Massive hemorrhage is the loss of a critical amount of blood volume and poses an immediate threat to life. It is among the most serious surgical emergencies and needs to be treated immediately and aggressively in order to avoid severe complications. It is crucial that everyone taking care of the patient perform tasks quickly, communicate clearly, and work as a team toward the common goal of resuscitation. Here, we will discuss how to prepare for massive hemorrhage, the equipment and supplies that are needed for treatment, and the role of the anesthesia technician in the management of massive hemorrhage.

There are two basic scenarios in which massive hemorrhage develops. First, it can be anticipated to occur during a regularly scheduled surgery. In this case, all the necessary equipment, intravenous (IV) access, and blood products can be obtained prior to actual blood loss. Hemorrhage can be anticipated with certain types of cases as well as with certain patients. The cases that are most prone to hemorrhage are large vascular cases, like abdominal aortic aneurysms (AAA or “triple A”), resection of large tumors around the internal organs or pelvis, procedures on or around the liver, procedures involving the brain, and any surgery in the chest. Patients particularly prone to massive bleeding are those taking anticoagulant medications or those with coagulopathies, platelet dysfunction, or low platelet count (thrombocytopenia), liver disease, or poor nutritional status. While surgical bleeding is usually steady and controlled, there is a high risk of rapid blood loss during these cases.

The second scenario is unanticipated hemorrhage, which is much more difficult to manage because the supplies, IV access, and blood products available are likely insufficient for adequate resuscitation. For example, unanticipated hemorrhage may occur from a vascular injury during a surgery in which minimal blood loss was anticipated. Massive hemorrhage may also present as a trauma patient who has just arrived to the operating room (OR) via the emergency department. In either case, the anesthesia provider will immediately need assistance.

The key to a successful resuscitation is to quickly establish adequate IV access, replace the volume that has been lost on the surgical field, and gain control of the hemorrhage. This requires a coordinated team-based approach with clear communication between the surgical and anesthesia team. What type of vascular access is needed, who will perform the procedures, what blood products are available or need to be ordered, how much bleeding will be anticipated, when can control of bleeding be expected, and what are the team priorities are all important items to discuss quickly so that everyone shares a common set of priorities. The care team will need to immediately establish those priorities and assign roles. If the anesthesia team is occupied with managing the airway or anesthetic, the surgical team can be tasked with starting venous access lines or an arterial line. The anesthesia technician should be prepared to help the surgical team members with procedures and equipment as well as the anesthesia team.

Anesthetic care starts with establishing an airway and obtaining IV access. Critically injured trauma patients may arrive in the OR with neither. If an airway is in place, its position and effectiveness will need to be confirmed. The team will need to verify that existing IV access functions properly, or place new lines, so that drugs and fluids
can be given. Gaining peripheral access may be difficult in the setting of hemorrhage because the patient will be hypovolemic, hypotensive, and likely cold, all causing peripheral vasoconstriction. The anesthesia technician should be prepared to assist by gathering vascular access supplies: catheters of multiple sizes, tourniquet, tape, gauze, alcohol swabs, IV tubing, and fluid (see Chapter 34). Larger IVs are preferred because they can be used later for large-volume resuscitation, but smaller IVs may be all that is possible during the initial resuscitation because they are easier to place. Anesthesia technicians may further assist by looking for veins or uncovering and positioning an extremity. If IV access cannot be established, intraosseous access can be obtained quickly. If there is time, additional IV access and an arterial line may be placed before induction of anesthesia. If the patient is already anesthetized when the crisis arises, the anesthesia provider may need to adjust the anesthetic by turning infusions down or off or changing ventilator settings. The anesthesia provider may need infusions of vasopressors to maintain blood pressure. The anesthesia technician should be ready to rapidly retrieve these drugs, along with infusion pumps, advanced cardiac life support (ACLS) drugs, and the code cart in case the situation worsens.

As discussed above, the first priority is to establish initial IV or intraosseous access to induce anesthesia and administer resuscitation drugs. Most patients have at least one working IV, placed either in the field, emergency department, or preoperative area for scheduled cases. These are often small bore, which are adequate for giving drugs, but their size limits the flow rate and the ability to give large-volume fluid resuscitation and blood transfusions. Pressure infusers or “pressure bags” can be used to increase flow through these IVs. A pressure bag system typically consists of a mesh sleeve with an inflatable nylon bladder (see Fig. 65.1). The fluid bag is placed in the sleeve, and the bladder is inflated with a hand pump so it squeezes the bag. Some models use alternative methods for pressurizing the bladder. A word of caution when using pressurized systems: These bags can infuse air intravenously (air embolism), which can be lethal. Any air in the IV bag will be above the fluid level, but once all fluid is forced out, air will be forced into the tubing and make its way to the patient. This must be prevented either by eliminating all air from the bag prior to use or by delegating that someone constantly watch and maintain these devices.

Another method to increase the flow rate through an IV is manual compression of the bag. If there is a surplus of people to help, they can squeeze the bags of IV fluid by hand. Alternatively, simply raising the height of the IV fluid bag as high as possible will increase the infusion rate. While not as effective as pressure bags or manual compression, this frees up hands and reduces the risk of air embolism. While these measures alone are not sufficient to treat massive hemorrhage in the long run, these simple maneuvers can greatly increase the rate of fluid administration until adequate access is obtained.

For large-volume fluid resuscitation and blood transfusion, large-bore IV

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