No problem, Just a Lap Chole

[Noyac]

So if this guy managed to bag any of those arteries placing trochars then his operating days need to end. That's just crazy.

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[risnwb]

I heard a case from a buddy of mine where the gyn "surgeon" made a nice hole in the aorta with a trochar.... Luckily it was a VERY small hole and vascular just came in and out in a stitch, but still, I like the idea of trochar induced retroperitoneal bleed. Where the hell else is the blood going...

 

[deleted171991]

I heard a case from a buddy of mine where the gyn "surgeon" made a nice hole in the aorta with a trochar.... Luckily it was a VERY small hole and vascular just came in and out in a stitch, but still, I like the idea of trochar induced retroperitoneal bleed. Where the hell else is the blood going...

Similar story here, but it was one of the iliac vessels.

 

[Noyac]

Ok so what's the story? Is that what happened here or what?

 

[pd4emergence]

Curiously, what did her urine look like? If she had hemolysis on this level with DIC, there should be some pink tinge starting to show I would think. In that case, maybe sodium bicarb ain't such a bad idea after all.

It was dark, like coffee dark.....

 

[Noyac]

It was dark, like coffee dark.....

well there you go. The fun is just beginning.

 

[pd4emergence]

Ok, sorry to let things linger, but couldn't get back to the thread. About the time of the second set of labs, I looked at her urine to check urine output. It wasn't concentrated, it was really dark. Before we started any blood. The surgeons were working. They looked for bleeding multiple times. They looked for a retroperitoneal hematoma. Nothing. Luckily, I noticed the urine before we started giving blood. It looked strange to me at the time but the total clinical picture had not become apparent. Once we started giving blood and her hemoglobin did not improve despite the fact that we did not seem to have any significant bleeding, I figured she was having some profound hemolysis. This was present before we gave blood. We started pouring the products to her. When the surgeons reviewed her CT, they left it up on the monitor. She had some free air and multiple gas filled abscesses. So we gave blood, and more products. We got a few rounds of labs. We gave more zosyn. Her hemodynamics weren't terrible considering, but her labs were looking worse and worse. More acidosis, increasing lactate. Hemoglobin would not go up. Why was she hemolyzing? Why wasn't she getting any better?

 

[Planktonmd]

Ok, sorry to let things linger, but couldn't get back to the thread. About the time of the second set of labs, I looked at her urine to check urine output. It wasn't concentrated, it was really dark. Before we started any blood. The surgeons were working. They looked for bleeding multiple times. They looked for a retroperitoneal hematoma. Nothing. Luckily, I noticed the urine before we started giving blood. It looked strange to me at the time but the total clinical picture had not become apparent. Once we started giving blood and her hemoglobin did not improve despite the fact that we did not seem to have any significant bleeding, I figured she was having some profound hemolysis. This was present before we gave blood. We started pouring the products to her. When the surgeons reviewed her CT, they left it up on the monitor. She had some free air and multiple gas filled abscesses. So we gave blood, and more products. We got a few rounds of labs. We gave more zosyn. Her hemodynamics weren't terrible considering, but her labs were looking worse and worse. More acidosis, increasing lactate. Hemoglobin would not go up. Why was she hemolyzing? Why wasn't she getting any better?

So she did not start hemolyzing until you started the surgery since her hemoglobin was ok preop.
Which means the laparoscopy has pushed something in the blood stream that caused hemolysis.
This makes me think of a clostridial infection inside the abdomen which explains the gas in the abscesses, probably secondary to a genital infection, and the laparoscopy has caused some infectious debris to enter the circulation and cause this DIC type reaction.

 

[Noyac]

Vascular injury with the initial trochar placement is a known risk, especially if they use a Veress technique. and I've seen it happen to a very good technical surgeon.

Yes agreed. I always pay close attention when the veress needle is going in. Usually more common when we are working in the pelvis but I know of a bad case of veress in the liver. Anyway, when the veress goes into something bad it isn't the bleeding that causes the issue, it's the air embolism. The only issue I've really seen with trochars is bleeding at the ports. But I understand that this can happen.

All this said, these complications are not very high on my index of suspicion in this case.

 

[dpmd]

So, I see this lady in the holding area and she has the look of somebody on the way to getting sicker. She has a 20g. IV and it looks like the ER was lucky to get that. BP's and HR are as above and stable. We open up her fluids and head to the OR, induce (gently), RSI, and she did ok with induction. Place an aline and CVL. With two good IV's I might have tried it but she just didn't have any other viable possibilities and she looked like she needed a CVL. I ask the resident in the room to draw an abg, coags, cbc, lactic acid and step out to put out other fires. They get started. It takes awhile to get the gallbladder exposed. In the mean time the labs come back with the expected septic looking picture ph of about 7.28, be around -5, LA around 2, hgb of 10, INR 1.2 and a PTT that was a little bit above normal. Also, when they get to the gallbladder, it does not look infected, it's not ruptured, it looks pristine. What do you think of the labs? What should be done next?

When you mentioned free air around the gallbladder (not within the wall) I figured things were going this direction. Next is to look for the perfed viscus that actually is the problem. I have taken some really bad ugly gallbladders out and I haven't had one yet that I didn't at least try lap first, but even if the gallbladder perfs it isn't going to give you free air so I would've brought the lady for an ex lap for perfed viscus not a lap chole.

 

[dpmd]

And now that I caught up I have to say I have no idea how this case got started as a lap chole at all. We still haven't explained why the bili was high to begin with which I am guessing is going to explain your dark urine.

 

[pd4emergence]

So she did not start hemolyzing until you started the surgery since her hemoglobin was ok preop.
Which means the laparoscopy has pushed something in the blood stream that caused hemolysis.
This makes me think of a clostridial infection inside the abdomen which explains the gas in the abscesses, probably secondary to a genital infection, and the laparoscopy has caused some infectious debris to enter the circulation and cause this DIC type reaction.

You know, I had not really thought of the laparoscopy causing some seeding from her infectious source. But it does make sense.

 

[dpmd]

Interesting about the seeding thought. There are some nasty suppurative appys i have done laparoscopically and i always expect an inflammatory response postop but attribute it to stirring up the nastiness while getting the appy out, but maybe there is a transient push of bugs into the system from the pneumoperitoneum that factors in. Wouldn't push me to change approach though because i think open wouldn't end up better for them. Now if you are talking about what sounds like an inappropriate use of laparoscopy (and now things are sounding like naybe nonop management with ir drainage of abscess could have been a consideration, depending on if we are talking free air with a peritoneal exam versus gas containing abscess with a more benign belly exam) that is different.

 

[pd4emergence]

Interesting about the seeding thought. There are some nasty suppurative appys i have done laparoscopically and i always expect an inflammatory response postop but attribute it to stirring up the nastiness while getting the appy out, but maybe there is a transient push of bugs into the system from the pneumoperitoneum that factors in. Wouldn't push me to change approach though because i think open wouldn't end up better for them. Now if you are talking about what sounds like an inappropriate use of laparoscopy (and now things are sounding like naybe nonop management with ir drainage of abscess could have been a consideration, depending on if we are talking free air with a peritoneal exam versus gas containing abscess with a more benign belly exam) that is different.

I don't know that I can comment on non op management. This ended up being a tuboovarian abscess. In my mind, I don't know that this would have gotten better without a surgery. But, I'm not a surgeon. I think the increased bili was from hemolysis. It was probably already started beforehand. But that's just speculation on my part.

 

[pd4emergence]

This is what we eventually did. We broadened her antibiotic coverage adding vanc and clinda. I don't know that the vanc was totally necessary but what the hell. We got out of there as quickly as I could get the gyns to finish. Continued with the blood products. By the end of the case she seemed to still be hemolyzing (at one point I saw a hgb of 5) but her coagulopathy seemed to be starting to get a little better. We continued on levophed and vaso and had to titrate up some but not to toes falling off rates. We got her to the unit and about an hour later she seemed to quit with the hemolysis. Blood cultures when she got to the unit grew C. perfringens in all tubes. She spent about 4-5 days intubated and on pressors but was eventually weened off and went to the floor.

 

[dpmd]

I am not a gyn but after they are done saying it must be an appy even when a normal appy is visualized they usually don't operate on toa. This is obviously not the typical case but it still is a thought. That or maybe a quick lap rinsy rinsy and whatever they do to the tube, then drains and gtfo. Of course that would rely on a gyn doing a quick lap case so...

 

[dpmd]

I don't know that I can comment on non op management. This ended up being a tuboovarian abscess. In my mind, I don't know that this would have gotten better without a surgery. But, I'm not a surgeon. I think the increased bili was from hemolysis. It was probably already started beforehand. But that's just speculation on my part.

Did they have d bili and c bili? I am guessing not if someone was going down the biliary path for something that clearly turned out not to be.

 

[Planktonmd]

This is what we eventually did. We broadened her antibiotic coverage adding vanc and clinda. I don't know that the vanc was totally necessary but what the hell. We got out of there as quickly as I could get the gyns to finish. Continued with the blood products. By the end of the case she seemed to still be hemolyzing (at one point I saw a hgb of 5) but her coagulopathy seemed to be starting to get a little better. We continued on levophed and vaso and had to titrate up some but not to toes falling off rates. We got her to the unit and about an hour later she seemed to quit with the hemolysis. Blood cultures when she got to the unit grew C. perfringens in all tubes. She spent about 4-5 days intubated and on pressors but was eventually weened off and went to the floor.

Excellent case... and I could smell the clostridium from over here

 

[Ignatius J]

This is what we eventually did. We broadened her antibiotic coverage adding vanc and clinda. I don't know that the vanc was totally necessary but what the hell. We got out of there as quickly as I could get the gyns to finish. Continued with the blood products. By the end of the case she seemed to still be hemolyzing (at one point I saw a hgb of 5) but her coagulopathy seemed to be starting to get a little better. We continued on levophed and vaso and had to titrate up some but not to toes falling off rates. We got her to the unit and about an hour later she seemed to quit with the hemolysis. Blood cultures when she got to the unit grew C. perfringens in all tubes. She spent about 4-5 days intubated and on pressors but was eventually weened off and went to the floor.

Great job. Thanks for sharing. Very interesting case.

 

[pd4emergence]

Did they have d bili and c bili? I am guessing not if someone was going down the biliary path for something that clearly turned out not to be.

I honestly don't remember the numbers. I would guess they were available and probably showed an early hemolysis picture.

 

[vector2]

Great case, hope you wrote it up. Only a dozen or so good case reports floating out there about C. perfringens-associated massive hemolysis- mortality appears to be upwards of 80-90% unless recognized very early and appropriate abx started.

This is what we eventually did. We broadened her antibiotic coverage adding vanc and clinda. I don't know that the vanc was totally necessary but what the hell. We got out of there as quickly as I could get the gyns to finish. Continued with the blood products. By the end of the case she seemed to still be hemolyzing (at one point I saw a hgb of 5) but her coagulopathy seemed to be starting to get a little better. We continued on levophed and vaso and had to titrate up some but not to toes falling off rates. We got her to the unit and about an hour later she seemed to quit with the hemolysis. Blood cultures when she got to the unit grew C. perfringens in all tubes. She spent about 4-5 days intubated and on pressors but was eventually weened off and went to the floor.