  • 18. It is assumed that the patient presents with coagulopathy Why assumed?
  • 19. key concepts CONVENTIONAL RESUSCITATION • Loads of crystalloids followed by blood transfusion DCR • Early use of plasma and other blood products • Rapid and early correction of coagulopathy • Permissive hypotension
  • 20. Permissive hyoptension • Keeping BP low enough to avoid Exsanguination but maintaining end organ perfusion – Judicial use of fluids – Avoid using vasoactive agents
  • 21. Addressing coagulopathy in resuscitation • Early use of RBC + plasma + platelets offers best chance of limiting coagulopathy 1:1:1 Holcomb et al. EARLY MASSIVE TRAUMA TRANSFUSION : STATE OF ART. The Journal of Trauma 2006
  • 22. MASSIVE TRANSFUSION GUIDELINES • Identify the patient in need of Massive Transfusion(MT) Unstable patient or who received 1-2 PRBCs but not responding Crystalloid infusion must be minimised • Blood bank must issue PRBCs, FFP and Platelets in 1:1:1 ratio • MT should be terminated once patient is not actively bleeding
  • 23. MONITORING A PATIENT Minimum ■ Electrocardiogram ■ Pulse oximetry ■ Blood pressure ■ Urine output Additional modalities ■ Central venous pressure ■ Invasive blood pressure ■ Cardiac output ■ Base deficit and serum lactate
  • 24. What is the End Point for resuscitaion?? It is much easier to know when to start resuscitation than to know when to stop!
  • 25. End Points Of Resuscitation • Traditional Parameters • Heart rate • Pulse • Urine output Measures Perfusion of organs which are usually maintained till late stages of shock • Gut and Muscle beds may be still underperfused – continues to produce inflammatory mediators – may cause reperfusion injury – OCCULT HYPOPERFUSION
  • 26. What measures occult hypoperfusion?? Base deficit or serum lactate level Mixed venous oxygen saturation Measurements for global hypoperfusion Measures the resuscitation at cellular level
  • 27. Points for taking back to ward Damage control resuscitation needed only in severely injured/ill patients Correction of coagulopathy PRBC : FFP : PLATELETS – 1:1:1 whenever possible Do not aim at restoring normal BP Do an ABG – Look for base deficit and resuscitate the patient till it normalises.
  • 28. Thank You

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