Polytrauma Patient (Duranteau)
Early mortality is usually due to uncontrolled haemorrhage. Late mortality and disability is due to brain injury and multiorgan failure
Control of haemorrhage
- Low volume volume resuscitation – SAP 80-90mmHg until bleeding stopped; MAP > 80mmHG in TBI. vaopressor may have role (animal models)
- Trauma-induced coagulopathy: multifactorial, complex and dynamic. Use TEG
- Euro recommends plasma:red cell ratio of at least 1:2
- Plts > 50 ( >100 if ongoing bleeding or TBI)
- Fibrinogen target of between 1.5-2g/L
- Early transexamic acid (1g load, followed by 1gm over 8)
References
European guidelines of major trauma
Damage control haematology
Trauma-Associated Severe Haemorrhage (TASH) Score
PROPPR Trial
CRASH-2 Trial
Perioperative Intensive Care Medicine (Hiesmayr)
Post op issues on the ICU
- Volume instability
- Bleeding – surgical and anaesthetics (lines)
- Fever
- Residual anaesthetic drugs
- Delirium
Know the patient (premorbid state) and know the surgery
Types of surgery and specific problems
- Vascular – comorbidities, bleeding, ischaemia
- Ortho – fat embolism, bone-cement cardiac event
- Solid organ transplant – infection, graft failure, vascular complications
- Neurosurgery – brain oedema, vascular spasm, hydrocephalus, CNS disturbances e.g. DI
- Cardiac – hear failure, stiff heart, pulmonary complications, cerebral complications
Consider post-op checklist
References
Post-operative hypoxia
Transplantation and Immunosuppression (Meyfroidt)
HLA; class 1 on all nucleated cells, class 2 on antigen presenting cells
Immunosuppresant drugs
- Glucocorticoids
- Calcineurin-inhibitors; cyclosporine, tacrolimus
- DNA-synthesis inhibitors; AZT, mycophenolate
- Antibodies; depleting or non-depleting
- mTOR inhibitors; sirolimus, everolimus
Rejection
- Hyperacute rejection
- Cellular rejection
- Humoral rejection
Kidney transplant complications
- Surgical complications; vascular, ureter
- Delayed graft function – living donor 5%, DBD 30%, DCD 50%
Liver transplant complications
- Monitor liver function
- Bleeding
- Arterial complications: ultrasound – early/late hepatic arterial thrombosis
Heart transplant complications
- Bleeding
- Rhythm – denervated
- RV failure – inotropes, iNO
- LV dysfunction/failure – inotropes, mechanical assist
- Renal dysfunction – calcineurin inhibitors
Lung transplant complications
- Respiratory – protective ventilation, assess structures with bronchoscopy, chest tubes, phrenic nerve injury, ischaemia/reperfusion, difficult weaning (anxious/pain)
- AF
- Cystic fibrosis: other manifestation e.g. liver GI
- Infections
Infections – bacterial, viral, fungal, protozoal
References
Review of immunosuppresant drugs