Dr James F Peerless October 2012

Objectives Management of the sick patient – Two broad categories: The sick laparotomy The major bleed

Emergency Laparotomy High risk of peri-operative complications 1 st 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 DO 2 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! Mx Pre- operative Induction Peri- operative Post- operative

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 – ScvO 2 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

[EKHT Protocol]

Activate MHP Bleep WHH 8662/QEQM 6114/ KCH**** State Specialty & Location Request & Transfuse Pack 1 4 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) ABG Take blood samples and send to the lab. (Crossmatch, FBC,U&E, Clotting Inc Fibrinogen) Inform lab staff of any known patient identifiers Reassess ABCDE If Haemorrhage continues Patient acutely bleeding/collapses/ ongoing severe bleeding eg 150mls/min. Clinical shock SBP 100 BE <-2 Obvious signs of uncontrollable bleeding Poor responder to fluid resuscitation Request & Transfuse Pack 2 4 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/dl Platelets >75x10 9 /l PT& APTT (INR) < 1.5 Fibrinogen > 1.0 g/l Ca² > 1 mmol/l pH: BE: ± 2 Tª > 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 Hypothermia Use fluid warming device Use warm air blanket Continuous cardiac monitoring Resuscitate ABCDE Achieve Haemostasis HAEMORRHAGE CONTROL Direct pressure/tourniquet techniques Stabilise fractures Surgical intervention Interventional radiology Endoscopic techniques Obstetric techniques HAEMOSTATIC DRUGS Tranexamic 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 TECHNIQUES Transfuse 1 x FFP every 250mls RBC Transfuse 1x Platelet dose every 1000ml RBC MAJOR HAEMORRHAGE PROTOCOL(MHP) FOR ADULTS AVOID HYPOTHERMIA 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 1 4 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) ABG Take blood samples and send to the lab. (Crossmatch, FBC,U&E, Clotting Inc Fibrinogen) Inform lab staff of any known patient identifiers Reassess ABCDE If Haemorrhage continues Patient acutely bleeding/collapses/ ongoing severe bleeding eg 150mls/min. Clinical shock SBP 100 BE <-2 Obvious signs of uncontrollable bleeding Poor responder to fluid resuscitation Request & Transfuse Pack 2 4 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/dl Platelets >75x10 9 /l PT& APTT (INR) < 1.5 Fibrinogen > 1.0 g/l Ca² > 1 mmol/l pH: BE: ± 2 Tª > 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 Hypothermia Use fluid warming device Use warm air blanket Continuous cardiac monitoring Resuscitate ABCDE Achieve Haemostasis HAEMORRHAGE CONTROL Direct pressure/tourniquet techniques Stabilise fractures Surgical intervention Interventional radiology Endoscopic techniques Obstetric techniques HAEMOSTATIC DRUGS Tranexamic 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 TECHNIQUES Transfuse 1 x FFP every 250mls RBC Transfuse 1x Platelet dose every 1000ml RBC MAJOR HAEMORRHAGE PROTOCOL(MHP) FOR ADULTS AVOID HYPOTHERMIA 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 HYPOTHERMIA ACIDOSIS COAGULOPATHY

Transfusion goals Hb 8-10g/dL (>10g/dl if actively bleeding) Fibrinogen >1.0g/L Platelets >75 x10 9 /L PT & APTT: aim for INR <1.5

Activate MHP Bleep WHH 8662/QEQM 6114/ KCH**** State Specialty & Location Request & Transfuse Pack 1 Red cells (O neg) 40ml/kg FFP (AB pos) 20ml/kg (group specific will be issued where possible) ABG Take blood samples and send to the lab. (Crossmatch, FBC,U&E, Clotting Inc Fibrinogen) Inform lab staff of any known patient identifiers Reassess ABCDE If 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 2 Red cells (O neg) 40ml/kg FFP (AB pos) 20ml/kg Platelets 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/dl Platelets >75x10 9 /l PT& APTT (INR) < 1.5 Fibrinogen > 1.0 g/l Ionised Ca (ABG > 1 mmol/l pH: BE: ± 2 Tª > 36 °C Monitor for Hyperkalaemia Request and transfuse Cryoprecipitate 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 Hypothermia Use fluid warming device Use warm air blanket Continuous cardiac monitoring Resuscitate ABCDE Achieve Haemostasis HAEMORRHAGE CONTROL Direct pressure/tourniquet techniques Stabilise fractures Surgical intervention Interventional radiology Endoscopic techniques Obstetric techniques MAJOR HAEMORRHAGE PROTOCOL(MHP) FOR CHILDREN AVOID HYPOTHERMIA 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