RECENT PRINCIPLES IN RESUSCITATING A BLEEDING PATIENT
Dr.Pradeep
TRAUMA OR GENERAL SURGICAL BLEED????
SURGERY IS A CONTROLLED FORM OF TRAUMA!!
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
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 Vs
DAMAGE CONTROL RESUSCITATION
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)
• 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–1;– platelets if platelet count < 50 × 109ml–1.
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
KEY POINTS IN PATHOPHYSIOLOGY
HAEMORRHAGE
REDUCED TISSUE PERFUSION
ACIDOSIS
REDUCES FUCTIONING OFCOAGULATION PROTEASES
ISCHAEMICENDOTHILIALCELLS ACTIVATEANTI-COAG.
COAGULOPATHY
UNDER PERFUSED MUSCLE BEDS AND GUT HYPOTHERMIA
The Deadly Triad PHSIOLOGICAL EXHAUSTION
RESUSCITATION MEASURES WORSEN THIS EFFECT!!!!
COAGULOPATHY
ACIDOSISHYOPTHERMIA
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
WHICH IS THE BEST RESUSCITATION METHOD??
ONE WHICH IS LESS HARMFUL!!!
• Treatment of Haemorrhage is SURGICAL CONTROL OF HAEMORRHAGE and not iv fluids.
DAMAGE CONTROLLED RESUSCITATION
• Aimed at halting or preventing the DEADLY TRIAD. While conventional methods tries to treat lethal triad of acidosis, hypothermia and coagulopathy
Coagulopathy of Trauma
The Deadly Triad PHSIOLOGICAL EXHAUSTION
COAGULOPATHY
ACIDOSISHYOPTHERMIA
LEVEL OF INTERVENTIONIN DCR TO HALT VISCIOUSCYCLE
It is assumed that the patient presents with coagulopathy
Why assumed?
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
Permissive hyoptension
• Keeping BP low enough to avoid Exsanguination but maintaining end organ perfusion– Judicial use of fluids– Avoid using vasoactive agents
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
MASSIVE TRANSFUSION GUIDELINES
• Identify the patient in need of Massive Transfusion(MT)Unstable patient or who received 1-2 PRBCs but
not respondingCrystalloid 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
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
What is the End Point for resuscitaion??
It is much easier to know when to start resuscitation than to know
when to stop!
End Points Of Resuscitation
• Traditional Parameters• Heart rate• Pulse • Urine output
• Gut and Muscle beds may be still underperfused – continues to produce inflammatory mediators – may cause reperfusion injury – OCCULT HYPOPERFUSION
Measures Perfusion of organs which are usually maintained till late stages of shock
What measures occult hypoperfusion??
Base deficit or serum lactate levelMixed venous oxygen saturation
Measurements for global hypoperfusionMeasures the resuscitation at cellular level
Points for taking back to ward
Damage control resuscitation needed only in severely injured/ill patients
Correction of coagulopathyPRBC : FFP : PLATELETS – 1:1:1 whenever
possibleDo not aim at restoring normal BPDo an ABG – Look for base deficit and
resuscitate the patient till it normalises.
Thank You