- ECG
- Pulse Oximetry
- Blood Pressure (Indirect, Direct)
- Hourly Fluid Balance
- Central Venous Pressure
- Body Temperature
- Capnometry
- Abdominal Ultrasound
- Cardiac Ultrasound
- EEG
- Brain CT (as indicated)
- Abdominal and Chest CT
- Laboratory Data
Goal: to maintain hemodynamic parameters and protect organs from ischemia.
Rule of 100:
- Systolic BP – 100 mmHg
- CVP – 100 mmH2O
- Heart Rate – 100 bpm
- Urine Output – 100 mL/hour
- Hemoglobin – 100 g/L
- PaO2 – 100 mmHg
- Dopamine ≤ 10 mcg/kg/min
- Dobutamine < 15 mcg/kg/min
- Epinephrine < 0.1 mcg/kg/min
- Norepinephrine – 2–4 mcg/kg/min
General care measures continue, including hygienic care of the skin and oral cavity, prevention of pressure sores, sanitation of the tracheobronchial tree, drainage of stagnant gastric contents, care of the cornea, and strict adherence to aseptic and antiseptic protocols.
Procedures
- Catheterization of the central and two peripheral veins
- Catheterization of the radial artery
- Foley urinary catheter
- Gastric tube
Monitoring of vital functions with hourly parameter recording in the observation chart.
- ECG, HR, SpO₂ – continuously
- Non-invasive BP – every 5–10 minutes
- Invasive BP (radial artery) – continuously
- CVP – continuously (via monitor) or hourly
- Diuresis – hourly
- Rectal or esophageal temperature – hourly
Monitoring of laboratory parameters:
Initial tests:
- Complete blood count (full cellular composition, hematocrit, hemoglobin)
- Biochemical blood analysis (glucose, electrolytes, osmolality, urea, creatinine, total protein, albumin, total and fractionated bilirubin, ALT, AST, ALP, LDH)
- Coagulation profile (PT, aPTT, INR, fibrinogen)
- Blood gas analysis and acid-base balance
- General urinalysis
Repeat every 4 hours:
- Hemoglobin, hematocrit, erythrocytes, platelets
- Sodium, potassium, creatinine, urea, glucose
- Acid-base balance and blood gases
Repeat blood glucose analysis every 1–2 hours if:
- Blood glucose is <5.0 mmol/L or >8.0 mmol/L
- Insulin is being administered
Donor examination:
- Chest X-ray
- ECG
- Blood group and Rh factor
По показаниям:
- Abdominal ultrasound
- Echocardiography
- Fibrobronchoscopy, etc.
Systemic hemodynamic parameters and correction:
Goal:
- HR: 60–110 bpm
- Mean arterial pressure (MAP): 60–90 mmHg
- Systolic BP: 100–160 mmHg
- CVP: 4–10 mmHg
Arterial Hypertension
Systolic BP >160 mmHg, Mean BP >90 mmHg
- Brevibloc (Esmolol) – Bolus 100–500 mcg/kg, then infusion 100–300 mcg/kg/min
- Nitroglycerin (Perlinganit) – Infusion 2–10 mg/hour
Arrhythmias
- Rule out hypothermia, hypovolemia, electrolyte imbalances, and acid-base disorders.
- Ventricular Arrhythmias – Lidocaine, Amiodarone
- Supraventricular Arrhythmias – Amiodarone
- Bradyarrhythmia – Epinephrine, Isoproterenol (atropine is ineffective)
Arterial Hypotension
Mean BP <60 mmHg, Systolic BP <90 mmHg
- Ensure normovolemia (CVP 6–10 mmHg, Ht 0.28, urine output ≥1.0 ml/kg/hour)
- Inotropes and vasopressors:
- Dopamine ≤10 mcg/kg/min (or Dobutamine ≤10 mcg/kg/min)
- Phenylephrine ≤0.05 mcg/kg/min (or Norepinephrine ≤0.05 mcg/kg/min)
- Epinephrine ≤0.05 mcg/kg/min
- ECG (to rule out MI)
- Echocardiography (Left Ventricular Ejection Fraction ≥45%)
- (+/-) Pulmonary artery catheterization
Infusion Therapy
Goals:
- CVP: 4–10 mmHg
- Urine output: 1–3 ml/kg/hour
- Sodium: 130–150 mmol/L
- Glucose: 5.0–8.0 mmol/L
- Hematocrit (Ht): 30, Hemoglobin (Hb): 100 g/L
Initial Volume Replacement – Based on BP, HR, CVP, and urine output:
- Crystalloids: 0.9% NaCl, Ringer’s solution
- Hydroxyethyl starch 6%
- Albumin 5–10%
- Dextrans: Avoid
- (+/-) Gelofusine
- Blood products (if indicated)
Maintenance of Volume – Choose based on blood Na and glucose levels:
- 0.9% NaCl, or
- 5%-20% Glucose, or
- 0.45% NaCl + 5% Glucose
Anemia
Goal: Ht 30, Hb 100 g/L
- Rule out ongoing bleeding
- If Ht <20 or Hb <60 g/L – Transfuse 2 units of red blood cell mass
Coagulopathy
Goals:
- Platelets >80–100 x 10³/µL
- Fibrinogen: 2–4 g/L
- PT <14.5 seconds
- APTT <36.5 seconds
- INR <2.0
Rule Out: Hypothermia, hemodilution, dextran use
Correction for Clinically Significant Coagulopathy:
- Platelets <50 x 10³/µL – Platelet transfusion
- PT >15 seconds or APTT >38 seconds – Fresh frozen plasma (FFP)
- Fibrinogen <1.5 g/L – Cryoprecipitate
Blood Glucose
Goal: 5–8 mmol/L
Hypoglycemia (<4 mmol/L):
- Administer 40–60 ml of 40% Glucose IV
- Recheck glucose levels in 15 minutes and after 1 hour
- Repeat glucose administration if hypoglycemia persists
Hyperglycemia:
Insulin infusion in 0.9% NaCl (1 unit/ml) at the following rates:
- 8–12 mmol/L: 1 unit/hour
- 12.1–16 mmol/L: 2 units/hour
- 16.1–20 mmol/L: 3 units/hour
- 20 mmol/L: 0.1 unit/kg/hour
Monitoring:
- Every 2 hours for blood glucose >12 mmol/L, every hour.
- Reduce infusion rate by 50% once levels reach 5–8 mmol/L.
- If reduction rate is ≥3 mmol/L over 2 hours, maintain infusion rate.
- If reduction is <3 mmol/L or glucose increases, raise infusion by 1 unit/hour and add a 2–8 unit bolus for glucose >12 mmol/L.
Polyuria
Goal:
- Urine output 1–3 ml/kg/hour (75–150 ml/hour)
- Sodium 130–150 mmol/L
Rule Out:
- Physiological diuresis (fluid overload) – Adjust infusion volume
- Osmotic diuresis (hyperglycemia >11 mmol/L) – Insulin
- Osmotic and saluretic diuretics (e.g., mannitol, furosemide) – Discontinue diuretics, replace losses considering blood glucose and Na levels
Diabetes Insipidus
- Urine output >4 ml/kg/hour
- Urine specific gravity <1.005
- Hypernatremia >150 mmol/L
- Serum osmolality >310 mOsm/L, urine osmolality <300 mOsm/L
Correction:
- If urine output <200 ml/hour – Infuse 5% glucose solution in a volume equal to urine output
- If urine output >200 ml/hour – Desmopressin every 6–8 hours
- Emosint 2–6 mcg IV
- Minirin (tablets) 0.2–0.6 mg via gastric tube
- Adiuretin (nasal drops) 2–4 drops (0.2–0.4 mcg)
Electrolytes
Sodium (Goal: 130–150 mmol/L):
Potassium (Goal: 3.5–5.0 mmol/L):
Acid-Base Balance (ABG)
Goal: pH 7.35–7.45