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Premium member Presentation Transcript General anaesthesia for intensive care patient with massive GI haemorrhage : General anaesthesia for intensive care patient with massive GI haemorrhage 14 yr old boy Referral from Mawlamying Hospital Diagnosed as Haematamesis and Malena due to DHF with DS$ Slide 2: c/o High Fever for 6 days associated with chill & rigor Fever Day 3, malena stool + No generalized bleeding such as gum bleeding, epistasis, petichae or purpuric spots, heam arthrosis, etc. Whole blood 11 bottles were given within 24 hr ( 9 pm/11-6-09 to 12-6-09) Day 6 – arrived at ward 17+18 of YGH Malena still passing Total 16 bottles of whole blood was given at MLM Hospital Slide 3: No past history of malaria No family history of haematological diseases Hess test positive Paracheck (ICT malaria) positive for P. falcipram Slide 4: In MLM Hospital, Inj Augmentin 250 mg 8H Inj Metro 200 mg 8H Inj Azeptil 1 amp 8H Quinine drip 150mg 8H Inj Artesunate (8 doses given) Inj pantocid 40mg 12H Inj dexa Slide 5: On admission to ICU (15-6-09) GCS 15/15 Marked pallor++++ , No Jaundice Heart I + II + 0 Lungs – normal VBS(+) BP 110/70 mmHg PR 160/min Abdomen soft, BS(+) Liver 3 cm PCV 36 RBS 152mg% Slide 6: Intubation done by Dr AMM indication : reduced GCS and SpO2 Ryle’s tube and urinary catheter also inserted VT 350ml, f 12, FiO2 60% SIMV Slide 7: Fresh blood 2 units urgent Whole blood 3 units urgent DS (1) NS (2) RL (1) Haemaccel (1) Dopamine 200mg in NS 50ml (2ml/hr) (5ug/kg/min) Inj Fortum 1g 12 H Iv omez 40mg 12 H Iv Azeptil 1amp 12 H Inj Artesunate 1 amp 12 H x 1 day Slide 8: 16-6-09 CVC insertion and femoral cutdown done by our Prof. Dr Tin Myint ABG ???? G6PD - not deficient SGPT 301 U/L SGOT 932 U/L Urea 10.7, Na 135, K+ 2.6, Cl- 91 HBs Ag negative AntiHCV negative Retro negative Slide 9: Inj artesunate 1 amp od x 4 days Iv hydrocortisone 200 mg stat & 6 H Iv zarnocin 200mg 12 H Po clindamycin 150 mg tds Iv K stat 1 amp 12 H Fresh blood 9 units NS 50 ml with lasix 20mg (2ml/hr) 500 DW octeride 600 ug (6 DPM) + 50 ug stat FFP 6 units 10% DW, NS, DS Slide 10: 17-6-09 CP Hb 9.3 g/dl WBC 7.1 plt 98? PT /INR 15.2/1.76 Endoscopy done - can’t be inserted beyond the 1st part of duodenum NAD 4:00 pm Ventilator off O2 inhalation - Catether in ETT 3L/min SpO2 92% Slide 11: Iv Omez 40 mg 6 H Iv Azeptil 250mg 6 H FFP 6 units Fresh blood 5 units Packed cell 2 uints 10% DW+ KCL 1.5 g (8 DPM) Octeride 600 ug in 500 DW (6 DPM) Slide 12: 18-6-09 Fresh blood 9 units FFP 3 units Packed cells 4 units 10% DW+ KCl 1.5 g DW + Octeride 600ug (6 DPM) NS + Dopamine 400mg ( 2ml/hr) Slide 13: 19-6-09 (Day of Operation) GCS 15/15 BP 110/70 mmHg PR 86/min RR 25/min CP Hb 9.3 g/dl WBC 7.1 plt 98,000/ul PT /INR 15.2/1.76 Transportation Accompanied by anaesthesiologist Dr AMM and two staff of ICU Slide 14: Monitoring CVS - NIBP - HR - ECG - CVP Respiration SpO2, multigas analyzer including Capnometer RR Renal Urine output Slide 15: IV line : 3 lines - the central line - Dopamine infusion 5ug/kg/min - Blood and crystaloid giving line FFP 2 units just prior to operation Induction Iv fentanyl 50 ug Iv ketamine 50mg Muscle relaxation iv atracurium 20mg Maintenance with Isoflurane 0.3 % + O2 1 L/min and N2O 2 L/min Slide 16: Ventilator setting VT 350ml, f 12, I:E 1:2, PEEP 0, Fluid challenge done according to CVP. All vital signs were being stable during intraoperative period. Slide 17: Indication for surgery : uncontrolled H & M due to GI haemorrhage Upper midline incision Slide 18: Findings: Clear ascities fluid 700ml Small and large intestine were pale Blood seen inside the lumen of intestine No pumping vessels in the mucosa and just congestion (mucosal erosion) at the 1st part of duodenum Mesenteric L/N enlargement (+) No inflammation and detectable lesion in small and large intestine Slide 19: Surgery : Duodenostomy and suturing of mucosal erosion at the first part of duodenum Duration : 9:30 AM to 11:30 AM (2 hr) Biopsy of mesenteric L/N : reactive follicular hyperplasia of the mesenteric L/N Slide 20: Fluid given Blood 600 ml Haemaccel 500 ml Crystaloid 1000 ml Total 2100 ml Fluid loss Deficit 420 ml Blood 250 ml Ascities fluid 700 ml Urine 100 ml Ongoing loss 360 ml Total 1830 ml Balance +270 ml Slide 21: Muscle relaxant -not reversed and PO care at ICU Manually ventilated with ambu bag + O2 during trasportation to ICU accompanied by anaesthesiologist Dr AMM, Dr KMHA and 2 staff of ICU Postop: SIMV VT 300ml, f 12, FiO2 60% Abdominal drain 380 cc FFP 2 units Fresh blood 3 units NS 50 ml + dopamine 400mg (1ml/hr) ....Off Slide 22: 20-6-09 (Postop 1st day) Iv dexa 8mg 9:36 am - Ventilator off and extubation done by Dr WWOM O2 inhalation 3L/min nasal prongs Abdominal drain 150 cc Slide 23: 21-6-09 (Postop 2nd day) Abdominal drain 250 cc No more haematamesis nor malena Causes of Haematamesis and Malena : Causes of Haematamesis and Malena Chronic peptic ulcer 65% Acute peptic ulcer and Multiple erosion 30% Oesophagial varices Carcinoma of the stomach Mallory-Weiss syndrome Peptic ulcer in Meckel’s diverticulum 5% Purpura Haemophilia Pernicious and other anaemia Ehlers-Danlos syndrome Management of Haematamesis and Malena : Management of Haematamesis and Malena Conservative Medical management Blood transfusion Morphine H2 receptor antagonists and proton pump inhibitor Diet Prevention of pulmonary complications Operative management A decision should be made within 48 hr of start of bleeding, particularly if the patient rebleeds. When the operation is delayed beyond that time, the mortality rises sharply. Screening test for Coagulation Disorder : Screening test for Coagulation Disorder FBC anaemia, thrombocytopenia PT Extrinsic pathway of coagulation cascade deficiency of factor I, II, V, VII, X Treatment with warfarin aPTT Intrinsic pathway of coagulation cascade deficiency of factor VIII, IX Treatment with heparin Fibrinogen concentration Hypofibrinogenaemia or dysfibrinogenaemia Treatment with heparin Massive Blood Transfusion : Massive Blood Transfusion Replacement of > 1 blood volume in 24 hr Transfusion of > 6 units of blood in 24 hr Transfusion of > 50% of blood volume in 24 hr Replacement of blood at >1ml/kg/min Target Value for Massive Haemorrhage : Target Value for Massive Haemorrhage Hb 7-8 g/dl Platelet count > 50,000/ul PT < 1.5 times control PTT < 1.5 times control Fibrinogen > 1.0 g/dl Complications of Massive Blood Transfusion : Complications of Massive Blood Transfusion Hypothermia Fluid overload Coagulopathy Hypocalcaemia Potassium Acid base inbalance Blood incompatibility Transfusion related acute lung injury (TRALI) Transmission of infectious diseases Some Facts on Blood and Blood Products : Some Facts on Blood and Blood Products Whole blood and packed cell 1 unit of whole blood / 250 ml of packed cell---increase Hct by 3 % or Hb by 1 g/dl Slide 32: FFP Indications for FFP Microvascular bleeding with elevated PT (INR)> 1.5 times normal elevated PTT > 1.5 times normal Urgent reversal of coagulation or known coagulation factor deficiency Pseudocholine esterase deficiency Initial therapeutic dose 10-15 ml/kg (3-5 units in 60 kg adult) Slide 33: Platelet count (normal 150,000-450,000/ul) < 20,000 - spontaneous bleeding 50,000 - minimal level for surgery or invasive procedure >100,000 - safe for surgery and regional anaesthesia Therapeutic dose - 1unit of platelet concentrate per 10 kg body weight Each unit raises the platelet count by 5,000-10,000/ul (10,000-20,000/ul) in the adult patient Thank you. : Thank you. 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