Bleeding

You have been asked to review a 27-year-old man who has recently undergone a splenectomy for trauma. The nursing staff report fresh blood in the drain. How would you approach this problem?

You need further information. The bleeding may be localised or generalised. It may be reactionary, primary or secondary. How long ago was the operation and how much blood is in the drain? A small amount of fresh blood a few hours after the operation may be of little consequence. Is the bleeding confined to the drain or is there evidence of bleeding at other sites (wound, intravenous cannula)? If the former, the problem may be haemorrhage from the operative site, and if the latter, the patient may have a disorder of coagulation.

Your initial assessment must include a review of the charts. In what circumstances was the operation performed? If the patient had a massive and rapid transfusion to maintain his circulatory state, then the problem may be one of a coagulation defect. What has happened since the operation? A rising pulse and falling blood pressure would suggest that the patient is still bleeding, and what is seen in the drain may only be the tip of the iceberg. In other words, there could be a considerable volume of blood collecting at the operative site, with only a little escaping into the drain. Remember that when a drain drains, positive information may be gleaned; however, an empty drain means little.

Examine the patient and look for evidence of circulatory insufficiency. The material in the drain tube and drainage bag may be fresh and not clotted, or it may be serosanguinous. A normotensive patient with old clot in the drain is probably a stable patient.

It is more important to pay attention to the general state of the patient, rather than the contents of the drainage bag.

In summary, your clinical assessment of this case should include:

• the severity of the bleed

• the site of the bleed

• the cause of the bleed

• the need for further action (e.g. coagulation studies, cross-matching blood, contacting senior staff).

Shock

You are on your way to the ward to review a 66-yearold man who collapsed 3 hours after a transurethral prostatectomy. He is hypotensive and confused. What are your thoughts?

Your priority will be on resuscitation. However, to do this effectively you must have a clear idea of the probable cause of his collapse. The important causes of shock to consider in these circumstances are:

• pump failure (cardiogenic)

• haemorrhage (hypovolaemia)

• sepsis (septicaemia)

• anaphylaxis (drug reaction).

What will you do at the patient's bedside?

Make a rapid assessment of the state of the patient. How profound is the hypotension? If he is connected to a monitor, see if you can determine any changes in the ECG that would suggest an acute myocardial problem.

Ensure that the patient has an oxygen mask in place and run oxygen at 6 L/min. Attach a pulse oximeter. On the assumption that the cause of the problem is not cardiac failure, run in 500 mL of isotonic saline rapidly. While this is happening, take blood samples for assay of cardiac enzymes (creatine kinase), myocardial breakdown proteins (troponin), haematological and biochemical screen, blood cross-match and culture. Arterial blood gas analysis should be considered.

Once these things have been done, stand back and review the situation. Look at the charts. Is there a history of ischaemic heart disease or other cardiac problems? Did the patient come in with urinary retention and could he have infected urine. How major was the procedure that was performed and how much fluid was used during the procedure, both intravenous administration and as irrigation? What is in the urine drainage bag? A large volume of fresh blood would suggest hypovolaemia as the cause of the collapse. Were there any complications during the procedure?Howhas been the patient's progress since the operation? It is important to know if this has been a sudden collapse or a steady deterioration since the procedure.

There is nothing of significance from the past medical history and the operation was uneventful and associated with minimal blood loss. The fluid in the bladder irrigation system is tinged with blood and there are no blood clots. The patient's vital signs were within normal limits until about 15 minutes before you were alerted to the problem. The ECG monitor does not show any acute changes. How are you going to further the management of this case?

The cause of the problem appears not to be hypovolaemia. It is either septicaemia or a cardiac event. A normal ECG does not exclude an acute myocardial problem and you must await the enzyme assays and troponin levels.

Work on the assumption that the patient is in septic shock. In addition to the oxygen by face mask and fluid loading, antibiotics should be given. The choice of antibiotics will depend on the likely organisms. Gramnegative aerobes are an important and common cause of urinary infection, and working on the assumption that the presumed sepsis has originated from the urinary tract, concentrate on these organisms. The trio of an aminoglycoside (gentamicin), metronidazole and amoxycillin remains perhaps the most effective antibiotic combination in the management of patients with Gram-negative septic shock.