Bleeding Post Cardiac Surgery

I:    You are the CICU registrar and are asked to prescribe a fluid bolus for a post-            surgical patient

S:   Nurse reports that night doctor forgot to prescribe more than one bolus, and the        patient is a little tachycardic but requiring sodium nitroprusside to achieve systolic blood pressure targets

B:   70F immediately post CABG+AVR

A: Mildly tachycardic requiring colloid therapy

R: Asked to chart fluids

• Initially A ETT, B SpO₂ 99% on FiO₂ 0.5, VCV 500mls @ 10breaths/min, PEEP 7, ETCO₂ 4.6kPa, reduced breath sounds both bases C HR 98bpm, BP 101/72, D Sedated
• Becomes more tachycardic despite fluid bolus
• Quick dump of 300mls into drain then stops
• BP falls – discontinue sodium nitroprusside
• Further dump of 600mls into the drain
• Candidate declares major haemorrhage – manages blood products and resuscitation

1. Red Cells
2. FFP
3. Platelets
4. Cryoprecipitate
5. Protamine
6. TXA
7. Calcium
8. Warm

• Calls for senior help and cardiac-surgical help
• Begins to package patient for return to theatre
• Discusses further blood product management with lab – requests further products appropriately
• Anaesthetist arrives to take patient back to theatre – give clear and succinct handover