# 2024.1 Day 1 VIVA 4

You have been called by the on-shift Emergency Department (ED) Medical Officer to attend the ED to assist with the resuscitation of a 50-year with known alcoholic liver cirrhosis and bleeding oesophageal varices.&#x20;

He had presented with coffee ground vomitus but is now vomiting frank fresh blood.&#x20;

His heart rate is 130 beats per minute, blood pressure 75/40 mmHg and oxygen saturations of 92% on room air. He is cool, clammy and peripherally shut down. He weighs 70 kilograms.

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<summary>You have been tasked with gaining vascular access by the Emergency Department Medical Officer, what do you do?</summary>

**Immediate vascular access strategy:**

* First attempt two **14-16G peripheral IVs** in antecubital fossa
* Rationale: Fastest way to achieve high-flow resuscitation (gravity flow \~100-150ml/min per 14G IV)
* If unsuccessful after 2 attempts by experienced operator → proceed to IO

**Intraosseous access as backup:**

* Preferred site: Proximal tibia (2cm below tibial tuberosity, medial flat surface)
* Alternative: Proximal humerus (greater tubercle, avoids long bone fractures)
* IO flow rates: Up to 100ml/min with pressure bag, equivalent to central access
* Special considerations:
  * Painful insertion → give lidocaine 40mg IO after placement
  * Temporary measure (max 24hrs) → arrange definitive access

**Central venous access if needed:**

* Femoral vein preferred in this scenario due to:
  * Easier compression if bleeding occurs (vs subclavian/IJ)
  * Preserved landmarks in hypotensive patient
  * Lower pneumothorax risk vs thoracic approaches
* Ultrasound guidance mandatory:
  * Identify vein/artery relationship (vein medial to artery in femoral triangle)
  * Use dynamic needle tip tracking to avoid arterial puncture
* Avoid subclavian: High risk of pneumothorax/bleeding in coagulopathic patient

</details>

<details>

<summary>The patient remains hypotensive after 2L crystalloid. What next?</summary>

**Activate major haemorrhage protocol as MTP unavailable in Scenarioville:**

* Call laboratory immediately
* Initial ratio: 4 units PRBC : 4 units FFP : 2 pools cryoprecipitate if available
* Rationale: Balanced resuscitation addresses coagulopathy of trauma/liver disease

**Vasopressor support:**

* Noradrenaline infusion starting at 0.05mcg/kg/min via central line
* Titrate to MAP >65mmHg
* Rationale: Cirrhotic patients often have relative vasodilation

**Adjuncts:**

* Tranexamic acid 1g IV over 10min (CRASH-2 evidence in bleeding)
* Vitamin K 10mg IV (corrects nutritional deficiency in alcoholics)

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<details>

<summary>What lab tests would you prioritise?</summary>

**Immediate priority tests (first 5 mins):**

* Venous blood gas: Lactate (prognostic), pH, hemoglobin (point-of-care)
* Coagulation: INR, fibrinogen (critical in liver disease)

**Secondary tests (next 15 mins):**

* Full blood count: Baseline Hb (may be normal initially in acute bleed)
* U\&E: Creatinine (HRS risk), Na+ (dilutional hyponatremia common)
* LFTs: Bilirubin (Child-Pugh staging), ALT/AST
* Group & Hold: 4 units minimum (crossmatch if time permits)

**Special considerations:**

* No ROTEM in Scenarioville → rely on clinical bleeding + fibrinogen level
* Thrombocytopenia likely → but no platelets available locally

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<details>

<summary>How would you monitor response to resuscitation?</summary>

**Clinical parameters (q5min initially):**

* Mental state (improving encephalopathy = good sign)
* Urine output (aim >0.5ml/kg/hr via catheter)
* Skin perfusion (capillary refill, temperature gradient)

**Hemodynamic (continuous):**

* Arterial line preferred once stable enough for placement
* Dynamic parameters: PP variation >13% suggests fluid responsiveness

**Laboratory trends:**

* Lactate clearance (>30% reduction in 2hrs = good prognosis)
* Serial Hb (expect 1g/dL rise per unit PRBC if no ongoing bleed)
* Fibrinogen >1.5g/L target (critical for clot stability)

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<details>

<summary>The INR is 2.5. How does this alter your transfusion strategy?</summary>

**FFP administration:**

* Initial dose 15ml/kg (≈1000ml for 70kg)
* Recheck INR after 30min
* Target INR <1.5 for procedural hemostasis

**Cryoprecipitate if fibrinogen low:**

* 2 pools (≈10 units) raises fibrinogen by \~1g/L
* Preferred over FFP for isolated hypofibrinogenemia

**Vitamin K adjunct:**

* 10mg IV slow push (works over 6-12hrs)

**Special considerations:**

* FFP has marginal effect when INR >2.0 in cirrhosis
* May accept higher INR (1.8-2.0) if volume overload concern

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<details>

<summary>What are the risks of over-resuscitation in cirrhosis?</summary>

**Portal hypertension exacerbation:**

* Increased intravascular volume → elevated portal pressures → rebleeding risk
* Target CVP 6-8mmHg (avoid >10)

**Volume overload complications:**

* Acute pulmonary edema (reduced cardiac reserve in cirrhosis)
* Worsening ascites (increases intra-abdominal pressure)

**Coagulation dilution:**

* Excessive crystalloid dilutes remaining clotting factors

**Management strategy:**

* Early vasopressor use rather than excessive fluids
* Target MAP 65-75mmHg (not normal BP)

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<details>

<summary>The team plans balloon tamponade. How would you secure the airway?</summary>

**Pre-RSI Preparation:**

* **Positioning:**
  * 30° head-up tilt to reduce aspiration risk
  * Left lateral tilt if active hematemesis (rarely practical)
* **Pre-oxygenation:**
  * HFNC at 60L/min, FiO₂ 1.0 for 3-5 mins (apneic oxygenation during laryngoscopy)
  * NIV contraindicated (risk of gastric insufflation → more vomiting)
* **Equipment:**
  * Video laryngoscope (hyperangulated blade) + bougie immediately available
  * Dual suction (Yankauer + catheter) with wide-bore tubing
  * Cricothyroidotomy kit opened and ready

**Drug Selection:**

* **Induction:**
  * Ketamine 1-1.5mg/kg (50-100mg) – maintains BP better than propofol
  * Avoid etomidate (adrenal suppression in sepsis)
* **Muscle Relaxant:**
  * Rocuronium 1mg/kg (70mg) – fast onset, no K⁺ release like suxamethonium
  * Sugammadex available for reversal if needed

**Intubation Technique:**

* **Modified RSI:**
  * Apply cricoid pressure only if trained assistant available
  * Quick-look with blade to assess for blood in airway
  * Suction under direct vision before tube passage
* **Tube Selection:**
  * 7.0-7.5mm ETT (smaller may impede scope passage)
  * Consider pre-loading Sengstaken tube over ETT before intubation

**Post-Intubation Management:**

* **Ventilation:**
  * Start with VC-VG mode: TV 6-8ml/kg, PEEP 5-8cmH₂O
  * Permissive hypercapnia (pH >7.2) to avoid excessive PEEP
* **NG Tube Controversy:**
  * Only insert after ETT placement confirmed
  * Soft silicone tube preferred, avoid suction initially

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<details>

<summary>Why avoid succinylcholine in this patient?</summary>

**Hyperkalemia risk:**

* Chronic liver disease → upregulated extrajunctional ACh receptors
* Potential for life-threatening K⁺ rise (even without overt renal failure)

**Prolonged paralysis:**

* Reduced pseudocholinesterase production in cirrhosis
* 2-3x longer duration of action expected

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<details>

<summary>The saturations drop to 85% during laryngoscopy. What now?</summary>

**Immediate actions:**

* Withdraw blade, resume facemask ventilation with 100% O₂
* Have assistant perform vigorous suction while ventilating

**Second attempt modifications:**

* Switch to video laryngoscope if not already using
* Apply optimal external laryngeal manipulation
* Limit attempt to <30 seconds

**If fails:**

* Insert supraglottic airway (e.g., i-gel) as bridge
* Prepare for front-of-neck access if SGA fails

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<details>

<summary>How would you modify ventilation for variceal bleeding?</summary>

**PEEP strategy:**

* Start with 5cmH₂O, increase only if hypoxia persists
* Avoid >10cmH₂O → increases right atrial pressure → ↑ portal hypertension
* **Tidal volume:**
  * Lower range (6ml/kg) to reduce risk of gastric insufflation

**Monitoring:**

* Watch for rising airway pressures → may indicate gastric distension

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<details>

<summary>The surgeon requests gastroscopy now. Your concerns?</summary>

**Hemodynamic stability:**

* Must have MAP >65mmHg and lactate trending down

**Airway protection:**

* ETT cuff pressure checked (20-30cmH₂O) to prevent aspiration

**Team preparation:**

* Surgeon must be skilled in variceal banding
* Anesthetist should remain at head for airway management

**Blood products:**

* At least 4 units PRBC and 2 FFP immediately available

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<details>

<summary>Would you transfer without endoscopy?</summary>

**Indications for transfer:**

* Failed endoscopic control after 2 attempts
* Unavailable specialist (e.g., no GI surgeon onsite)

**Logistics:**

* Retrieval team ETA 2hrs → balloon tamponade as bridge
* Minnesota tube preferred if transfer delayed

**Risks:**

* 30% rebleed rate during transfer
* Must have secured airway + 2 large-bore IVs

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<details>

<summary>The surgeon insists on gastroscopy despite instability. How do you proceed?</summary>

**Graded Assertiveness Framework (ANZCA PG07):**

1. **Advise:**
   * "His lactate is still 5.2 - I recommend correcting his acidosis first"
2. **Suggest:**
   * "Perhaps we could start terlipressin while preparing?"
3. **Assert:**
   * "I cannot safely anesthetize him with his current Hb of 65"
4. **Escalate:**
   * "Let's call the ICU consultant for a second opinion"

**Risk-Benefit Analysis:**

* **Procedural risks:**
  * 40% mortality if scope performed in shock
  * High aspiration risk despite intubation
* **Benefits:**
  * 80% success rate if banding achieved

**Scenarioville limitations:**

* No interventional radiology for salvage TIPS
* Blood product limitations (no platelets)

**Alternative Strategies:**

* **Pharmacologic bridge:**
  * Terlipressin 2mg q4h (reduces portal pressure by 20%)
  * Octreotide infusion 50mcg/hr
* **Mechanical tamponade:**
  * Minnesota tube placement (requires ETT size ≥7.5mm)
  * 500ml gastric balloon inflation + 0.5kg traction

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<details>

<summary>What are the anaesthetic risks during gastroscopy?</summary>

**Aspiration:**

* Blood clots may occlude suction
* Requires two working suctions

- **Hemodynamic swings:**
  * Stimulation may cause vagal Bradycardia
  * CO₂ insufflation → reduced venous return

**Airway compromise:**

* Scope may dislodge ETT
* Requires 2-person technique (one for airway, one for scope)

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<details>

<summary>How would you prepare for intra-procedural arrest?</summary>

**Pre-assign roles:**

* Airway: Anaesthetist
* Chest compressions: Surgeon
* Drugs: Nurse

**Equipment check:**

* Defibrillator pads applied pre-procedure
* Emergency O-negative blood in room

**Drug preparation:**

* Adrenaline 1:10,000 drawn up
* Calcium chloride ready (for citrate toxicity)

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<details>

<summary>The retrieval team is delayed. Would you give vasopressin?</summary>

**Terlipressin preferred:**

* 2mg IV stat then 1mg q4h
* Selective V1 receptor action → fewer cardiac side effects

**Vasopressin alternative:**

* 0.01-0.04 units/min infusion
* Requires arterial line for BP monitoring

**Monitoring:**

* Watch for hyponatremia (SIADH effect)
* Limb ischemia risk in peripheral administration

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<details>

<summary>What are the CVC insertion risks in this patient?</summary>

**Bleeding (most significant):**

* Femoral site allows direct compression
* IJ approach risks carotid puncture

**Infection:**

* Cirrhotic patients have 5x higher CLABSI risk

**Technical:**

* Ultrasound guidance reduces complications by 60%
* Avoid subclavian (high pneumothorax risk)

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<details>

<summary>How would you hand over to retrieval?</summary>

**ISBAR format:**

* **I:** "This is Dr Smith from Scenarioville ED"
* **S:** "50M cirrhotic with uncontrolled variceal bleed"
* **B:** "6U PRBC, 4FFP given, ETT in situ"
* **A:** "Currently MAP 70 on noradrenaline 0.1mcg/kg/min"
* **R:** "Urgent transfer for possible TIPS"

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**Critical Phrases:**

* "Peripheral IV first, IO if delayed, femoral CVC if needed"
* "MTP with 1:1:1 ratio, but no platelets in Scenarioville"
* "Monitor lactate clearance and fibrinogen trends"
* "RSI with ketamine + rocuronium, not propofol/sux"
* "Video laryngoscopy + bougie as first choice"
* "Limit PEEP to <10cmH₂O in portal hypertension"
* "Graded assertiveness: advise → suggest → assert → escalate"
* "Terlipressin as pharmacologic bridge"
* "ISBAR handover with transfusion totals"

#### **Key Concepts Covered:**

1. **Cirrhosis-specific resuscitation:**
   * Avoid over-transfusion (target Hb 70-80)
   * Early FFP/cryoprecipitate for coagulopathy
2. **Airway in GI bleed:**
   * RSI with hemodynamically stable induction
   * Video laryngoscopy first-line
3. **Resource-limited practice:**
   * No platelets in Scenarioville
   * 2hr retrieval time impacts decision-making
