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Cardiac Case Based Discussion

Cardiac Case Based Discussion. Case summary. 56 year old gentlemen admitted 35 days ago with pancreatitis and sepsis. Since been intubated and ventilated. Laparostomy for abdominal compartment and ischaemic bowel during second week in ITU.

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Cardiac Case Based Discussion

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  1. Cardiac Case Based Discussion

  2. Case summary • 56 year old gentlemen admitted 35 days ago with pancreatitis and sepsis. • Since been intubated and ventilated. • Laparostomy for abdominal compartment and ischaemic bowel during second week in ITU. • Stoma working but still abdominal wall open and vac dressing. • Absorbing feed and able to talk. • Kidney function recovering from initial AKI. • Now passing good amount of urine. • Overall improvement since last 1 week

  3. Current Situation • In a DGH with no emergency intervention radiology or vascular service out of hours. • Had episode of fresh blood coming out of laparostomy wound- about 250-300 mls in the afternoon. Drop in Hb by 75 to 65. • How will you manage in ITU?

  4. Further plans • Reviewed by surgeon- CT angio- no active bleeding point as bleeding stopped by that time. • However, likely bleeding from gastro- duodenal artery and surgical intervention not possible. • No bed in ITU RF currently but will be available later in the evening for planned transfer. • Plan to transfer to RFL if further bleed for interventional radiology urgently. Otherwise SATs ambulance booked for 8pm.

  5. Change in situation • Just as SATs ambulance crew in ITU and preparing the patient for transfer to trolley- A massive bleed noticed coming out of laparostomy. • What will you do?

  6. Emergency! • Patient unstable now. HR 140/m; BP 70/40 ABG Hb 50; patient in distress and agitated. • Scoop and run Vs resuscitate/stablise and transfer? • Aim of resuscitation? • Normal BP vs permissive hypotension?

  7. Management and communication • Aim for slight hypotension BP systolic 80-90 mmHg. • Massive haemorrhage protocol. • Initial resuscitation followed by transfer with continued resuscitation. • Need to go to RF for control of source of bleeding – not possible to deal locally. • As situation changed communication with receiving hospital- both ITU/anaesthetic and interventional radiology.

  8. Management and communication • Direct transfer to intervention radiology suite with team scrubbed and ready to start procedure. • Intervention radiology consultant informed and on his way to hospital for procedure. • Anaesthetic/ITU team ready to take over in intervention radiology. • Transfusion team at both hospital- blood form faxed so that blood can be used and tracked. • How much blood for ambulance and immediately after at receiving hospital?

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