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Managing Massive Bleed in ITU Patient: Emergency Protocol and Transfer

Discussion of urgent management and communication strategies for a 56-year-old patient with massive bleeding in ICU, including permissive hypotension, resuscitation protocols, and coordination for transfer to intervention radiology suite.

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Managing Massive Bleed in ITU Patient: Emergency Protocol and Transfer

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  1. Cardiac Case Based Discussion

  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

  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 250-300 mls in the afternoon. Drop in Hb by 75 to 65. • How will you manage in ITU?

  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.

  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?

  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 80-90 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?

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