Challenges of volume resuscitation in polytraumatized patient following massive transfusion protocol and prolonged mechanical ventilation

Prikaz slučaja 58-godišnje bolesnice, bez dotad poznatih komorbiditeta, stradaloj prilikom pada s 12 metara visine, prilikom kojeg je zadobila nekoliko vitalno ugrožavajućih ozljeda. Tijekom boravka učinjeno je 5 velikih kirurških operacija, a poseban izazov u liječenju predstavljale su volumna nadoknada i prolongirana mehanička ventilacija. Po prijemu u JIL uslijed zadobivenih ozljeda (multifragmentarne frakture zdjelice i laceracija abdominalnih organa), ubrzo dolazi do značajnog pada u krvnoj slici i nastupa hemoragijskog šoka. U tom razdoblju bolesnica je invazivno monitorirana, hitno kirurški zbrinuta, a za vrijeme zahvata zahtijevala je vazoaktivnu potporu noradrenalinom i vazopresinom, te masivnu transfuziju (ukupno 21 doza KE, protrombinski kompleks, 12 doza SSP). 10. dan boravka ponovno je hitno operirana zbog aktivnog krvarenja iz slezene, nakon čega se drastično smanjuje potreba za transfuzijskim liječenjem i svodi se na minimalne korekcije. Boravak se dalje komplicira razvojem ARDS-a zbog traume toraksa, razvojem pneumonije uzrokovane hospitalnim infekcijama, te progresijom obilnih pleuralnih izljeva obostrano s velikim prometom tekućina na drenove. Detaljnijom kardiološkom obradom nađe se i kardijalna podloga izljeva, te se bolesnici učini zamjena mitralne valvule. Postoperacijski dolazi do akutnog renalnog zatajenja, kao posljedica kombinacije faktora koji uključuju traumu organa, primjenu nefrotoksičnih antibiotika, te nezavisne rizike vezane uz kardiokirurški zahvat. Nakon dva ciklusa CVVHDF polagano dolazi do oporavka renalne funkcije. Respiratorni status također je predstavljao izazov u liječenju, budući da je bolesnica primljena s obostranom serijskom frakturom rebara i kontuzijama pluća. Unatoč tome, većinu vremena je spontano disala uz manju potporu respiratora i niski PEEP, te frakcijom kisika do 50%. Nakon 60 dana ovisnosti o respiratoru, postiže se uredno spontano disanje bez potrebe za potporom respiratora. Bolesnica je uz vitalno ugrožavajuće ozljede i brojne komplikacije istih uspješno zbrinuta tijekom 95 dana boravka u JIL-u, te se u adekvatnom kontaktu, hemodinamski i respiratorno stabilna, premješta na odjel, te ubrzo i na kućnu njegu.Case report of a 58-year-old polytraumatized patient, without known prior comorbidities, injured during a fall from a 12 meter height, while sustaining multiple life-threatening injuries. She underwent 5 subsequent serious surgical interventions, followed by special dedication to volume management and prolonged mechanical ventilation. Initially, her injuries led to severe blood loss and onset of haemorrhagic shock, which was temporarily obscured by her compensation mechanisms. On admission the patient had invasive monitoring and temporarily required continuous vasoactive support (norepinephrine and vasopressin). She also required immediate surgical intervention and resuscitation through massive transfusion protocol. On the 10th day of hospitalization, she once again required surgery due to active spleen haemorrhage, after which the need for blood derivates was drastically reduced. Her recovery is further complicated with development of ARDS due to trauma of the thorax and hospital acquired pneumonia, accompanied by bilateral pleural effusions. Detailed cardiac examinations discovered cardiac background to the problem and a mitral valve replacement was mandatory. Postprocedural period was characterized by acute renal failure as a combination of elements which include organ trauma, treatment with nephrotoxic antibiotics, along with independent risks applied to cardiopulmonary bypass during cardiac surgery. After two cycles of continuous haemodiafiltration, renal function shows progressive improvement and recovery. Another challenge in patient´s recovery was her respiratory status and dependence on mechanical ventilation. Despite being admitted with bilateral multiple rib fractures and lung contusions, she was successfully ventilated with minimal pressure support and lower PEEP values for the vast majority of time. After 60 days of mechanical ventilation, spontaneous breathing is successfully established. Despite several life-threatening injuries and numerous following complications, the patient was successfully treated over the course of 95 days in the Intensive Care Unit

Framing gender equality in the European Union and its current and future Member States. Deliverable No. 61: Final LARG Report

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