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AS9.1-4 | Fluids, Blood Products and Vascular Access — PBL Case

CLINICAL SETTING

Mr. Rajan Kumar, a 62-year-old retired schoolteacher weighing 72 kg, is brought to the emergency department at 11 PM with a 3-day history of worsening abdominal pain, jaundice, and fever (temperature 39.2°C). His family reports that he has not passed urine adequately for the past 18 hours. He has no significant past medical history but takes aspirin 75 mg daily for primary cardiovascular prevention. On examination, he is visibly jaundiced, tachycardic (heart rate 112/min), and hypotensive (blood pressure 88/56 mmHg) with a tender right upper quadrant. His mucous membranes are dry. Emergency investigations reveal: haemoglobin 8.2 g/dL, platelet count 80 × 10⁹/L, PT-INR 2.1, fibrinogen 1.2 g/L, serum creatinine 198 μmol/L (baseline unknown), total bilirubin 18 mg/dL, and serum albumin 2.8 g/dL. CT abdomen confirms a large choledocholithiasis with bile duct obstruction, features of ascending cholangitis, and a suspicious periductal collection. The surgical team plans emergency laparotomy and choledochotomy within 90 minutes. The anaesthesiology resident is called to assess and prepare Mr. Kumar for theatre.

Trigger 1: Securing Access and Preparing for Theatre

The anaesthesiology resident attempts peripheral IV cannulation. Mr. Kumar is agitated and peripherally vasoconstricted from sepsis. After two failed attempts at the antecubital fossa bilaterally, a single 20G cannula is successfully inserted in a dorsal hand vein. The nurse asks: 'Is this enough access for emergency surgery?' Meanwhile, the resident reviews the coagulation profile: INR 2.1, platelets 80 × 10⁹/L, fibrinogen 1.2 g/L. The haematologist advises that central venous access should be considered given the likely need for vasoactive drug infusion and difficult peripheral access. Rapid infusion of 500 mL Hartmann's solution is begun.

DISCUSSION POINTS

  • Is a single 20G peripheral cannula adequate for emergency laparotomy with anticipated significant blood loss? What are the minimum access requirements, and what are your options when peripheral access is difficult in a vasoconsticted, septic patient?
  • Which site would you choose for central venous catheter insertion in this patient, and why? Consider the coagulopathy (INR 2.1, platelets 80 × 10⁹/L) when selecting your approach and preferred technique.
Click to reveal Trigger 2: Intraoperative Crisis — Massive Haemorrhage (discuss previous trigger first!)

Trigger 2: Intraoperative Crisis — Massive Haemorrhage

At laparotomy, the surgeon finds dense adhesions around the common bile duct with a friable, infected periductal collection. During dissection, the portal vein is inadvertently nicked, causing rapid haemorrhage. Estimated blood loss reaches 1,400 mL in 8 minutes. Blood pressure falls to 60/30 mmHg. The scrub nurse calls for blood products. The blood bank reports: 2 units PRBCs available immediately; FFP will take 20 minutes to thaw; platelets available. The anaesthesiologist activates the massive transfusion protocol (MTP). Current haemoglobin on point-of-care testing: 5.8 g/dL.

DISCUSSION POINTS

  • The massive transfusion protocol is activated. What is the recommended ratio of blood products (PRBCs : FFP : platelets) in damage-control resuscitation? How does this differ from traditional component therapy, and what is the physiological rationale?
  • The fibrinogen is 1.2 g/L at baseline and will have fallen further with haemorrhage. Should cryoprecipitate be given? At what fibrinogen level is it indicated, and what is its composition? While FFP is being thawed, what immediate measures can maintain haemostasis?
Click to reveal Trigger 3: Post-Resuscitation Assessment and Ongoing Management (discuss previous trigger first!)

Trigger 3: Post-Resuscitation Assessment and Ongoing Management

After surgical control of haemorrhage and 4 units PRBCs, 4 units FFP, 1 pool of platelets, and 10 units of cryoprecipitate, Mr. Kumar's blood pressure has stabilised at 95/60 mmHg. Total intraoperative fluid administered: 3.8 litres crystalloid + blood products. Urine output for the past 2 hours: 18 mL total. Post-resuscitation results: Hb 8.1 g/dL, INR 1.4, platelets 62 × 10⁹/L, fibrinogen 2.0 g/L, pH 7.22, HCO3- 14 mEq/L, lactate 5.2 mmol/L, serum Cl- 119 mEq/L. Temperature is 35.4°C. The ICU team asks for a handover plan.

DISCUSSION POINTS

  • Mr. Kumar has oliguria, metabolic acidosis with elevated lactate, hypothermia, and a pH of 7.22. The serum Cl- is 119 mEq/L. Identify all contributors to his metabolic acidosis. Which is most concerning from a tissue perfusion standpoint, and how would you distinguish between them?
  • What targets would you set for the first 6 hours in ICU for urine output, haemoglobin, lactate clearance, temperature, and coagulation — and what interventions would you use to achieve them? Is further fluid administration appropriate, and what type?

Group Task Assignments

Group 1: Collaborative Task

  • Construct a timeline of fluid and blood product administration for this case from the emergency department through ICU handover. Include volumes, product types, and the clinical triggers that drove each decision. Present this as a structured document suitable for an ICU handover note.

Group 2: Collaborative Task

  • Prepare a 5-minute teaching summary for junior colleagues explaining the 'lethal triad' (hypothermia, acidosis, coagulopathy) in massive haemorrhage — how each element worsens the others, how the transfusion strategy addresses all three simultaneously, and two monitoring parameters for each element.

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [AS9.1] What are the evidence-based strategies for establishing peripheral IV access in a vasoconsticted or difficult-access patient, including ultrasound-guided peripheral venous cannulation? When does failed peripheral access warrant escalation to central access?
  2. [AS9.2] How does the presence of coagulopathy (INR 2.1, platelets 80 × 10⁹/L) affect site selection and technique for central venous catheter insertion? Which site carries the lowest bleeding risk in a coagulopathic patient and why?
  3. [AS9.3] What is damage-control resuscitation, and how does it differ from the traditional crystalloid-first approach? What is the physiological rationale for avoiding large-volume crystalloid infusion in haemorrhagic shock?
  4. [AS9.4] What is the recommended PRBC:FFP:platelet ratio in massive transfusion protocols, and what evidence supports this approach? What are the thresholds for cryoprecipitate use, and what does cryoprecipitate contain that FFP does not provide in adequate concentrations?