1. Cardiac case base discussion
NE NC London Critical Care Network

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
Haemodynamically stable, tracheostomy on TM with speaking valve with 28% Oxygen

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 mls in the afternoon. Drop in Hb by 75 to 65.
How will you manage in ITU?
ABCD; Transfusion; Surgical review; CT ?angio
HR increased from 85 to 100, BP dropped from 110/70 to 100/65 mmHg

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.
Surgical intervention not possible at all due to condition of bowel which is fragile and lot of adhesions. It will be impossible to reach bleeding point without damaging bowel and causing further bleeding and complication

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?
Patient unstable now. HR 140/m; BP 70/40 ABG Hb 50; patient in distress and agitated.
Need to stabilise or scoop and run; active bleeding ? Likely arterial; how much to resucitate?
Aim for slight hypotension BP systolic mmHg. Massive haemorrhage protocol.
Need to go to RF for control of source of bleeding. As situation changed communication with receiving hospital- both ITU/anaesthetic and interventional radiology. 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.

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 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?