Haemorrhagic shock assessment management and colloid

Try to focus only Assessment and
Management of haemorrhagic shock
It was my first presentation during course of anaesthesiology

1. Chairperson Prof. Dr. Abdul Kader Principal and Professor of Anaesthesiology Mymensingh Medical College,Mymensingh Speaker Dr. Amimul Ahsan Rafi DA Student Session: July [2023-25] MMCH

2. Typical blood volume Infant – 90ml/kg Child – 80ml/kg Adult male 70ml/kg Adult female 60ml/kg In operating theatre Suction apparatus Gauze [10 X10cm] - Fully soaked 10ml Gauze [30 X 30 cm] – Fully soaked 100ml Blood clot – Size of clenched fist roughly equal to 500ml Swelling in close fracture Moderate swelling – Tibia 500- 1000 ml Femur 500-2000 ml

3. Classification of Haemorrhagic shock Class 1 Class 2 Class 3 Class 4 Blood volume lost As percentage < 15% 15 to 30% 30 to 40 % >40% Pulse >100 >100 >120 >140 Blood pressure Normal Normal Decrease More decrease Pulse pressure Normal or Decrease Decrease More decrease More Decrease Capillary refill time <2 sec 2 to 3 sec 3 to 4 sec >5 sec Respiratory rate 14-20 20-30 30-40 >40 Urine output ml/hour 30 or more 20 to 30 5 to 10 Negligible

4. Shock is a progressive disorder, If uncorrected leads to death Phase 1 : An initial non progressive phase Phase 2 : A progressive stage characterized by hypoperfusion and onset of worsening circulatory and metabolic imbalance Phase 3: An irreversible stage cellular and tissue injuries are so severe That even if haemodynamic defects are corrected survival is not possible

5. Minimum ■ Electrocardiogram ■ Pulse oximetry ■ Blood pressure ■ Urine output Additional modalities ■ Central venous pressure ■ Invasive blood pressure ■ Cardiac output ■ Base deficit and serum lactate This Photo by Unknown Author is licensed under CC BY-NC-ND

6. It is important to recognize the limitations of the clinical examination and to recognize patients who are in shock despite the absence of classic signs Capillary refill time Tachycardia Tachycardia Patients who are on β-blockers or who have implanted pacemakers are unable to mount a tachycardia. Blood pressure Children and fit young adults are able to maintain blood pressure until the final stages of shock by dramatic increases in stroke volume and peripheral vasoconstriction. The diagnosis of shock may be difficult unless one is alert to these pitfalls.

7. Identify haemorrhage Immediate resuscitative maneuvers Direct pressure over the site external haemorrhage Airway and breathing should be assessed and controlled as necessary Large bore I/V access Identify the site of haemorrhage Haemorrhage control must be achieved rapidly to prevent the patient entering the triad of Coagulopathy – Acidosis – Hypothermia CONTINUE

8. Management of Haemorrhagic shock Avoid unnecessary things Investigations Prolonged attempts to volume resuscitate the patient before surgery which will result further hypothermia and clotting factor dilution until the bleeding is stopped Damage control surgery 1.Arrest haemorrhage 2.Control sepsis 3.Protect from further injury 4.Nothing else continue……..

9. Management of Haemorrhagic shock Once haemorrhage is controlled patient should be aggressively resuscitated and warmed and coagulopathy corrected Correct heart rate & rhythm by – Atropine Sympathomimetics Pacing Antidysrhythmic Improve myocardial contractility & SVR Maximize oxygen intake by -  FIO2 - Hb%

10. Attention should be paid to fluid responsiveness blood transfusion should be avoided if possible The indications for blood transfusion are as follows: Acute blood loss, to replace circulating volume and maintain oxygen delivery [ In case of adult >20% ,Children>10% ] Perioperative anaemia, to ensure adequate oxygen delivery during the perioperative phase Symptomatic chronic anaemia without haemorrhage or impending surgery.

11. Pre-medication with atropine IV Vomiting – with anti emetic Shocked patients requires less anesthetic & relaxants Induction with low dose Thiopentone or ketamine Light anesthesia with IPPV is the methods of choice O 2 high concentration continue

12. Volatiles anesthetic with caution Aim of anesthesia is to preserve blood flow to heart, brain & kidneys Inotropic support should be ready Regional anesthesia may be satisfactory if BP can be maintained

13. Cardiac index (CI) = 3 L/min./m2 Systemic O2 delivery (DO2) >500ml/min./m2 Systemic O2 uptake (VO2) >100ml/min./m2 Arterial lactate level < 2mmol/L or Base deficit > - 2mmol/L

14. Colloid is defined as a high molecular weight (MW) substance that largely remains in the intravascular compartment, thereby generating an oncotic pressure All are derived from either plasma proteins or synthetic glucose polymers and are supplied in isotonic electrolyte solutions. Example Dextran Albumin Gelatin Hydroxyethyl starch

15. Generally accepted indications for colloids include Fluid resuscitation in patients with severe intravascular fluid deficits (eg, hemorrhagic shock) prior to the arrival of blood for transfusion Fluid resuscitation in the presence of severe hypoalbuminemia or conditions associated with large protein loss Some clinicians suggest that during anesthesia, maintenance (and other) fluid requirements be provided with crystalloid solutions and blood loss be replaced on a milliliter-per-milliliter basis with colloid solutions

16. Colloid Molecular weight Duration of effect Advantages Drawback Albumin 25% Albumin 5% 69 69 16 hours 16 hours More useful in protein loss Like peritonitis, Liver failure , Burns, Protein losing enteropathies Quite expensive Allergic reaction Dextran 70 150 40 70000 150000 40000 6 hours Low molecular weight dextran Improves microcirculation Therefore useful for microsurgery Interfere with Blood grouping, Platelate transfusion Severe anaphylaxis ARDS Block renal tubule Gelatin 3.5% 30000 2 hours Expand plasma effectively Severe anaphylactic reaction Hydroxyethyl Sterch 6%, 10% 4 hours Expand plasma effectively High dose interfere With clotting and renal dysfunction

17. Crystalloids not only replace intravascular volume but they also replace extravascular volume (and cellular hydration depends on extravascular volume) Crystalloids do not interfere with clotting while all colloids in high doses can interfere with clotting. Colloids can cause renal dysfunction Colloids are expensive There is risk of anaphylactic reaction with colloids.

18. Haemorrhage controlled must be achieved rapidly to prevent patient entering the triad of coagulopathy , Acidosis , Hypothermia There is no ideal resuscitation fluid and it is more important to understand how and when to administer them Any shock should be assumed to be hypovolemic until proved otherwise and similarly hypovolemia should be assumed to be due to haemorrhage

19. References Bailey & Love's Short Practice of Surgery, 27th Edition Morgan & Mikhail's Clinical Anesthesiology Book by David C. Mackey, John D. Wasnick , and John F. Butterworth Short Textbook of Anesthesia - Ajay Yadav The American College of Surgeons | ACS Previuos seminar Lecture and classes of respected teachers