1) The patient has signs of shock including hypotension, tachycardia, and elevated lactate and base deficit.
2) Fluid resuscitation with 2L LR improved hemodynamics but lactate and base deficit remain elevated, indicating ongoing shock.
3) Aggressive resuscitation with blood products following a 1:1:1 ratio of PRBCs, FFP, and platelets is indicated to replace blood loss and prevent coagulopathy, given the suspicion for hemorrhage.
د/عاصم محرم
Blood product transfusion & Principles of Fluid Therapy
المحاضرة التي قدمت يوم الثلاثاء 8 ابريل 2014 في دار الحكمة بالقاهرة
من فعاليات مشروع اعداد طبيب حكيم ناجح بالتعاون مع معتمد باتحاد الاطباء العرب
و ضمن موديول الطوارئ و التخدير و العناية المركزة
د/عاصم محرم
Blood product transfusion & Principles of Fluid Therapy
المحاضرة التي قدمت يوم الثلاثاء 8 ابريل 2014 في دار الحكمة بالقاهرة
من فعاليات مشروع اعداد طبيب حكيم ناجح بالتعاون مع معتمد باتحاد الاطباء العرب
و ضمن موديول الطوارئ و التخدير و العناية المركزة
Assessment and management of shock in acute trauma setting based on ATLS recommendations .Lecture given in Trauma update at Perintalmanna on19th August 2014.
Assessment and management of shock in acute trauma setting based on ATLS recommendations .Lecture given in Trauma update at Perintalmanna on19th August 2014.
Teaching with Twitter: Is There A Place For Social Media In Higher Education?Kristopher Maday
This is a talk I gave at the 2015 University of Alabama System Scholars Institute Conference. In it I discuss how we as educators need to utilize social media to reach the "Millenial" generations and how we can use this medium as part of our promotion and tenure evidence for scholarly activity.
Ciertamente la represión no es el modelo de combatir el tema.
En el Trabajo lo que debemos prevenir es el Siniestro Laboral.
De allí la viabilidad de los Test.
Prot. 876 17 pl institui a gratuidade para pacientes acometidos de lúpus no...Claudio Figueiredo
Projeto de Lei nº 876/17, de autoria do vereador Valdir do Restaurante (PT do B), que institui a gratuidade, nos ônibus do sistema de transporte coletivo municipal, para pacientes portadores de Lúpus
[Webinar] Give Your SDRs An Unfair Advantage with Predictive Mintigo1
To view the full webinar replay, please visit:
http://www.mintigo.com/give-sales-development-reps-unfair-advantage-predictive/
Description:
Whether you are following an Account-Based Marketing (ABM) strategy or a traditional demand generation approach, employing a team of sales/business development reps (SDRs or BDRs) for teleprospecting is the new normal for almost every B2B sales and marketing organization.
In the early days of sales development — and even to this day — small armies of hungry yet inexperienced recent college graduates were tasked to complete hundreds of calls and voicemails per day with the goal of setting follow up meetings with potential prospects for their account executives. And because the positive outcome of these activities were generally low, it was a numbers game.
However, with today’s ever-expanding sales and marketing technology landscape, sales development teams can now utilize new technology tools to perform smarter, better and faster. One of these critical new technologies is predictive analytics and big data.
In this webinar, you’ll hear from industry thought leaders and experts from SiriusDecisions, Sales Hacker and Mintigo to hear how predictive insights and intelligence can be used to give your SDR team an unfair advantage over your competition.
You will learn:
- SiriusDecision’s 8-Factor Model for Teleprospecting/SDRs
- Why predictive is critical for target optimization
- How insights from predictive can enable SDRs to have great conversations with prospects
- Effective strategies for teleprospecting
- Tips on how to utilize intelligence about the account to create engagement
Speakers:
- Kerry Cunningham, Sr. Research Director of Demand Creation Strategies at SiriusDecisions
- Max Altschuler, Founder & CEO of Sales Hacker
- Tony Yang, VP of Demand & Marketing Ops at Mintigo
Understand principles of fluids, fluid compartments and composition
Identify role of kidneys in fluid management
Establishing Target Weight
Understand consequences of fluid overload
Assessing and implementing successful fluid overload management practices according to guidelines
Intended Learning Outcomes:
Describe the physiology of human fluid dynamics.
Define Intravenous therapy.
List the aims of adult perioperative fluid therapy.
Recognize the commonly used fluid preparations.
Describe the properties and indications of widely used IV solutions.
Describe the side effects and precautions of widely used IV solutions.
Explain the (NICE) principles and protocols for intravenous fluid therapy.
Discuss the assessment and management of hydration and volume status of surgical patients.
Describe the type, rate, and volume of fluid administered to surgical patients.
Recognize the different types of venous access.
Explain the potential local complications of peripheral IV therapy.
Identify the universal equations used by nurses to calculate the IV flow rate and medication dosage.
This is a talk I gave to a group of biomedical science students on how to write a narrative statement for graduate professional programs. Go to https://painepodcast.com/2016/07/20/how-to-write-a-personal-statement/ to listen to the associated podcast.
UAB PA Program White Coat Ceremony Keynote SpeechKristopher Maday
This is the keynote presentation I give every year at our white coat ceremony. In it, I discuss the history of the white coat and what it stands for in the profession of medicine. I highlight various points with my favorite quotes from Sir William Osler.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
NVBDCP.pptx Nation vector borne disease control program
Update on Fluid Resuscitation
1. Fluid Resuscitation
From The Basics To Being A Resuscitationist
Kristopher R. Maday, MS, PA-C, CNSC
University of Alabama at Birmingham
Physician Assistant Program
Pegasus Emergency Group
2.
3. Objectives
• IV Access and types of IVF
• Fluid dynamics and physiology
• Criteria for assessing volume status and fluid
responsiveness
• How to become a Resuscitationist
5. Intravenous Access
• Peripheral IV
– Standard access
• 14-25 gauge
– Pros
• Quick, inexpensive
• Lower infection risk
– Cons
• Short term
– Need to rotate every 72-96 hr
• Blow out
Cheung E, et all. Canadian Family Physician. 2009;55:494-496.
6. Intravenous Access
• Central Venous Line
– Terminate within the thorax
– Indications
• Long term access
• High osmolar fluids, vasopressors
• Inaccessible peripheral access
– Cons
• More technically challenging
• Increased infection risk
• Iatrogenic complications
Cheung E, et all. Canadian Family Physician. 2009;55:494-496.
7. Intraosseous Access
• Inserted into tibia, sternum, or humerus
• Indications
– Unable to perform traditional peripheral IV
– Bridge to traditional line
• Cons
– Unable to infuse rapid volume
– Risk of compartment syndrome
– Fractures
Day MW. Critical Care Nurse. 2011;31(2):76-89.
8. Let’s Take You WAAAAAAY Back…….
• Poiseuille’s Law
– Resistance to flow is dependent on radius
and length of tube and viscosity of fluid
– R=(8ηL)/(πr
4
)
• A 2x increase in diameter will yield a 16x increase in flow
11. Normal Body Fluid Composition
• Total body water
– Gender differences
• Males - 60% of body weight
• Females – 50% of body weight
– Components
• Intracellular – 2/3 of total body water - 40% of body weight
• Extracellular – 1/3 of total body water - 20% of body weight
– Intravascular
» 20-25% of extracellular volume
» 5% of body weight
– Interstitial
» 75-80% of extracellular volume
» 15% of body weight
– Obese/elderly – decrease by 10%
• Total blood volume - 7% of body weight
Ch. 3. In: Schwartz’s Principles of Surgery. 9th ed. 2010
12. Fluid Movement
• Fluid movement is constant and is influenced by:
– Hydrostatic pressure
– Colloid osmotic pressure
– Membrane permeability
Ch. 49. In: Morgan and Mikhail’s Clinical Anesthesiology. 5th ed. 2013
13. Fluid Movement
• Hydrostatic pressure
– The mechanical force of water pushing against a
membrane. In the intravascular space, it is the pumping
action of the heart that generates this force.
– At the arterial end of the capillary, hydrostatic pressure
forces water, sodium and glucose across the membrane
into the interstitial space
Ch. 49. In: Morgan and Mikhail’s Clinical Anesthesiology. 5th ed. 2013
14. Fluid Movement
• Osmotic Pressure
– Movement of fluid between the ICF and ECF is primarily
a function of osmotic forces
• Plasma proteins pull water back into the vascular space at the
venous end of the capillary bed
– Measurement of solute concentration in serum is termed
osmolarity
• Serum osmolarity – 2(Na+) + glucose/18 + BUN/2.8
– Normal – 270-290 mOsmo/L
– Dehydrated - >290 mOsmo/L
– Fluid Overload - <270 mOsmo/L
Ch. 49. In: Morgan and Mikhail’s Clinical Anesthesiology. 5th ed. 2013
15. Fluid Movement
• Membrane permeability
– Transport of substances across the
cell membrane depends on the
substance to be transported
– Passive
• Transport does not require energy and
is accomplished by osmosis, diffusion,
or the force of hydrostatic pressure
– Active
• Transport requires the expenditure of
metabolic energy by the cell
– Larger and electrically charged particles
Ch. 49. In: Morgan and Mikhail’s Clinical Anesthesiology. 5th ed. 2013
Myburgh JA, et al. N Engl J Med. 2013;369:1243-51
16. Types of IV Fluids
• Crystalloids
– Hypertonic
– Isotonic
– Hypotonic
• Dextrose solutions
• Colloids
– Albumin
– Dextran
– Hetastarch
– Gelatins
17. Crystalloids
• Electrolyte solutions with small molecules that can
diffuse freely throughout the extracellular space
• Principle component is NaCl
– Most abundant solute in extracellular fluid
Predominant effect of volume resuscitation with
crystalloids in to expand interstitial volume, rather
than intravascular volume
3 types
– Hypertonic
– Isotonic
– Hypotonic
18. Crystalloids
• Isotonic
– 0.9% NaCl (normal saline, NS)
– Closer to physiologic norms
• Can produce metabolic acidosis
– Allows for larger volume to be infused for resuscitation
– Lactated Ringers (Ringer’s lactate, LR)
• Contains less sodium and chloride, more potassium, more
calcium
• Higher pH than NS
• Contains lactate which is converted to HCO3- by liver
Myburgh JA, et al. N Engl J Med. 2013;369:1243-51
19. Crystalloids
• Hypertonic
– 1.5%, 3%, 7%, 23.5% NaCl
– Solute concentration higher than the solute concentration
of the serum
• Infusion causes an increase in the solute concentration of the
serum, pulling fluid from the interstitial space to the vascular space
through osmosis
– Can be used to treat increasing ICP
Myburgh JA, et al. N Engl J Med. 2013;369:1243-51
20. Crystalloids
• Hypotonic
– 0.45% NaCl (1/2 NS), 0.225% NaCl (1/4 NS)
– Considerably lower osmolarity than serum
– Good for fluid maintenance and replacing free water
deficit
Myburgh JA, et al. N Engl J Med. 2013;369:1243-51
22. Dextrose Solutions
• Dextrose added to a crystalloid fluid
– D5, D10 in NS, 1/2NS, or water
• 1 gram of dextrose provides 3.4 kcal
• Benefits
– Combat protein catabolism by providing calories when
NPO
• D51/2 NS @ 125/hr x 24 hr = 510 kcal
• Disadvantages
– Hyperglycemia, hyponatremia, hypertonicity
23. Colloids
• More effective at increasing intravascular volume
because they contain large, poorly diffusible, solutes
that create an osmotic pressure to keep water in the
vascular space
– ***3 times more effective than crystalloids***
• Good for fluid resuscitation in patients with full
interstitial reserves
• 4 main types
– Albumin
– Hetastarch
– Dextran
– Gelatins
Mitra S, et al. Indian J Anaesth. 2009;53(5):592-607
Ch. 12. In: The ICU Book. 4th ed. 2013
24. Colloids
• Albumin solutions
– 5%, 25%, given in 250mL aliquots
– Blood product, so slight risk of
transfusion reaction
• Hydroxyethyl starches (HES)
– 6%, 500-1000mL, do not exceed
20mL/kg
– Chemically manufactured starch
polymer
– Inhibits factor VII and vWF and
impairs platelet aggregation
Mitra S, et al. Indian J Anaesth. 2009;53(5):592-607
• Dextrans
– 10% dextran-40, 6% dextran-70
– Glucose polymer
– Inhibits factor VII and vWF,
impairs platelet aggregation, and
increases fibrinolysis
– Can cause ARF (unknown)
• Gelatins
– 4% Succinylated, 3.5% Urea-
crosslinked, Oxypolygelatins
– Less reactions, uncommon in
US
27. Who Needs Resuscitation?
Initial Assessment and Resuscitation. In: Current Therapy of Trauma and Surgical Critical Care. 1st ed. 2008
• Labs
– Lactate
• Normal - < 2 mg/dL
– Base Deficit
• Normal – > -2
28. Predicting Fluid Responsiveness (Old and Busted)
• Central Venous Pressure
– No association between CVP and
circulating blood volume
– CVP does not predict fluid
responsiveness
• Pulmonary Capillary Wedge Pressure
– Risk > Benefit
• Jugular Venous Distension
– More accurate modalities
Marik PE. CHEST. 2008;134(1):172-178. Leier CV. Circ Heart Fail. 2010;3:175-177.
29. • Orthostatic Measurements
– Supine and Standing measurement of BP and HR
• Positive test
– Decrease in 1) systolic > 20mmHg or diastolic > 10mmHg and 2) increase
in pulse rate 10-25 bpm within 3 min
– > 1L blood loss needed for 97%
sensitivity and 98% specificity
Carlson JE. Southern Medical Journal. 1999;92(2):167-173.
Predicting Fluid Responsiveness (Old and Busted)
McGee S et al. JAMA. 1999;280(11):1022-1029
30. Predicting Fluid Responsiveness (New Hotness)
• Passive Leg Raise
– Increases venous return in patients who are preload
responsive
• Identifies patients on ascending portion of Starling Curve
Marik PE. Annals of Intensive Care. 2011. 1:1.
45o 45o
31. • IVC Distensibility
– Change in diameter of IVC between end-inspiration
(dMax) and end-expiration (dMin)
• dIVC Index – (dMax-dMin)/dMin
– > 18% change predicts fluid responsiveness with > 90% sensitivity and
specificity
Barbier C et al. Intensive Care Med. 2004;30:1740-1746
Predicting Fluid Responsiveness (New Hotness)
32. Barbier C et al. Intensive Care Med. 2004;30:1740-1746
33. • Stroke Volume Variation (SVV)
– Changes in SV during inspiration/expiration
– Normal <15%
Michard F. Anesthesiology. 2005;103:419-428
Predicting Fluid Responsiveness (New Hotness)
35. Endpoints of Resuscitation
• 3 main goals to achieve
– Restoration of adequate oxygen delivery
– Resolution of existing oxygen debt
– Elimination of anaerobic metabolites
• Traditional endpoints
– HR, BP, mental status, urine output
• Global endpoints
– Lactate, base deficit, ScvO2
Rady MY. Crit Care. 2005;9(2):170-176 Goodrich C. AACN Adv Crit Care. 2006;17(3):306-316
36. Endpoints of Resuscitation
• Lactate
– Metabolic byproduct of anaerobic metabolism
• Most sensitive marker of tissue perfusion
– Lactate clearance and mortality
• < 24 hours – 0%
• 24-48 hours – 25%
• > 48 hours – 86%
– Higher lactate and duration of hyperlactatemia
correlated with increased rates of MODS
Abramson D et al. J Trauma. 1993;35:584-589 Manikis P et al. Am J Emerg Med. 1995;13:619-622
37. Endpoints of Resuscitation
• Base Deficit
– Used as a lactate proxy
– Grades
• Mild (2-5 mmol/L)
• Moderate (6-14 mmol/L)
• Severe (> 14 mmol/L)
– Studies have shown:
• Elevated initial BD was associated with lower initial BP and
increased fluid requirement
• 2/3rd of patients with increasing BD had ongoing blood loss
• Increase in BD between ED and ICU had increased risk of
hemodynamic collapse, increased transfusion requirements,
coagulopathy, and mortality
Tisherman SA et al. J Trauma. 2004;57:898-912 Davis JW et al. J Trauma. 1988;44:1464-1467 Rixen D et al. Shock. 2001;15:83-89
38. Endpoints of Resuscitation
• Central Venous Oxygen Saturation (ScvO2)
– Proxy of mixed venous oxygen saturation (SvO2)
• Global indicator of the balance of O2 delivery and O2
consumption
– < 70% suggests tissue hypoperfusion
– Need CVL or PA catheter
Rivers E et al.N Eng J Med. 2001;345(19):1368-1377
Oxygen Delivery
DO2=Qx[1.39x(Hgb)(SaO2)+(0.003xPaO2)
40. Hemostatic Resuscitation
• Used in the acutely bleeding trauma patient
• Benefits
– Maintains circulating volume
– Limits IVF administration
• Uses blood products instead of crystalloids
– Limits ongoing hemorrhage
• Revolves around 2 principles
– Permissive hypotension
– Aggressive blood product use
41. Permissive Hypotension
• Balance of maintaining adequate perfusion, but
preventing exsanguination until surgical bleeding
can be controlled
– Target = MAP of 65 mmHg
• If MAP < 65, then resuscitate with IVF or products
• If MAP > 65, then check perfusion
– Good perfusion Masterful inactivity
– Poor perfusion Fentanyl
• Special considerations
– Non-hemorrhagic causes of hypotension, TBI
“Injection of a fluid that will increase blood pressure has dangers in itself…If the pressure is raised before the surgeon is ready to check any
bleeding that might take place, blood that is sorely needed may be lost” Cannon W. JAMA 1918;70:618-621
Dutton RP et al. J Trauma. 2002;52(6):1141-1146 Wiles MD. Anaesthesia. 2013;68(5):445-449
42. Massive Transfusion
• Roots in the military and started gaining civilian traction
in mid 2000s
• 2 principles
– Replace what is lost
– Prevent coagulopathy before it develops
• Multiple definitions of triggers
• Shoot for a 1:1:1 of blood products
– 1 unit PRBC – 335ml, Hct 55%
– 1 unit FFP – 275ml, 80% coagulation activity
– 1 unit Plt – 50ml, 3x1011
• Use hemostatic adjuncts
– Transexamic acid, Prothrombin Complex Concentrate
Richard Dutton, “Hemostatic Resuscitation”, EM Crit Conference Lecture, 2011
43. 57yo male with AMS, BP-82/50 (MAP-60), HR-114, RR-23, O2-89% on RA
IVC U/S shows dIVC 73%, Intubate, NGT placed
A-line and 18g PIV x 2 placed, FloTrac shows SVV 31% and CI 3.4, ABG shows BD -11, Lactate 4.2
2L LR bolus, Labs sent, Foley placed (~50cc)
SVV 16%, BD -10, BP-81/54 (MAP-62), HR-111, Lactate 4.0
R IJ CVL placed, ScvO2 59%, Hgb 7.4, INR 2.8, EtOH 321, BUN 63
4U PRBC, 4U FFP, 25mcg Fentanyl
SVV 11%, CI 3.2, BD -6, Lactate 2.8, Hgb 9.1, INR 2.4
BP-102/72 (MAP 81), HR-94, O2-98%
ScvO2
> 70%
< 70% SaO2
< 92%
O2
Intubate
> 92% CI
< 2.5
> 2.5
Hgb
> 8.0 < 8.0
Sedation Transfuse
Volume
Status
SVV < 15%
SVV > 15%
Pressors
Volume
Check
Perfusion
44. How to be a Resuscitationist
• Critically evaluate patients who may need volume
• Identify the need and type of access
• Select appropriate fluid and know the expected
physiologic changes
• Interpret endpoints of resuscitation
• Assess special populations for more aggressive
management
45. Questions, Comments, Concerns, Criticisms
Kristopher R. Maday, MS, PA-C, CNSC
UAB Physician Assistant Program
Pegasus Emergency Group
Email: maday@uab.edu
Twitter: @PA_Maday