1% Terror

[supahfresh]

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So I finally had my 1 percent terror 8 months into my CA-1 year. I've had some pants poopers before but this was a good one.

57 yo male, vietnam vet, tough as nails with every disease, CAD, DM, HTN, COPD, big smoker, drinker, PTSD. comes in for a redo lum lam. Case takes forever - 10 hours, mainly because the surgeon is slow.

blood loss in the 9th hour is about 700. fluids so far-roughly 6L crystalloid, 1L colloid. i'm giving him back about 300-400 from the cell saver. BP starts to get weak, hanging in the 80s-90s, needing more and more phenylephrine. I go back and see the suction chamber has over a liter more fluid than it did 30 minutes ago.

"hey, did you guys just loose a ton of blood?"
surgeon--"well, it just keeps coming."

it does appear that they may have lost over a liter or more in 30 min so, i check a crit -31 which was up from 28 when i started his cell saver.

suddenly, bp drops to the 40s. i check the transducer, re-zero, etc. everything is working. so i start with the epi. recheck crit-still 31. the surgeon freaks out and quickly closed. we flipped him and dropped in the echo. wall motion fine, but the heart is empty. bp now 39. dumped in 2 units of blood, and a bunch of fluid.

any thoughts about what happend next?

 

[vegas]

So I finally had my 1 percent terror 8 months into my CA-1 year. I've had some pants poopers before but this was a good one.

57 yo male, vietnam vet, tough as nails with every disease, CAD, DM, HTN, COPD, big smoker, drinker, PTSD. comes in for a redo lum lam. Case takes forever - 10 hours, mainly because the surgeon is slow.

blood loss in the 9th hour is about 700. fluids so far-roughly 6L crystalloid, 1L colloid. i'm giving him back about 300-400 from the cell saver. BP starts to get weak, hanging in the 80s-90s, needing more and more phenylephrine. I go back and see the suction chamber has over a liter more fluid than it did 30 minutes ago.

"hey, did you guys just loose a ton of blood?"
surgeon--"well, it just keeps coming."

it does appear that they may have lost over a liter or more in 30 min so, i check a crit -31 which was up from 28 when i started his cell saver.

suddenly, bp drops to the 40s. i check the transducer, re-zero, etc. everything is working. so i start with the epi. recheck crit-still 31. the surgeon freaks out and quickly closed. we flipped him and dropped in the echo. wall motion fine, but the heart is empty. bp now 39. dumped in 2 units of blood, and a bunch of fluid.

any thoughts about what happend next?

yeah!, the surgeon probably went RAMBO on anesthesia 😉

what inhalation agent were you using?

 

[Noyac]

I'll bet he got into a big vein, possibly Illiac.

 

[InGasWeTrust]

Im still wet behind the ears but.....


HCt like that me think hemoconcentrated.....proceed to yell at yourself for not keeping up w/ ebl , then yell at the surgeon for not sac'n up and telling you "houston we have a problem"

 

[Soon2BENT]

very interesting. any people say anesthesia is boring! 1 year and 3 months away. where? i have no clue. hopefullly somewhere rainy with monument that looks like a giant syringe.

 

[militarymd]

Well, the patient either got better with volume resuscitation or didn't...so which is it?


"distributory" shock is another thing to consider.....vasopressors can sometimes "fill" the heart.

 

[VentdependenT]

does he still have his fingers n' toes after that clamped down on his empty peripheral vasculature?

Whatever happened I'm sure a big ol fat ass line went in somewhere's followed by a fully charged level one or a belmont. All this while you are resolving the hypovolemic induced PEA which is probably in full gear.

Rock on!

 

[seattledoc]

venous air embolism could have caused this.
But I'd have to think the volume must have improved things.

 

[supahfresh]

The first thing that went through my head was that the surgeon ripped into the aorta and he had a massive retroperitoneal bleed.

His pressure did improve with blood and fluid and I actually had badass lines in from the start of the case. but yes, we placed an ij during this time. we got him stabilized after 2 units of blood and 2 more liters of fluid. then we took him straight to CT to scan his chest and belly. it was clean. took him to the unit and he did well over night. extubated in the am, feeling great. no problems whatsoever.

I felt like I was on top of his blood loss. I was dumping in cellsaver and checking the field and looking at the suction containers quite frequently. During that 30 minutes, the surgeon never mentioned a big blood loss. So what do you guys think? What about an allergic reaction? I was giving him vec during the whole case and I redosed him with ancef 1g at hour 4 and hour 8. or just behind on fluids.

The surgeon actually was extremely thankful with how we handled everything and stood and watched while we took over.

 

[toughlife]

The first thing that went through my head was that the surgeon ripped into the aorta and he had a massive retroperitoneal bleed.

His pressure did improve with blood and fluid and I actually had badass lines in from the start of the case. but yes, we placed an ij during this time. we got him stabilized after 2 units of blood and 2 more liters of fluid. then we took him straight to CT to scan his chest and belly. it was clean. took him to the unit and he did well over night. extubated in the am, feeling great. no problems whatsoever.

I felt like I was on top of his blood loss. I was dumping in cellsaver and checking the field and looking at the suction containers quite frequently. During that 30 minutes, the surgeon never mentioned a big blood loss. So what do you guys think? What about an allergic reaction? I was giving him vec during the whole case and I redosed him with ancef 1g at hour 4 and hour 8. or just behind on fluids.

The surgeon actually was extremely thankful with how we handled everything and stood and watched while we took over.

By now you should know that comments like this do not sit well with misterioso.

Awesome job !

 

[Noyac]

👍 I'm impressed b/c that much bleeding doesn't come all of a sudden without hitting something big. So if he hadn't hit the iliac then that **** was there just pooling and waiting for some suction. Either way, I always stand up and watch the case as it goes by for one reason or another. That way I know early on when the blood letting is coming, not that you did any different. Trust me, you will enjoy private practice. The surgeons are better.

Just remember, that 300 mls in the cell saver means 900ml blood loss. You were probably way behind from the start and therefore lost ground when the bozo started his bloodletting.

And about your surgeon being thankful with how you handled his disaster. Don't hang yourhat on that one. They are not as thankful in private practtice, they expect it. But then again so will you.

Nice Job. 👍

 

[supahfresh]

👍 I'm impressed b/c that much bleeding doesn't come all of a sudden without hitting something big. So if he hadn't hit the iliac then that **** was there just pooling and waiting for some suction. Either way, I always stand up and watch the case as it goes by for one reason or another. That way I know early on when the blood letting is coming, not that you did any different. Trust me, you will enjoy private practice. The surgeons are better.

Just remember, that 300 mls in the cell saver means 900ml blood loss. You were probably way behind from the start and therefore lost ground when the bozo started his bloodletting.

And about your surgeon being thankful with how you handled his disaster. Don't hang yourhat on that one. They are not as thankful in private practtice, they expect it. But then again so will you.

Nice Job. 👍

Estimating blood loss has been frustrating for me. I think in another year I'll be able to stand up and watch more, but sometimes I'm just to damn busy with my own thing. As far as miscalculating the blood loss, if I use the cell saver chamber total and subtract the irrigation plus the heparin flush that should give me my total. Then the total in the chamber plus the laps and whats on the field or on the floor is my EBL. But, this always hinges on whether the scrub tells me the accurate amount of irrigation they have used. Sometimes they are just not accurate at all. any tips on how to handle this?

 

[supahfresh]

I've discussed this case with my attending whom I had come in the room before the BP crashed and the rest of the case as you would expect. He doesn't believe that there was a big blood loss that caused this, although he offers no other explanation. allergic reaction maybe. Although he got 2 units of donated blood, I gave them after his pressure crashed so transfusion reaction not possible. Unless of course you can get some kind of reaction to your own cellsaver blood, but that doesnt seem possible, unless heparin could have caused a reaction.

 

[Idiopathic]

unless heparin could have caused a reaction.

certainly not out of the realm of possibility. i wouldnt bet on it here though. since it was a redo, isnt it likely/possible that something was adhered to something else important, that got taken down and the **** hit the fan? perhaps your crit didnt have time to catch up to the loss. end tidal co2/pulse o2 stable before this? Ischemic change on EKG? I cant imagine the scenario you describe without some ischemic insult.

i agree with a big vein.

 

[militarymd]

Were the surgeons using surgicel , topical thrombin or other topical procoagulants?


they can cause systemic inflammation.

 

[supahfresh]

Were the surgeons using surgicel , topical thrombin or other topical procoagulants?


they can cause systemic inflammation.

I don't know what they used. But you're right, they usually use these topical agents in these cases.

Idio, I still have questions about the Hct. It was 31,31,31, then all of sudden 26 after we were well underway with our resuscitation. I thought that perhaps the hct takes time to reflect the loss. However my attending told me that the patient should have immediately begun redistributing fluid back into the intravascular space and the hct should change immediately. not sure what to believe about that one.

pulse ox and co2 were stable. st was showing signs of depression.

 

[UTSouthwestern]

Ahhh how I don't miss the double digit lumbar laminectomy of academia.

Your private practice lami's take 1-2.5 hours, typically do not need cellsaver or A line, and you usually will put in a single 18 or 16 ga IV.

Ten hours in the prone position is just asking for multiple distasters.

Were your using a Jackson frame, OSI, or other type of frame/bed? Ten hours in a Jackson frame while having to infuse a lot of fluid lends itself to dependent edema extraordinaire and possible IVC compression --> marked though usually incremental decrease in preload. I have, however, reviewed one case for trial in which a precipitous drop occurred as fluid was rapidly and overgenerously infused --> caval compression --> BP to the ****ter.

 

[Idiopathic]

Idio, I still have questions about the Hct. It was 31,31,31, then all of sudden 26 after we were well underway with our resuscitation. I thought that perhaps the hct takes time to reflect the loss. However my attending told me that the patient should have immediately begun redistributing fluid back into the intravascular space and the hct should change immediately. not sure what to believe about that one.

That drop makes sense, but after 7 liters of fluid (6 of crystalloid) youd expect to see at least some normal dilution before that, right? Im surprised that HCT was 31 for all that time, especially with all that fluid. How is this guy doing now, btw?

 

[Idiopathic]

IVC compression --> marked though usually incremental decrease in preload. I have, however, reviewed one case for trial in which a precipitous drop occurred as fluid was rapidly and overgenerously infused --> caval compression --> BP to the ****ter.

I was also considering this, either in the form of compression (more likely) or some sort of crazy clot (much less likely)

 

[supahfresh]

That drop makes sense, but after 7 liters of fluid (6 of crystalloid) youd expect to see at least some normal dilution before that, right? Im surprised that HCT was 31 for all that time, especially with all that fluid. How is this guy doing now, btw?

sorry, let me clarify. things are a little hazy but
hct's were something like this:
36
34
32
31 still fine, getting cellsaver ready, giving colloid
28 still fine, giving cellsaver and more colloids
31 badness, 2 units started
31 still badness 2 units going in
26 still bad, but almost over

UT, which is the jackson frame? Is that the one with the openings so that the fat belly can hang thru? because we didnt use that one. this bed was your basic OR table.

 

[Idiopathic]

28 still fine, giving cellsaver and more colloids
31 badness, 2 units started

So this is obviously where the confusion comes from. The cellsaver must have given back PRBC's essentially. Does your device typically hemoconcentrate? Some do...

 

[UTSouthwestern]

UT, which is the jackson frame? Is that the one with the openings so that the fat belly can hang thru? because we didnt use that one. this bed was your basic OR table.

The Jackson frame is the one with the belly hanging opening down the center of the grame.

Just using the regular OR table with jelly rolls is even worse than the Jackson.

 

[supahfresh]

The Jackson frame is the one with the belly hanging opening down the center of the grame.

Just using the regular OR table with jelly rolls is even worse than the Jackson.

what makes it worse? and why use the jackson frame?

yes, our cellsaver concentrates the RBCs.

 

[UTSouthwestern]

what makes it worse? and why use the jackson frame?

yes, our cellsaver concentrates the RBCs.

The frame, although padded, is composed of two solid, parallel, crescent shaped rods that counter the normal lumbar lordosis and provide a better exposure and curvature of the spine. Unfortunately, the majority of the patient's weight will be distributed to the anterior surfaces in contact with the frame and for your larger patients, that pressure/surface area ratio can be extremely high and compressive.

Fluid boluses following gravity add to the pressure experienced by the dependent tissues and the body being soft and compressible as it is will begin to experience increasing surface and intracavitary pressures which can be transmitted to venous capacitance vessels, the IVC, and even epidural venous plexi. This is one reason that long running back surgeries tend to get bloodier as time passes.

 

[VentdependenT]

you brilliant bastard

 

[Lizard1]

The frame, although padded, is composed of two solid, parallel, crescent shaped rods that counter the normal lumbar lordosis and provide a better exposure and curvature of the spine. Unfortunately, the majority of the patient's weight will be distributed to the anterior surfaces in contact with the frame and for your larger patients, that pressure/surface area ratio can be extremely high and compressive.

Fluid boluses following gravity add to the pressure experienced by the dependent tissues and the body being soft and compressible as it is will begin to experience increasing surface and intracavitary pressures which can be transmitted to venous capacitance vessels, the IVC, and even epidural venous plexi. This is one reason that long running back surgeries tend to get bloodier as time passes.

maybe someday this will just roll off my tongue 😀 ... hopefully by the time orals come around

 

[ThinkFast007]

so now that everyone is waaaaaaaaaaaay past their CA1 year, do you all think you can better handle the stress. Do those things that used to 'scare the begizers out of ya, still do it?"

what were the tricks that enabled you to do so?

Thanks

~thankful future CA1s 🙂

 

[CanGas]

No tricks. Simply experience from seeing most types of cases by now and the knowledge that you can get a tube in, get an IV or line in and run with the pressors.

That and the understanding that a ruptured AAA or crash CABG has a >50% chance of dying despite your best efforts makes it a little easier to take when things go south.

That said a stat C-section for fetal distress, or a "difficult" intubation on the floor still makes me anxious. But again that is probably because my number of those cases are still relatively small.

Actually I guess I do have a trick. It is called keeping your head when everyone else is loseing theirs. Simply by presenting a calm exterior helps to keep the interior calm. How many times have you arrived at a code and while everyone is trying to get an IV or line but no one has even gotten an IV set ready? Keep your head, manage the ABCs and delegate properly and everything will go as best as it can.

 

[nimbus]

I've discussed this case with my attending whom I had come in the room before the BP crashed and the rest of the case as you would expect. He doesn't believe that there was a big blood loss that caused this, although he offers no other explanation. allergic reaction maybe. Although he got 2 units of donated blood, I gave them after his pressure crashed so transfusion reaction not possible. Unless of course you can get some kind of reaction to your own cellsaver blood, but that doesnt seem possible, unless heparin could have caused a reaction.

If there is a bunch of blood in the bucket, and the echo shows an empty heart, and the patient responds to volume, then the old vet was hypovolemic/exsanguinated. Your attending needs to go to common sense school.

BTW nice save. 10 hrs??? Jeeeeeeeesssssh

 

[nimbus]

Was the patient becoming progressively acidemic during the case? Would be interesting to see serial ABGs

 

[supahfresh]

progressivley acidemic, yes. sure seemed like he bled to me.