May 2019

 C. E
 69 y.o./ Female/ Married

 Chief complaint: bilateral leg pain

 Medical: Hypertension, Type 2 DM (CKD stage V on dialysis 3x a week) , Non-

asthmatic. No food and drug allergies
 Surgical: S/P IJ cath insertion (2013)
 Social: Non-smoker, Non-alcoholic beverage drinker
 1 month PTA
 Noted onset of left leg wound, approximately 2 cm in diameter dusk in color, no other
complaints noted
 In the interim
 The wound was noted to increase in size, condition tolerated, continued hemodialysis 3x
weekly
 1 week PTA
 Consulted a surgeon and was advised for admission for surgery

 Morning PTA
 Had her regular dialysis session, purplish discoloration was also noted on her left breast

 Admission
 At ER: Conscious, coherent, cooperative and not in acute respiratory distress
 Vitals: BP 110/80 O2 sat 94% RR 20 HR 81
 Admission (con’t.)
 Started on Piperacillin-Tazobactam 4.5 gms IV, Tygacil 100mg IV, Tramadol 50mg x 1 dose,
Paracetamol 500mg 2 tabs po, Levofloxacin 250 mg IV drip every other day

 Maintenance meds were continued: ISMN 30 ½ TAB PO , Clonidine 150 mg 1 tab po,
Carvedilol 6.25mg tab OD , Lacidipine 2mg/tab 1 tab OD , Vitamin D BID , Ferrous Sulfate
OD , Gabapentin 100mg/ cap OD , Telmisartan 50 OD

 Referred to surgery for co-management

 Scheduled for debridement of bilateral thighs

 General: Awake, comfortable, NIRD
 EBW: 60-65 kg, Estimated Height: 5’00 feet/152.4 cm, Estimated BMI: 25.73-27.87
 Vitals: T 36.7, BP: 110/80, P85 bpm, RR 20, O2 saat: 94%
 SKIN: dry with dark plaques on the proximal part of bilateral thighs with
purplish discoloration
 HEENT: Normocephalic, AIS, PPC, neck supple and nontender, - LAD
 C/L: ECE, CBS
 CV: DHS, RR, - murmurs
 GU: -KPS
 CNS: Nonfocal
 Labs
 CBC

Normal Results Normal Results

Hgb (12-16 g/dL) 6.6 ----8.8 iCa2+ 1.12-.132 1.01
Hct (36-46%) 19.4----26.8 TCa2+ 8.4-10.3 7.6
Platelet(150-400) 144----109 Phosphorus 2.5-4.7 0.8
 Pro-time

Normal Results Normal Results

Patient (11.5-15.5) 20.9
Clotting time (7-15 mins) 13’00”
Control 13.2
Bleeding time (2-8 mins) 8’00”
% Activity (70-100%) 45%
INR (<1.2) 1.77
 ECG: SR, PRWP, NSSTWC

 2DED:EF 48% (M-MODE and Simpsons) CLVH with SWMA indicative of CAD
with moderately depressed LVSF with Doppler evidence of grade 2 diastolic
dysfunction, dilated left atrium, aortic sclerosis with mild aortic regurgitation, mild
tricuspid regurgitation, mild to moderate mitral regurgitation, normal pulmonary
artery pressure with pulmonic regurgitation. Compared with previous study
done 6/13/2015: there is improvement in the wall motion and the present EF
of 48% from 39%.

 Chest AP: Cardiomegaly, minimal left pleural effusion, subsegmental atelectasis,

right mid lung field, Atherosclerotic aorta, thoracic spondylosis with
dextroscoliosis and vascular catheter in place
 Calciphylaxis bilateral thigh
 CKD Stage V secondary to DM Nephropathy and HPN Nephrosclerosis
 HCVD
 Type 2 DM
 Attached to standard ASA monitors
 Inducted via GETA
 BP: 150/100
 PR: 60-65
 O2 sat: 100%
 IVF: D5 0.3% NaCL @ 20 gtts/min
 Preoxygenation at 8LPM
 Pre-induction with Midazolam 1mg and Fentanyl 75mcg.
 Induction with Propofol in increments of 10mg
 Neuromuscular blocker with Cisatracurium 10mg
 DL using MAC 4 Blade and an ETT size 7.0 was cuffed and secured at
level 20.
 Maintenance with Sevoflurane
  Operation started

 Operation ended
 Extubated

5:35pm  Estimated blood loss was 50-100ml

  Stable VS: BP 110/61 mmHg, PR 51 bpm, RR 13 cpm, 96% O2 saturation
6:00 pm

 VS: 71/46 mmHg, 56 bpm, 17 cpm, 95% O2 saturation

 Wound dressing were fully soaked with blood approximately 250cc.
 Wound dressing were changed.
7:15PM  100 cc IVF bolus
 Ephedrine 10mg given
  VS: 94/54 mmHg, 60bpm, 13 cpm, 99% O2 saturation
7:30 PM  1st aliquot of PRBC was ordered to be transfused STAT

 Persistently hypotensive with BP range of 64/40-85/48

7:45PM-
 1st aliquot of PRBCs transfusion started at 10 PM
10:00PM
  10:00pm
 Norepinephrine 16mg in 84 cc D5W at 10cc/hr started.
 Another 2 units of PRBCs were ordered
10:00PM  ABG now and CBS now
 ABG:
 PH 7.12
 PCO2 31
 PO2 9
 HCO3 10.1
 FiO2 99%

 Started on Albumin drip 25% to run for 4 hours

11:30pm
  For venous cutdown
11:55pm

 VS: BP 0, HR 0, RR (no spontaneous breathing)

 Code initiated
 Intubated using VL CMAC BL 4 ET 7.5 lip level 20
 ECG: VT
 Rate: 130’s
 Atropine 0.5 mg x 2 doses given
12:00 am-  Epinephrine 1mg/ml IVTT x 11 doses
1:23 am  Family appraised of patient’s condition and opted for DNR
 1:23AM
 TIME OF DEATH
 Cardiopulmonary arrest secondary to shock multifactorial:
 Hypovolemic shock
 Septic shock secondary to Necrotizing Fascitis and Bacteremia

 CKD stage V secondary to DM Nephropathy and HPN Nephrosclerosis

 HCVD
 Type 2 DM
 Failure to meet the metabolic needs of the cell and the consequences that ensue.
 6 types of shock:
 Hypovolemic shock
 Cardiogenic shock
 Septic (Vasogenic)
 Neurogenic shock
 Traumatic shock
 Obstructive shock
 Acute blood loss results in:
 reflexive decreased baroreceptor stimulation from stretch receptors in the large arteries
 increased chemoreceptor stimulation of vasomotor centers
 diminished output from arterial stretch receptors.

 Peripheral vasoconstriction is prominent, while lack of sympathetic effects on

cerebral and coronary vessels and local autoregulation promote maintenance of
cardiac and CNS blood flow.
 Clinical signs of shock:
 Agitation
 Cool clammy extremities
 Tachycardia
 Weak or absent peripheral pulses
 Hypotension

 Such apparent shock results from at least 25%-30% loss of blood volume.
Advanced Trauma Life Support Classification of Hemorrhagic Shock
Class I Class II Class III Class IV
Blood loss (mL) < =750 750-1500 1500-2000 >=2000
Blood loss (% <=15 15-30 30-40 >=40
blood volume
Pulse rate (per <100 >100 >120 >=140
minute)
BP NORMAL NORMAL DECREASED DECREASED
Pulse pressure Normal or Decreased Decreased Decreased
increased
Respiratory rate 14-20 20-30 30-40 >35
(breaths/min)
Urine output >=30 20-30 5-15 negligible
(ml/h
Mental status Slightly anxious Mildly anxious Anxious and Confused and
confused lethargic
Fluid replacement crystalloid cyrstalloid Crystalloid+ Crystalloid+
(3:1 rule) blood blood
Classification of hemorrhage
Parameter Class
I II III IV
Blood loss (mL) <750 750-1500 1500-2000 >2000
Blood loss % <15 15-30 30-40 >40
Heart rate (bpm) <100 >100 >120 >140
BP normal orthostatic Hypotension Severe
hypotension
CNS Symptoms normal anxious confused obtunded

Source: Schwartz's Principles of Surgery 10th edition

  Laboratory values are not helpful until redistribution of interstitial fluid after 8-12H

 Hemoglobin and Hematocrit values

 Unchanged immediately after acute blood loss.
 During resuscitation, the HCT may fall

 Acidosis is the best indicator in early shock of ongoing oxygen imbalance at the
tissue level.

Kasper, D. L., Fauci, A. S., Hauser, S. L., Longo, D. L. 1., Jameson, J. L., & Loscalzo, J. (2015). Harrison's principles of internal medicine (19th
edition.)
  Primary treatment is to control the source of bleeding as soon as possible and to
replace fluid.

 Crystalloid is the first fluid of choice for resuscitation.

 2 L of isotonic sodium chloride solution or lactated Ringer’s solution

 Colloids restore volume in a 1:1 ratio.

 Human albumin, hydroxy-ethyl starch products, hypertonic saline-dextran
 15 mg/kg/Day (used to be 50 mg/kg/day)

Kasper, D. L., Fauci, A. S., Hauser, S. L., Longo, D. L. 1., Jameson, J. L., & Loscalzo, J. (2015). Harrison's principles of internal medicine (19th edition.)
Barash, Paul G., Bruce F. Cullen, and Robert K. Stoelting. 2017. Clinical anesthesia (8th edition)
  PRBCs should be transfused if the patient remains unstable after 2000 mL of
crystalloid resuscitation.

 FFP generally is infused when the patient shows signs of coagulopathy, usually after 6-
8 U of PRBCs.

Kasper, D. L., Fauci, A. S., Hauser, S. L., Longo, D. L. 1., Jameson, J. L., & Loscalzo, J. (2015). Harrison's principles of internal medicine (19th edition.)
Barash, Paul G., Bruce F. Cullen, and Robert K. Stoelting. 2017. Clinical anesthesia (8th edition)
 Complications
 Acidosis – Hypoperfusion, massive transfusion
 Hypothermia
 Cold fluids and blood products, opening of body cavities, decreased heat
production, and impaired thermoregulatory control
 Coagulopathy
 Dilution of clotting factors, consumption of clotting factors, and hyperfibrinolysis
 blood products are stored in anticoagulation solutions

 Electrolyte abnormalities
 TRALI - Leukocyte antibodies transfused in plasma

Kasper, D. L., Fauci, A. S., Hauser, S. L., Longo, D. L. 1., Jameson, J. L., & Loscalzo, J. (2015). Harrison's principles of internal medicine (19th edition.)
Barash, Paul G., Bruce F. Cullen, and Robert K. Stoelting. 2017. Clinical anesthesia (8th edition)
  Despite significant advances in trauma management, mortality from hemorrhagic
shock remains the number one cause of death.

 Data suggests that reconstituting components of blood to resemble whole blood

have better survival profile.

ASA COMMITTEE on BLOOD MANAGEMENT, MASSIVE TRANSFUSION PROTOCOL (MTP) FOR

HEMORRHAGIC SHOCK
  The Traditional definition of massive transfusion is 20 units RBCs in 24 hours
 Corresponds to approximately 1 blood volume in a 70 kg patient.

 Trauma literature: > 10 units RBCs in 24 hours

 Both of these definitions are reasonable for publications, but are not practical in an
ongoing resuscitation.

 Other definitions are:

 Loss of 50% blood volume within 3 hours
 50 units of blood components in 24 hours
 6 units RBCs in 12 hours.

ASA COMMITTEE on BLOOD MANAGEMENT, MASSIVE TRANSFUSION PROTOCOL (MTP) FOR

HEMORRHAGIC SHOCK
  From a practical standpoint
 Requirement for > 4 RBC units in one hour , with ongoing need for transfusion
OR
 Blood loss > 150 ml/min with hemodynamic instability

Are reasonable definitions in the setting of a MTP situation.

 The variability in defining massive bleeding may result in variability initiating a MTP

ASA COMMITTEE on BLOOD MANAGEMENT, MASSIVE TRANSFUSION PROTOCOL (MTP) FOR

HEMORRHAGIC SHOCK
THANK YOU!