the use of medications could give rise to an Increased risk of bleeding, need for pacing or more

complex fluid management. Similarly, if Mrs Raipul has any drug allergies, Reviews These must
be Noted, together with the nature of the reaction An understanding of any significant issues in
Mrs Raipul's family or social history can also be useful in planning her care, and this can usually
be gained from admission and nursing notes. Details regarding Mrs Raipul's next of
KMaependents, o history of smoking, excessive use of alcohol or drugs ofrecreational and her
occupation can be helpfull in building a holistic assessment and package of care. This
information, integrated with the initial patient assessment and routine cardiovascular
observations (heart rate, rhythm, systolic / mean / diastolic pressures, central venous pressures,
peripherals inspection) can Ensure that the three cardiac principles of preload, afterload and
contractility can be individually optimized for Mrs Raipul.
Developing scenarios bleeding and hypovolaemia
on undertaking routine observations on Mrs Raipul, you note:
Heart rate 98 beats per minute. Sinus rhythm.
Blood pressure 95/55 mmHg Central venous pressure (CVP) 3 mmHg.
Core temperature has not risen markedly over the past hour (35.8-36.0 ° C) and Mrs Raipul, who
was warm to mid thigh, is now only warm to the knee.
Chest drain losses have risen from 50 mL over the first 2 hours to 100 ml over the past 30
minutes.
Reader activities
Consider the following:
What physiologic terms describe Mrs Raipul's clinical signs?
Why is Mrs Raipul especially at risk of bleeding?
How can a clotting screen help Determine the cause of bleeding?
What drugs can be administered to reverse clotting abnormalities?
What other treatment options can be used to minimize blood loss?
Applied pathophysiology
Mrs Raipul's clinical signs indicate hypotension due to hypovolaemia. Her blood pres sure is
low, and certainly lower than when it was measured pre-operatively at 145 195 mmHg. Her
right-sided filling pressure (CVP) IS ALSO reading low, Indicating reduced venous return.
Hypovolaemia Occurs when circulating blood volume is insufficient to fill intravascular spaces.
The resultant reduction in venous return to the right heart leads to a Decreased cardiac output,
and reduced systolic and mean arterial pressure. A 10% int hat and COO jud sult plas clott of ca
force ation poter back aut If blood will r Criti whils al Surger clot can fo 195 can on reduction in
circulating volume will initiate compensatory mechanisms Including tach cardia and peripheral
vasoconstriction with higherdiastolic blood pressure values (Ganong 2005), as evidenced in Mrs
Raipul's observations. Losses the resulting in a 20% or more re duction of circulating volume
will lead to clinical signs and symptoms of hypovolaemic shock Including reduced renal,
cerebral and splanchnic perfusion with impaired functi
Any patient who sustains injury or trauma (post surgery, bums, road traffic acciden
dehydrated or has gastrointestinal obstruction is at risk ofhypovolaemic shock UNLESS the
underlying cause is well managed. Mrs Raipul has undergone cardiac surgery and has a number
o risk factors for hypovolaemia. Pre-operatively, Mrs Raipul will have been n mouth prior to
surgery and will have a degree of dehydration, especially if receiving high dose diuretics. She
will have sustained some blood loss peri operatively and this may not have been fully replaced.
Fluid volume deficit could have been further aggravated by the interstitial fluid shifts that occur
post-CPB. during cardiac surgery, Patients are centrally cooled to 32 ° cr palsy and dial
protection, and when re-warming begin udicious volume replacement is required to Ensure
further hypovolaemia does not result.
Hypovolaemia due to blood loss Cleary is a key consideration in Mrs Raipul's case
Factors that increase of risk of post-operative bleeding include the pathophysiology of CPB and
cardiac surgical techniques. CPB activates whole body inflammatory responses re sulting from
blood contact with non-endothelial CPB circuitry. Such contact activates plasma protein systems
and the intrinsic and extrinsic coagulation pathways, with the risk of clotting. To counteract this,
intra-operative heparin is administered and this requires reve sal post-surgery. Also CPB
activates platelet activity, decreasing overall platelet numbers and function. Cardiac surgery
requires suturing Also of key blood vessels and placement of cannulae into major cardiac
structures. A sub-optimal surgical technique or excessive force (high systemic pressures) on sites
Reviews These increases risk of post-operative bleeding, These are all major contributors to the
risk of post-operative bleeding.
There are many other specific factors that may pre-dispose Mrs Raipul to bleed post-
operatively. In line with current practice secondary prophylactic, Mrs Raipul will hav received
pre-operative aspirin and anti-platelet therapy (clopidogrel) to reduce the risk of myocardial
infarction (Antiplatelet Trialists' Collaboration 1994). Even with discontinu ation of Reviews
These prior to surgery, some residual anti-coagulation effect remains, increasing potential for
blood loss. Furthermore, as the patient re-warms post-operatively, residual heparin given during
CPB and trapped in vasoconstricted peripheries will be washed back into the systemic circulation
and have an anti-coagulation effect (heparin rebound). If autotransfusion is used in theater, or if
blood drained from CPB is transfused (pump bloody, Reviews These will Contain heparin and /
or citrate phosphate; whilst volume replacement will restore normovolaemia, further coagulation
problems can result.
Critical care assessment and diagnostics
Whilst there are key diagnosticsto assists in the treatment of blood loss, patient assessment can
also offer pointers for management. Chest drains are routinely placed at the en surgery to aid the
flow ofserous and blood losses away from the heart, thereby Preventing clot formation. It would
be standard for Mrs Raipul to have a minimum of one portex