1. AN ANESTHETIST PERSPECTIVE Dr.Senthil Kumar Post Graduate Dr.Anand Associate Professor Dr.Yachendra Assistant Professor DEPT. OF ANESTHESIOLOGY MEENAKSHI MEDICAL COLLEGE A ND RESEARCH INSTITUTE

2. HISTORY 24 YEAR OLD PRIMI 32 WEEKS GESTATIONAL AGE BOOKED CASE NO COMORBID ILLNESSES ADMITTED WITH ABDOMINAL PAIN AND FEATURES OF U.T.I.

3. HISTORY …. PRECIPITATE LABOUR DELIVERED A PRETERM LIVE MALE CHILD VIA NATURALIS WEIGHING 1.8 Kg POST PARTUM BLEEDING NOTICED WITH VAGINAL AND FORNICIAL TEARS POSTED FOR EXPLORATION AND SUTURING UNDER ANESTHESIA

4. PRE OP INVESTIGATIONS Hb : 10 gm% P.C.V. : 32% BLOOD UREA : 12 mg/dl SERUM CREATININE : 0.8 mg/dl RANDOM BLOOD SUGAR : 134 mg/dl BLEEDING TIME : 1 min 35 sec CLOTTING TIME : 3 min 10 sec BLOOD GROUP : A +VE

5. MANAGEMENT

6. PREOPERATIVE ASSESMENT CLINICAL EXAMINATION:- - CONCIOUS, ORIENTED - PERIPHERIES COLD, FEEBLE PULSE - PALLOR : ++++ - HEART RATE : 136/min - BLOOD PRESSURE : 96/60mmHg - SPO 2 : 100% (O 2 6 l/min) PROFUSE BLEEDING PER VAGINUM

7. PREPARATION & OPTIMISATION I.V. ACCESS : 14 G VENFLON LEFT ELBOW 18 G VENFLON RIGHT WRIST MONITORS : E.C.G., N.I.B.P., SPO 2 FLUID RESUSCITATION : - 6% HETA STARCH 500 ML - BLOOD MOBILISED ANESTHETIC PLAN : I.V. SEDATION

8. 1st exploration Under IV sedation – 1 hour INPUT : - CRYSTALLOIDS : 2500 ml - COLLOIDS : 500 ml - WHOLE BLOOD : 3 UNITS OUTPUT : - BLOOD LOSS : 1.5 – 2 lts - URINE : 50 ml

9. Shifted to Surgical ICU VITALS END OP : - CONCIOUS, ORIENTED - H.R. : 112/ min - B.P. : 116/68 mm Hg - SPO 2 : 1OO% WITHIN 20 MIN : - HYPOTENSION 80/40 mm Hg - REBLEEDING PER VAGINUM SHIFTED TO O.T. FOR RE-EXPLORATION

10. 2 nd Exploration GENERAL ANESTHESIA : - RAPID SEQUENCE INTUBATION - INJ. THIOPENTONE: 125mg I.V. - INJ. KETAMINE : 50mg I.V. - INJ. SCOLINE : 75mg I.V. ENDOTRACHEAL INTUBATION : 7.0 mm CUFFED TUBE N 2 O/0 2 : SEVOFLURANE : CONTROLLED VENTILATON WITH VECURONIUM RIGHT I.J.V. CANNULATED

11. SURGERY RE-EXPLORATION AND SUTURING OF VAGINAL TEARS ULTRASONOGRAM WITH NO EVIDENCE OF INTRA ABDOMINAL COLLECTION EXPLORATORY LAPAROTOMY UTERINE ARTERY LIGATION HYSTERECTOMY

12. Intra op……. ANESTHESIA TIME : 8 HOURS INPUT : - CRYSTALLOIDS : 6000 ml - COLLOIDS : 500 ml - WHOLE BLOOD : 10 UNITS OUTPUT : - BLOOD LOSS : 4 lts - URINE : 150 ml

13. POST OPERATIVE MANAGEMENT ELECTIVE VENTILATION INFUSION : - INJ. MORPHINE 2mg/hr - INJ. PANCURONIUM 2mg/hr PIPERACILLIN WITH TAZOBACTAM NEBULISATION SUPPORTVE MEASURES I.V.FLUIDS TITRATED TO MAINTAIN URINE OUTPUT &CVP monitoring

14. WEANED AND EXTUBATED AFTER 36 HOURS POST EXTUBATION MAINTAINING SATURATION URINE OUTPUT MAINTAINED THROUGHT POST OPERATIVE PERIOD LOW GRADE PYREXIA ORALS STARTED ON THE 4 TH P.O.D.

15. POST OPERATIVE COMPLICATIONS DUE TO MASSIVE BLOOD T X : -DILUTIONAL THROMBOCYTOPENIA - COAGULATION ABNORMALITIES RESPIRATORY COMPLICATIONS : -PNEUMONITIS

16. THROMBOCYTOPENIA P.O.D.PLATELET COUNT PLATELET CONCENTRATE T X 052,0004 177,000 40,0004 284,000 31,44,000 42,01,000

17. COAGULATION ABNORMALITY NO SIGNS OF ANY SPONTANEOUS BLEEDING COAGULATION PARAMETERS NORMAL THROUGHOUT POST OPERATIVE PERIOD LIVER FUNCTION TESTS NORMAL REQUIRED FURTHER R.B.C. TRANSFUSION FOR MAINTAINING HAEMOGLOBIN LEVELS

18. P.O.D.Hb Gm% WHOLE BLOOD T X F.F.P. T X 08.825 17.214 28.9 39.6 410.6

19. TOTAL BLOOD COMPONENTS TRANSFUSED WHOLE BLOOD : 16 FRESH FROZEN PLASMA : 9 PLATELET CONCENTRATE : 8 Total = 33

20. RESPIRATORY COMPLICATION DESATURATON ON 3 rd post op ROOM AIR SPO 2 : 87 – 90% REQUIRING HIGH FiO 2 – 60% R.S. : EXTENSIVE CREPTS WITH WHEEZE CXR : FEATURES OF RIGHT MID AND LOWER ZONE PNEUMONITIS A.B.G. : pH : 7.04 pCO 2 :33.4 pO 2 :92.0 B.E. :0.4 HCO 3 :23.4 ECHO : NORMAL STUDY

21. CXR A.P. VIEW P.O.D. 3

22. TREATMENT MOBILISATION WITH RESPIRATORY EXERCISES CHEST PHYSIOTHERAPY INCENTIVE SPIROMETRY AGGRESSIVE NEBULISATION I.V. FRUSEMIDE ANTIBIOTICS

23. CXR A.P. VIEW P.O.D. 7

24. DISCHARGED FROM S.I.C.U. ON THE 7 TH P.O.D. MOTHER AND BABY ALIVE AND WELL

25. MASSIVE TRANSFUSION DEFINITION - >10 UNITS T X IN 24 HOURS - T X OF ½ OF E.B.V. IN ONE HOUR - T X OF 1 B.V. IN FIRST 12 HRS OF RESUSCITATION AIM - RESTORE ADEQUATE BLOOD VOLUME - MAINTAIN HEMOSTASIS - MAINTAIN O 2 CARRYING CAPACITY - MAINTAIN ACID BASE BALANCE

26. COMPLICATIONS - MASSIVE T X DILUTIONAL THROMBOCYTOPENIA CITRATE TOXICITY – HYPOCALCEMIA ELECTROLYTE DISTURBANCES T.R.A.L.I. / A.R.D.S. COAGULATION ABNORMALITY / D.I.C. HYPOTHERMIA ACID BASE DISTURBANCES O 2 AFFINITY CHANGES

27. RECOMMENDATIONS ESTABLISH MASSIVE T X PROTOCOL RECOMMENDED T X RATIOS - F.F.P. : R.B.C. – 2 : 3 (OR) 1 : 1 - PLT. : R.B.C. – 0.8 : 1 ACTIVE PREVENTION OF HYPOTHERMIA MAINTAIN END ORGAN PERFUSION

28. THANK YOU