Resuscitation of a bleeding patient

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Resuscitation of a bleeding patient

  1. 1. RECENT PRINCIPLES IN RESUSCITATING A BLEEDING PATIENT Dr.Pradeep
  2. 2. TRAUMA OR GENERAL SURGICAL BLEED???? SURGERY IS A CONTROLLED FORM OF TRAUMA!!
  3. 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. 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. 5. CONVENTIONAL RESUSCITATION Vs DAMAGE CONTROL RESUSCITATION
  6. 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. 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. 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. 9. KEY POINTS IN PATHOPHYSIOLOGY
  10. 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. 11. The Deadly Triad PHSIOLOGICAL EXHAUSTION COAGULOPATHY HYOPTHERMIA ACIDOSIS RESUSCITATION MEASURES WORSEN THIS EFFECT!!!!
  12. 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. 13. WHICH IS THE BEST RESUSCITATION METHOD?? ONE WHICH IS LESS HARMFUL!!!
  14. 14. • Treatment of Haemorrhage is SURGICAL CONTROL OF HAEMORRHAGE and not iv fluids.
  15. 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. 16. Coagulopathy of Trauma
  17. 17. The Deadly Triad PHSIOLOGICAL EXHAUSTION COAGULOPATHY HYOPTHERMIA ACIDOSIS
  18. 18. It is assumed that the patient presents with coagulopathy Why assumed?
  19. 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. 20. Permissive hyoptension • Keeping BP low enough to avoid Exsanguination but maintaining end organ perfusion – Judicial use of fluids – Avoid using vasoactive agents
  21. 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. 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. 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. 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. 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. 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. 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. 28. Thank You

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