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