Mr Gerant McWhirter is a 77 year old man who has been admitted to ICU after a Hartmann’s procedure for faecal peritonitis secondary to perforated diverticular disease.
Past Medical History:
Chronic Renal Failure – Creatinine 136 pre-op Smoker
Previous triple coronary artery bypass grafting (2012) Alcoholic related liver disease (Child-Pugh Grade B) Recent weight loss (current weight 48kg)
Peritoneal soiling – full wash out performed. Diseased section of sigmoid colon resected. Rectal stump and end colostomy created.
SC Heparin 5000 BD Tazocin QDS
Paracetamol 1g QDS Morphine PCA No Known Drug Allergies
|Haematological values Analysis||Reference range|
|Haemoglobin||96 g/L||130-180 g/L|
|Leucocytes (WBC)||18.1 x109/L||4-11 x109/L|
|Platelets||252 x109/L||150-350 x109/L|
|Prothrombin time Ratio||1.1||1-1.2|
|Activated partial thromboplastin time||1.0||1-1.2|
|Fibrinogen||2.3 g/L||1.5-4 g/L|
|Biochemical Analysis||Result||Reference range|
|Na||143 mmol/L||134-144 mmol/L|
|K||4.6 mmol/L||3.5-5 mmol/L|
|Urea||7.9 mmol/L||2.5-6.6 mmol/L|
|Creatinine||144 umol/L||60-120 micromol/L|
You are called to see the patient 12 hours post-op due to tachycardia, hypotension and high airway pressures.
A: COETT 8.0
B: VCV 400X16 PEEP 5. Dyssynchronous. See-saw movements of chest and abdomen. SpO2 88% on FiO2 0.6. Peak airway pressure 38cmH2O. Trachea central, percussion normal.
Chest auscultation clear.
C: Pallor. Peripherally cool and mottled. Peripheral capillary refill 6 seconds, central capillary refill 3 seconds. HR 140, thready pulse. BP 85/55. Urine output since theatre, initially 40 ml/hr – last three hours 20ml/5ml/5ml.
D: Sedated with Propofol/Alfentanil. Pupils equal and reactive to light. Blood sugar 6.3 E: Abdomen tense and distended. Temperature 38.1oC
Arterial Blood Gas
|Arterial blood gases Analysis||Results||Reference range|
|Hydrogen ion||53 nmol/L||37-45 nmol/L|
|PaCO2||3.6 kPa||4.4-6 kPa|
|PaO2||8.8 kPa||12-15 kPa|
|Base deficit||– 4||-2 to +2|
- What is the likely cause of Mr McWhirter’s deterioration?
- What would be the most important immediate management steps for Mr McWhirter?
Mr McWhirter’s coagulation results are rung through to the unit:
- Outline some possible reasons for Mr McWhirter’s coagulation derangement
- Describe how you might approach blood product transfusion in major haemorrhage – how do you choose which products to administer and when?
- What other pharmacological and non-pharmacological treatments do we employ in major haemorrhage and why?
Mr McWhirter returns to theatre where he is found to have 3L of blood in his abdominal cavity. An arterial bleeder is identified and tied off. In total he receives 4 units of packed red cells, 4 units of FFP, and 1 pool of platelets.
- What are the serious hazards of transfusion?
- How can they be avoided?
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