Perioperative Management & Monitoring of the Sick Patient

includingMassive Haemorrhage

Dr James F PeerlessOctober 2012

Objectives

Management of the sick patient– Two broad categories:

• The sick laparotomy

• The major bleed

The Sick Laparotomy

Emergency Laparotomy

• High risk of peri-operative complications• 1st National Audit from the Emergency Laparotomy

Network (BJA; June 2012)– Data collected September 2010 – April 2011– Highlighted huge variability in management

• Poor outcomes due to:– Inability to mount sufficient inflammatory response– Poor cardiac function– Inadequate DO2 and organ failure (poor perfusion,

sepsis)

Indications for Emergency Laparotomy

• Acute onset pain– Peritonitis

• Perforation• Ischaemic bowel

– Intestinal obstruction– Intra-abdominal collection/abscess

• Trauma– Organ damage, haemorrhage, perforations

• Haematemesis/melaena• Diagnostic

“Peri-operative” Management

• Starts pre-operatively!

Pre-Operative Assessment

• Time vs. optimisation– Will have to talk to surgeons…

• Airway & allergies• Examination

– Organs [dys]function– Fluid status

• Bloods• ABGs

– to assess degree of metabolic derangement and help determine post-operative destination

• Discussion with patient (and family)

Optimisation

• Time vs optimisation– Experience will dictate whether optimising the

patient prior to theatre is advantageous over taking the patient straight for surgery

– Again, requires communication with surgical team

Pre-operative Preparation

• Plan– Help– Induction– Access– Monitoring – awake or asleep– Analgesia– Pre-empt complications• E.g. noradrenaline ready

Monitoring

• IA BP monitoring• CVC line– Fluid status– ScvO2

• Consider Oe doppler/ other cardiac monitoring to help guide fluid/vasopressor therapy– Numbers may be highly inaccurate in the very sick

patient, but trends remain useful.

Induction

• Consider anaesthetising on table• Aspirate NG• Ensure good oxygenation prior to RSI– Beware low FRC

• Anticipate cardiovascular collapse• Choice of induction agent• Consider inotropes early (after correcting

circulating volume) so tissue perfusion is not jeopardized.

Peri-operative Mx

• Positioning and access to patient• Monitoring• Analgesia– Epidurals to be used with caution• Infection• Coagulopathy• Cardiovascular instability

• Temperature control

Post-operative Mx

• Post-operative care determined by peri-operative findings

• ABG analysis– Awake/asleep

• Acidaemia• Hypothermia• CV instability • Hypoxia

• MDT approach– e.g. chest physio

• Liaise early with HDU/ITU

Complications

• Paralytic ileus• Intra-abdominal

collections• Wound infection• Wound dehiscence• Pulmonary atelectasis• Delayed– Fistula– Adhesions– Hernias

Major Haemorrhage

[EKHT Protocol]

Activate MHP

Bleep WHH 8662/QEQM 6114/ KCH****State Specialty & Location

Request & Transfuse Pack 14 x O Rh D neg RBC (female) or 4 x O Rh D pos (Male)

4 x AB FFP(group specific will be issued where possible)

ABGTake blood samples and send to the lab.

(Crossmatch, FBC,U&E, Clotting Inc Fibrinogen)Inform lab staff of any known patient identifiers

Reassess ABCDEIf Haemorrhage continues

Patient acutely bleeding/collapses/ ongoing severe bleeding

eg 150mls/min. Clinical shock

SBP <90 Ph <7.35 HR > 100 BE <-2

Obvious signs of uncontrollable bleedingPoor responder to fluid resuscitation

Request & Transfuse Pack 24 x RBC, 4 x AB FFP & 1 x Platelet dose

(group specific will be issued where possible)Confirm to lab location of patient

Take blood samples and send to the lab (FBC, clotting inc fibrinogen)

& ABG

Aims for therapy:

Hb: 8-10 g/dlPlatelets >75x109/lPT& APTT (INR) < 1.5Fibrinogen > 1.0 g/lCa² > 1 mmol/lpH: 7.35-7.45BE: ± 2Tª > 36 °C Monitor for Hyperkalaemia

Request and transfuse 2 packs of Cryoprecipitate if Fibrinogen <1.0g/l

or <2.0g/l in Obstetric Haemorrhage

Stand Down – Notify lab - Return unused components – Complete documentation – Resume standard ordering practices

Consider 10mmols Calcium chloride over 10 mins

Prevent HypothermiaUse fluid warming device

Use warm air blanket

Continuous cardiac monitoring

Resuscitate ABCDE

Achieve Haemostasis

HAEMORRHAGE CONTROLDirect pressure/tourniquet techniques

Stabilise fracturesSurgical intervention

Interventional radiologyEndoscopic techniquesObstetric techniques

HAEMOSTATIC DRUGSTranexamic acid 1g bolus followed by

1g 8 hourly.Vit K and Prothrombin Complex Concentrate

( for patients on Warfarin)Other haemostatic agents to be discussed with

Consultant Haematologist

CELL SALVAGE TECHNIQUESTransfuse 1 x FFP every 250mls RBC

Transfuse 1x Platelet dose every 1000ml RBC

MAJOR HAEMORRHAGE PROTOCOL(MHP) FOR ADULTS

AVOIDHYPO

THER

MIA ACIDOSIS

COAGULOPATHY

Major Haemorrhage

• Areas where major haemorrhage occur:– Trauma– General/vascular– Obstetrics– G.I. haemorrhage– Paediatrics

Major Haemorrhage

• Early recognition of massive blood loss is vital if avoidance of hypovolaemic shock and its consequences are to be avoided

• Key element: effective communication between all staff involved in the provision and transportation of blood

• Urgent provision of blood for haemorrhage requires a rapid and focussed approach

Major Haemorrhage

• Clinician who recognises haemorrhage needs to seek the appropriate help:– Duty haematologist– Consultant surgeon– Consultant anaesthetist– Theatres– Critical care– Porters

Management

• ABCDE approach

• Stabilise as time allows whilst preparing for definitive treatment

Activate MHP

Bleep WHH 8662/QEQM 6114/ KCH****State Specialty & Location

Request & Transfuse Pack 14 x O Rh D neg RBC (female) or 4 x O Rh D pos (Male)

4 x AB FFP(group specific will be issued where possible)

ABGTake blood samples and send to the lab.

(Crossmatch, FBC,U&E, Clotting Inc Fibrinogen)Inform lab staff of any known patient identifiers

Reassess ABCDEIf Haemorrhage continues

Patient acutely bleeding/collapses/ ongoing severe bleeding

eg 150mls/min. Clinical shock

SBP <90 Ph <7.35 HR > 100 BE <-2

Obvious signs of uncontrollable bleedingPoor responder to fluid resuscitation

Request & Transfuse Pack 24 x RBC, 4 x AB FFP & 1 x Platelet dose

(group specific will be issued where possible)Confirm to lab location of patient

Take blood samples and send to the lab (FBC, clotting inc fibrinogen)

& ABG

Aims for therapy:

Hb: 8-10 g/dlPlatelets >75x109/lPT& APTT (INR) < 1.5Fibrinogen > 1.0 g/lCa² > 1 mmol/lpH: 7.35-7.45BE: ± 2Tª > 36 °C Monitor for Hyperkalaemia

Request and transfuse 2 packs of Cryoprecipitate if Fibrinogen <1.0g/l

or <2.0g/l in Obstetric Haemorrhage

Stand Down – Notify lab - Return unused components – Complete documentation – Resume standard ordering practices

Consider 10mmols Calcium chloride over 10 mins

Prevent HypothermiaUse fluid warming device

Use warm air blanket

Continuous cardiac monitoring

Resuscitate ABCDE

Achieve Haemostasis

HAEMORRHAGE CONTROLDirect pressure/tourniquet techniques

Stabilise fracturesSurgical intervention

Interventional radiologyEndoscopic techniquesObstetric techniques

HAEMOSTATIC DRUGSTranexamic acid 1g bolus followed by

1g 8 hourly.Vit K and Prothrombin Complex Concentrate

( for patients on Warfarin)Other haemostatic agents to be discussed with

Consultant Haematologist

CELL SALVAGE TECHNIQUESTransfuse 1 x FFP every 250mls RBC

Transfuse 1x Platelet dose every 1000ml RBC

MAJOR HAEMORRHAGE PROTOCOL(MHP) FOR ADULTS

AVOIDHYPO

THER

MIA ACIDOSIS

COAGULOPATHY

Airway & Breathing

• Ensure patent airway and is breathing adequately

• Ensure adequate oxygenation• Monitor SpO2• Give High flow Oxygen (Mask with reservoir,

15L/min) if not intubated and ventilated.

Circulation• Permissive hypotension until haemostasis achieved (limit sys to 90)

– Then resuscitate to normal haemodynamic values– Not appropriate for head injury patients (MAP >70)

• Limit crystalloid use• Avoid vasoconstrictors• Tranexamic acid• Normocalcaemia – give calcium• Use BE to guide fluid resuscitation;

maintain pH > 7.2• Avoid hypothermia

– All fluids should be warmed– Used warming blankets

AVOID

HYPO

THER

MIA ACIDOSIS

COAGULOPATHY

Transfusion goals

• Hb 8-10g/dL (>10g/dl if actively bleeding)• Fibrinogen >1.0g/L• Platelets >75 x109/L• PT & APTT: aim for INR <1.5

Activate MHP

Bleep WHH 8662/QEQM 6114/ KCH****State Specialty & Location

Request & Transfuse Pack 1Red cells (O neg) 40ml/kgFFP (AB pos) 20ml/kg

(group specific will be issued where possible)

ABGTake blood samples and send to the lab.

(Crossmatch, FBC,U&E, Clotting Inc Fibrinogen)Inform lab staff of any known patient identifiers

Reassess ABCDEIf Haemorrhage continues

Ongoing severe bleeding (overt/covert) and received 20ml/kg of red cells or 40ml/kg of any fluid for resuscitation in preceding hour.

Signs of hypovolaemic shock and/or coagulopathy

Request & Transfuse Pack 2Red cells (O neg) 40ml/kgFFP (AB pos) 20ml/kgPlatelets 10ml/kg

(group specific will be issued where possible)Confirm to lab location of patient

Take blood samples and send to the lab (FBC, clotting inc fibrinogen)

& ABG

Aims for therapy:

Hb: 8-10 g/dlPlatelets >75x109/lPT& APTT (INR) < 1.5Fibrinogen > 1.0 g/lIonised Ca (ABG > 1 mmol/l pH: 7.35-7.45BE: ± 2Tª > 36 °C Monitor for Hyperkalaemia

Request and transfuseCryoprecipitate 10ml/kg

if Fibrinogen <1.0g/l

Stand Down – Notify lab - Return unused components – Complete documentation – Resume standard ordering practices

Consider 0.2mls/kg Calcium chloride (max 10mls) over 30 mins

Prevent HypothermiaUse fluid warming device

Use warm air blanket

Continuous cardiac monitoring

Resuscitate ABCDE

Achieve Haemostasis

HAEMORRHAGE CONTROLDirect pressure/tourniquet techniques

Stabilise fracturesSurgical intervention

Interventional radiologyEndoscopic techniquesObstetric techniques

MAJOR HAEMORRHAGE PROTOCOL(MHP) FOR CHILDREN

AVOIDHYPO

THER

MIA ACIDOSIS

COAGULOPATHY

Further Cryoprecipitate (10ml/kg) if fibrinogen <1g/l

Summary

• Recognition of a sick patient is key• Ensure good communication with surgeon• Balance patient optimization with early

surgery• Try to anticipate issues before they occur.

The End