Quick case from last week.

[sevoflurane]

4:00am. You get a call from your surgeon.

67 y/o male coming to the OR because IR can't embolize a large ruptured splenic artery aneurysm.
You get to the hospital, go to the ICU. Blood hanging through a couple of AC's. B.P.s in the 60's.
You tell the OR team that we need to go now.
To the OR table. Induction with 50 of ketamine, 30 of propofol, 100mg of roc + 300mcg neo flush. First B.P. after induction is 58/35. Volitiles are turned down to .2 mac and this is followed by .4mg of scopolamine.
As the surgeons open up the belly, Mac catheter goes in under the drapes followed by a-line.
CBC/BMP/Coags and lactate sent out.
I peak over the drapes and see a pool of blood raising in the belly.
I ask our surgeon if he has control? He says no.
Hgb comes back at 4.6. The patients skin color is starting to ash.

5 minutes later, your surgeon says he has his finger in the dike.

What is your plan at this point?

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[BuzzPhreed]

Skip to the punchline: did you leave the OR in a stretcher or a body bag?

In the meantime, massive transfusion protocol. Hope you got a cordis in the neck. Either way, this is a no-lose situation.

 

[sevoflurane]

Either way, this is a no-lose situation.

You can still win this battle though. This isn't going to be a long thread, but there is a message in it I think merits special attention for those who are in training/recent grads, or those who don't do trauma frequently .

 

[BuzzPhreed]

I'll let the residents play, but I'd also have a lot of calcium chloride in the room and I'd check a lactate and ABG with the iStat to see how far behind I was, as well as pushing as much blood product as fast as they could get it to me.

(Reminds me of a case I did recently where there was a bleeding jejunal AVM and the patient came to the OR with a Hb of 5.4. This happened after having been scoped, prodded, examined, etc. for a week, during which time she had received a total 35 units of RBCs up to that point. She went home 10 days after having the offending part of her intestine removed.)

 

[sevoflurane]

Hope you got a cordis in the neck.

I prefer the Mac catheter to just about anything. Bilateral rics with a belmont ready to go is prolly the exception. I didn't have this luxury unfortunately.

 

[pgg]

Ideally you've got some kind of rapid infusion device, pick your brand, with a person or two dedicated to checking blood products and running the infusion device. You really need extra hands on the anesthesia side of the drapes to keep up so call for help early. 1:1:1 transfusion ratios. Get the room Africa hot and try to keep the patient warm. Calcium. TXA. Survival's going to hinge on a surgeon who can both achieve hemostasis and know when to quit, and a good blood bank with a massive transfusion protocol that's been used or drilled recently.

 

[FSUseminoleEM1]

M2 future anesthesia hopeful here. We're in our last block of 2nd year which happens to be CNS, so I'm finally recognizing these drugs you all talk about. Just wanted to stop by and say a big thanks for taking the time to write out these cases.

 

[Stank811]

Other things I would add is watch your BP until the surgeon gets control could be argued in this situation in the setting of no TBI…no need to keep MAPs around 70 before the artery has been controlled. Otherwise agree transfuse in a 1:1:1 as needed but obviously try not to overshoot bc transfusion always carry risk as well. Obtain frequent labs to follow. Also agree with getting the room africa hot and watching calcium and mg. I would through in lung protective ventilation with PEEP when you feel the preload can tolerate reasonable amount of PEEP. And as always frequent communication with surgeon.

 

[okayplayer]

Other things I would add is watch your BP until the surgeon gets control could be argued in this situation in the setting of no TBI…no need to keep MAPs around 70 before the artery has been controlled. Otherwise agree transfuse in a 1:1:1 as needed but obviously try not to overshoot bc transfusion always carry risk as well. Obtain frequent labs to follow. Also agree with getting the room africa hot and watching calcium and mg. I would through in lung protective ventilation with PEEP when you feel the preload can tolerate reasonable amount of PEEP. And as always frequent communication with surgeon.

I am with you up to the LPV part. Why is that indicated here? Are we worried about ARDS or TRALI? Until either manifested itself I think I would favor a routine ventilation strategy.

 

[risnwb]

MAP low until surgeon has control of bleed. Once he had his "finger
In the dike" I'd tell him to leave it there until I have a chance to catch up with transfusion, get a gas, place another line, call for help, etc. once patient is tanked up he can go ahead and try and fix the problem.

The MAC line is great. I'd probably throw in a ric in one of his ac ivs as well and be done with it.


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[okayplayer]

The MAC line is great. I'd probably throw in a ric in one of his ac ivs as well and be done with it.

Seems like you guys are big fans of the RIC. Me, not so much. I feel like it adds an extra step with the dilation and suturing and it doesn't buy you much more in terms of maximal flow rate over a 14g (forget the numbers but they are printed on the package for each). I also worry about long term vascular injury/dvt risk from that thing (obviously not an issue in this case).

One thing I have been meaning to try but haven't had the opportunity to would be to just take one of these ER 18/20g pivs, disconnect and see if blood comes back and then use a guide wire and throw a 14 in. Might need a nick too, not sure. Anyone ever do that as opposed to a RIC?

 

[BuzzPhreed]

I like the RIC but haven't used one in a long time. I remember once a senior resident showing how to put one in and he tore the vein. That thing bleed worse than the surgical site. haha

Like the tranexamic acid idea. Just need time to set it up. And if Sevo was in the OR at 4:00 am by himself he was probably busy with other things. This is like the AAA rupture that comes in at 2:00 AM and you're by yourself. Talk about high sphincter tone in the OR.

TRALI and late transfusion reactions... eh you just deal with those. Better than letting the guy die on the table. The good thing about TRALI is that it happens fast and is gone fast.

Again the 4:00 AM thing is what sucks about this case. You are dead tired yourself and all alone. There is not much worse scenario than this when you call for help and all you hear is chirping crickets.

 

[deleted9493]

I'd suggest finding that big, maybe weakly pulsatile tube just below the diaphragm and getting a cross clamp on it. After that it's just a volume resuscitation with blood products. A good surgeon should be able to cross clamp by palpation, clean up the field and put a ligating suture on the proximal splenic artery in a matter of minutes. Trying to localize the bleeding at the distorted aneurysmal site in a flooded field seems inefficient.

MAC catheter and belmont are ideal here...I have used RI and 14g catheters in large volume loss situations but am more comfortable with the garden hose in the neck.

 

[sevoflurane]

MAP low until surgeon has control of bleed. Once he had his "finger
In the dike" I'd tell him to leave it there until I have a chance to catch up with transfusion, get a gas, place another line, call for help, etc. once patient is tanked up he can go ahead and try and fix the problem.

The MAC line is great. I'd probably throw in a ric in one of his ac ivs as well and be done with it.


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Bingo! Exceptional answer.
The point of this thread is highlighted above. I knew it wouldn't take long.


These are busy cases and one needs to not get caught up in the trees. It is easy to not communicate and carry-on on our side of the drapes. It’s busy. That is for sure.

You absolutely don’t want a high B.P., especially when the patient was conscious with B.Ps in the 60’s. Raising the B.P. too fast or too much can dislodge any hemostatic plug that is already there making your ongoing hemorrhage much worse.


The most important part of this case was communication with the surgeon. Once he told me he had the “finger in the dike” I asked him if he could keep it there before he went after more proximal control. He looked up at me and instantly understood and this move was probably the most important one of the whole case. I needed time to "catch up" as this patient could not afford one extra drop of blood leaving his circulation. For the next 20 minutes we dropped in 6 units of PRBC’s, 4FFP and 4 of platelets + some fluids and albumin. I agree with 1:1:1, but this guy needed Hgb more urgently.


So our vascular surgeon and general surgeon patiently waited as we regained control of the hgb, platelets, coags. Worked on acid base status in the mean time and gave some calcium, bicarb, etc.


Once we got to a repectable hgb of 8, they went in and got proximal control while we hung more product.
The case suddenly was the easiest case in the world… but that is because we communicated and did what needed to be done. Hgb in the ICU was 10.2. Small release of troponins (demand mediated) that went down postoperatively. The patient did very well.


The moral of the story is that these cases really need to be focused on the team environment and you need to look at the forest instead of the trees.
If you can substantially improve patient outcome by asking the surgeon to hold off, then it’s the right thing to do…. and the good surgeons know that 100% of the time.

Great discussion.

 

[BuzzPhreed]

You absolutely don’t want a high B.P., especially when the patient was conscious with B.Ps in the 60’s. Raising the B.P. too fast or too much can dislodge any hemostatic plug that is already there making your ongoing hemorrhage much worse.

Well one would assume that the surgeon would work and make a priority to put a bulldog on the splenic artery proximal to the aneurysm once he or she got exposure. I wouldn't let the pressure go too low for too long personally. And I would work hard first to correct any coagulopathy (platelets, FFP, Factor VII, prothrombin concentrates). There is a big difference between perfusion, pressure, and flow. If you have an open artery you're pretty damned no matter what you do.

But you're right. Pressors might exacerbate the problem. Cellsaver is also hard to find and set-up at 4:00 am too.

And also good lesson about communication. And telling them to slow down while you work on gaining some ground.

 

[Venko]

As an EM physician we are expanding the use of txa for those with life threatening hemorrhage; what is the anesthesia perspective on its use?

Great case discussion; thank you!

 

[Stank811]

I am with you up to the LPV part. Why is that indicated here? Are we worried about ARDS or TRALI? Until either manifested itself I think I would favor a routine ventilation strategy.

Pt having a major abdominal surgery and is going to receive a large amount of blood products which will put the patient at increased risk for post operative pulmonary complications. See article below

http://www.nejm.org/doi/full/10.1056/NEJMoa1301082#t=articleMethods

 

[urge]

Seems like you guys are big fans of the RIC. Me, not so much. I feel like it adds an extra step with the dilation and suturing and it doesn't buy you much more in terms of maximal flow rate over a 14g (forget the numbers but they are printed on the package for each). I also worry about long term vascular injury/dvt risk from that thing (obviously not an issue in this case).

One thing I have been meaning to try but haven't had the opportunity to would be to just take one of these ER 18/20g pivs, disconnect and see if blood comes back and then use a guide wire and throw a 14 in. Might need a nick too, not sure. Anyone ever do that as opposed to a RIC?

I doubt it will work without the dilator. It will probably get hung up on tissue. Kind off like an ett over a fiberoptic that doesnt want to go.

 

[urge]

Txa makes sense but it is not standard of care. I have wondered about antifibrinolytics in trauma since the days of aprotinin. I have asked many "gurus" at meetings over the years and nobody has been able to answer. My concern is that if the pt gets a thrombotic complication, lets say the arm with the a line goes bad, are they going to hang you to dry?

 

[Stank811]

Txa makes sense but it is not standard of care. I have wondered about antifibrinolytics in trauma since the days of aprotinin. I have asked many "gurus" at meetings over the years and nobody has been able to answer. My concern is that if the pt gets a thrombotic complication, lets say the arm with the a line goes bad, are they going to hang you to dry?

http://www.thelancet.com/crash-2

 

[pgg]

Txa makes sense but it is not standard of care. I have wondered about antifibrinolytics in trauma since the days of aprotinin. I have asked many "gurus" at meetings over the years and nobody has been able to answer. My concern is that if the pt gets a thrombotic complication, lets say the arm with the a line goes bad, are they going to hang you to dry?

The military's been using tanker trucks full of TXA in Iraq and Afghanistan without thrombotic complications. It appears to be very safe. The CRASH-2 trial had good data too.

Here are the current clinical practice guidelines for damage control resuscitation. It talks about TXA a bit on page 4.
http://www.usaisr.amedd.army.mil/assets/cpgs/Damage Control Resuscitation - 1 Feb 2013.pdf

Of course the military's experience with healthy 18-35 year old trauma patients with 30-45 minute injury-to-surgery times, mostly extremity injuries, rare thoracic injuries ... may not be applicable to a 67 year old with a blown splenic artery aneurysm.

In this case, depending on how long they played around trying to embolize the splenic artery in IR, maybe we're out of the 3h window of good results from TXA.

 

[urge]

The military's been using tanker trucks full of TXA in Iraq and Afghanistan without thrombotic complications. It appears to be very safe. The CRASH-2 trial had good data too.

Here are the current clinical practice guidelines for damage control resuscitation. It talks about TXA a bit on page 4.
http://www.usaisr.amedd.army.mil/assets/cpgs/Damage Control Resuscitation - 1 Feb 2013.pdf

Of course the military's experience with healthy 18-35 year old trauma patients with 30-45 minute injury-to-surgery times, mostly extremity injuries, rare thoracic injuries ... may not be applicable to a 67 year old with a blown splenic artery aneurysm.

In this case, depending on how long they played around trying to embolize the splenic artery in IR, maybe we're out of the 3h window of good results from TXA.

It also says this:

TXA Performance Monitoring.
Department of Defense Trauma Registry (DoDTR) data reveals mortality of 6.7% in casualties who did not receive TXA versus 10.1% who did receive TXA in a series of 322 combat casualties who required massive transfusion from 11 January 2011 to 06 October 2012 as ongoing theater performance improvement.

It does not imply causality though.

The real question is: is it standard of care?

If it is not, then you are screwed the moment something bad happens.

BTW, there is no malpractice in the military.

 

[urge]

4:00am. You get a call from your surgeon.

67 y/o male coming to the OR because IR can't embolize a large ruptured splenic artery aneurysm.
You get to the hospital, go to the ICU. Blood hanging through a couple of AC's. B.P.s in the 60's.
You tell the OR team that we need to go now.
To the OR table. Induction with 50 of ketamine, 30 of propofol, 100mg of roc + 300mcg neo flush. First B.P. after induction is 58/35. Volitiles are turned down to .2 mac and this is followed by .4mg of scopolamine.
As the surgeons open up the belly, Mac catheter goes in under the drapes followed by a-line.

My approach would have been to not let them open the belly until the patient is better resuscitated (extra lines or whatever is necessary). Once the belly is open it is a downhill race from there. I'm sure this has been going for hours.

 

[pgg]

The real question is: is it standard of care?

Thorny question. In the continental US, certainly not.

At a combat hospital in Afghanistan ... it is. The CPGs are the standard.

Regardless, either place, its use is more than defensible, and not outside the standard of care, which is the more salient point if we're talking thrombotic events and malpractice.

If it is not, then you are screwed the moment something bad happens.

I don't think I agree with that. We've got a lot of good data favoring its use in these patients. It's more than defensible.

BTW, there is no malpractice in the military.

Abroad in a combat zone, that's true (IF the patient is a US servicemember). Within the US the reality is somewhat different, as the great majority of patients taken care of at military hospitals are spouses, children, and retirees ... and Feres doctrine doesn't apply to them. Most of the cases I do as a military doctor at a military hospital in the US could result in a lawsuit.

 

[risnwb]

Seems like you guys are big fans of the RIC. Me, not so much. I feel like it adds an extra step with the dilation and suturing and it doesn't buy you much more in terms of maximal flow rate over a 14g (forget the numbers but they are printed on the package for each). I also worry about long term vascular injury/dvt risk from that thing (obviously not an issue in this case).

One thing I have been meaning to try but haven't had the opportunity to would be to just take one of these ER 18/20g pivs, disconnect and see if blood comes back and then use a guide wire and throw a 14 in. Might need a nick too, not sure. Anyone ever do that as opposed to a RIC?

8 fr RIC less likely to extravasate under pressure than a 14 since it's longer. Also as long as the vein feels straight and I don't get a lot of resistance I haven't had a problem with damage to the vein from a RIC, but certainly possible, just not my main concern in a patient who is about to code.
I never suture the RIC, just put a chlorhexadine tegaderm on it and secure it real well.. Only takes an extra 30 seconds to wire and dilate.



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[sevoflurane]

My approach would have been to not let them open the belly until the patient is better resuscitated (extra lines or whatever is necessary). Once the belly is open it is a downhill race from there. I'm sure this has been going for hours.

Sure. Fill e'm up before you loose whatever temponade effect that is had. Been there many times and it works. These cases are truly hard to describe over the internet. Getting access ahead of time would not be the right choice with such robust blood loss. The time to act was now. Not 20 minutes later. They already had blood products hanging in the ICU through 2 ACs. Aneurysmns leak, crack, then blow up.
Think AAA rupture with an anurysmal splenic artery rupture- the sidewall of the aorta is open. Would you ask your vascular surgeon to hold off while you get some products in?
That was the situation.
There are those cases where you just can't keep up... and getting proximal control sometimes is not the most straight forward approach to managing the patient. Communication is key.

Risk/Benefit + Forest.

 

[sevoflurane]

The military's been using tanker trucks full of TXA in Iraq and Afghanistan without thrombotic complications. It appears to be very safe. The CRASH-2 trial had good data too.

Here are the current clinical practice guidelines for damage control resuscitation. It talks about TXA a bit on page 4.
http://www.usaisr.amedd.army.mil/assets/cpgs/Damage Control Resuscitation - 1 Feb 2013.pdf

Of course the military's experience with healthy 18-35 year old trauma patients with 30-45 minute injury-to-surgery times, mostly extremity injuries, rare thoracic injuries ... may not be applicable to a 67 year old with a blown splenic artery aneurysm.

In this case, depending on how long they played around trying to embolize the splenic artery in IR, maybe we're out of the 3h window of good results from TXA.

Thanks for the link.

What's up w/ the greatest clinical benefit being w/in 3 hours of injury? Nature of combat injuries themselves or demographics? Intersting topic.

 

[Stank811]

Thanks for the link.

What's up w/ the greatest clinical benefit being w/in 3 hours of injury? Nature of combat injuries themselves or demographics? Intersting topic.

Under the link I post above regarding the CRASH-2 trial there is an additional link to an article called:

The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial

In the above mentioned article the discussion section dives into the reasoning on why there was a difference before 3hrs to after three hours. There is no answer at this time just thoughts on why the effect was seen. At the same time it is important to note that mortality secondary to bleeding increased if TXA was given after 3hrs….but all cause mortality was not shown to be statistically significant when TXA was given after 3 hrs.