Exploratory Laparotomy:
A Case Study
Presented by
Nicole Z., Raymond C., and Tony A.
WF
- 47 yo African American Male
- Surgical Dx: Large Retroperitoneal Fibrosarcoma
- NKDA
- ASA 3
- PMH
- h/o seizures (GSW in the '90s) & right eye blindness & short-term memory loss
- T2 fibrosarcoma of the femur s/p excision & radiation
- Metastatic retroperitoneal sarcoma with displacement of the mesenteric portal & right renal vasculature
- Severe stomach cramping & 30lb weight loss, unable to keep food down
- Hepatitis C
Medications
- Carbamazepine
- Phenobarbitol
- Percocet
Vital Signs
BP 107/81
HR 79
RR 18
SpO2 97%
Wt 66.2 kg
Ht 5'7"
BMI: 22.87
Labs
Na 141
K 3.9
Cl 104
Glu 80
BUN 6.0
Cr 0.73
Ca 8.5
Hgb 11.3
Hct 34.2
Plt 524
WBC 6.7
Pt 13.1
INR 1.0
aPTT 30
- GSW w/ TBI & resulting Sz & blindness
- Plan to continue antiepileptics, but may induce hepatic enzymes
- Faster metabolism of NMBs
- Hepatitis C:
- Progression of chronic hep C to cirrhosis may be slow, but ESLD due to HCV-associated cirrhosis is the most common indication for liver transplantation
- Sx: Dark urine, fatigue, malaise, anorexia, N/V, RUQ pain, myalgias, arthralgias, jaundice, hepatomegaly, or splenomegaly.
- Anesthesia: Liver fx tests, effect of metabolism of drugs
- Fibrosarcoma
- Composed of malignant fibroblasts in a collagen background
- Can occur as a soft tissue mass or bone tumor
- Primary: medullary canal
- Secondary (more aggressive): periosteum
- Occurs in men > women in 4th decade of life, often in femur or tibia
- Epidural* for intra/post-op pain control
- GETA (7.5 vs 8.0)
- Potential Aspiration Risk?
- Full stomach
- Modified RSI with Rocuronium
- Standard Monitors...
- CRNA had similar case that went poorly
- Central Line
- Arterial Line
- 2 x PIVs
*Epidural test dose only, not dosed
intra-operatively
- Never gave potassium
- 4mEq/L in LR x 8L = 32 mEq K+
- Banked blood ~ 10mEq/1U
- When given in large quantities, NS can produce a dilutional hyperchloremic acidosis (M&M p. 694)
- Plasma bicarb concentration decreases as chloride concentration increases
- Lactated Ringers:
- The most physiologic soln. when large volumes are necessary
- Slightly hypotonic (100ml free H2O/L)
- Tends to lower serum Na+ to 130mEq/L
- Lactate is converted to bicarbonate in the liver
- Only 3mEq/L Ca, no magnesium* (need to supplement)
- DISADVANTAGES: contraindicated for RBC transfusion, amicar, ampicillin & thiopental (all due to Ca binding)
- PRBCs contain citrate, which binds Ca
- Fluid Management
- 11L EBL
- 7300ml Colloid (1:1)
- Need 3.7L replaced
- Using Crystalloid 3:1 = 11.1L
- 16.5L (crystalloid total) - 11.1L = 5.4 L excess crystalloid
- MIVF + NPO deficit + 3rd Space/insensible losses = 5.1L /6hr
- 110ml/hr
- 1100ml NPO deficit
- 8ml/kg insensible ~ 560ml/hr
- Net: a mere 300ml!
CENTRAL LINES
- CVP monitoring
- Administration of fluid to tx hypovolemia & shock
- Infusion of caustic drugs & TPN
- Aspiration of air emboli
- Insertion of TC pacing leads
- Access in pts with poor peripheral access
- RA tumors/fungating tricuspid valve vegetations (absolute)
- anticoagulation
- ipsilateral carotid endarterectomy
- Arterial Puncture
- bleeding
- occlusive thrombosis
- PTX
- Infection
- More "secure"
- Can't observe PIVs
- Proximity to provider
- Bypassing peripheral circulation = faster (good or bad?)
- Patient: 47yo, "relatively" healthy, no obvious indications for invasive CV monitoring
- Procedure: based on pre-op expectations (CT scan, surgeon's expectations)
- CRNA: "potential" for disaster
- Surgery is exploratory
- Proximity to great vessels = potential for blood loss
- Potential pt. will have to stay intubated
Radius > Length in determining FLOW
ETT Diameter
~ 30% increase in flow from a 7.5 to an 8.0 ETT
PLACE YOUR BETS!
Introducer = 9F = 1.6mm = 11g
TL
What was used for this case?
- Rapid Infuser "Level 1"
- 3 Lines (all under pressure)
- Volume Line x2
- Push Dose Line
- No Cell Saver
- Warming of FFP & Plts?
- 2 x 1L Pressure Bags
- Bair Hugger & Fluid Warmer
Resusitation Strategies
- The consequences of low CO are far more threatening than those of anemia, so the first priority is to support cardiac output
- End-points of resuscitation in hemorrhagic shock is to restore 3 parameters: Blood flow, O2 transport & tissue oxygenation
- Cardiac Index = 3L/min/m2
- Systemic Oxygen Delivery (DO2) > 500ml/min/m2
- Systemic Oxygen Delivery (VO2) > 100mL/min/m2
- Arterial Lactate < 2 mmol/L or base deficity > -2 mmol/L
For a 50 kg recipient with normal hepatic function and perfusion:
- The maximum rate of blood transfusion to avoid citrate toxicity is 66.5 mL/min
- Equal to 8.9 units of whole blood per hour (450 mL per unit)
- 33.3 units of PRBCs per hour (approximately 120 mL per unit).
- Thus, significant hypocalcemia should not develop in this setting except under extreme circumstances.
- Plasma ionized calcium concentration should be monitored and calcium replaced with either calcium chloride or calcium gluconate if ionized hypocalcemia develops:
- If 10 percent calcium gluconate is used, 10 to 20 mL should be given intravenously (into another vein) for each 500 mL of blood infused.
- If 10 percent calcium chloride is used, only two to five mL per 500 mL of blood should be given.
- Trust your instincts
- If you think you need equipment, have it available
- Be observant in the field
- Surgeons "kept calm and carried on"
- Meanwhile... exanguination
- Communication = key
- Be cognizant of physiologic effects of our IVFs
- How do they effect the patient's chemistry
- Know how to use equipment
- Protocol for obtaining blood products
- Is it available & how do you get it?
- Administration of medications
- Hanging blood products
- Monitoring patient/drawing labs/checking labs
- 2 people needed to check blood
- Keep up with documentation
- Consider organizing bags of blood products/IVF
- Brown, N.J., Duttchen K.M., Caveno, J.W.J. (2008). An Evaluation of Flow Rates of Normal Saline through Peripheral and Central Venous Catheters [Electronic version]. Anesthesiology. 109 A1484.
- Esper, S.A., Water, J.H. (2011). . Intra-operative cell salvage: a fresh look at the indications and contraindications [Electronic version]. Blood Transfusion, 9(2), 139-147. Hagberg, C. 2007. Benumof’s Airway Management, 2nd Edition. Philadelphia, PA: Mosby.
- Harty, E. 2011. Inserting peripheral intravenous cannulae – tips and tricks. Update in Anaesthesia. 22-26.
- Kleinman, S. Feb. 19, 1998. Massive Blood Transfusion. Retrieved January 11, 2013, from http://www.uptodate.com/contents/massive-blood-transfusion.
- Marino, P.L. (2007). The ICU Book. (3rd Ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
- McGee, W., Headley, J., Frazier, J. 2010. Quick Guide to Cardiopulmonary Care, 2nd Edition. Irvine, CA: Edwards Life Sciences.
- Morgan, E.G., Mikhail, M.S., Murray, M.J. (2006). Clinical Anesthesiology. (4th Ed.). New York: McGraw-Hill Companies, Inc.
Care Plan
Pathophysiology &
Anesthetic Considerations
5
4
2
Upon Completion...
Surgery: 6L EBL
Anesthesia: 11L EBL
PreOp Eval
Exploratory Laparotomy
Resection of Retroperitoneal Mass
Portal Vein Reconstruction
Pancreatico-jejunostomy
Hepato-jejunostomy
Duodeno-jejunostomy
Emergency Repair of Supermesenteric Vein
Surgical Course
Pre Operatively
5
4
2
- 6th Hour
- EBL: "hemostasis achieved"
- UOP adequate
- 300cc FFP
- 1U PRBC
- Remained intubated, transported to ICU
- 5th Hour:
- EBL: 1350
- UOP: adequate
- 250cc Plts
- 1.5L LR, 1L NS
- Vascular transplant surgeon called in
- for repair of superior mesenteric vein
- HR 100-120
- MAP 50-75mmHg
- Epi gtt @ 0.03 mcg/kg/min
- SRNA out
- 4th Hour
- EBL: ~3300
- UOP: adequate
- 1500mg CaCl
- Ephedrine, vasopressin & phenylephrine for HOTN
- 500cc FFP
- 3L LR, 2L NS
- 2U PRBC
- 100-120 HR
- MAPs 50-75 mmHg
- 3rd Hour
- EBL: ~3400
- UOP adequate
- 1gm CaCl
- 50mEq NaHCO3
- 2gm MgSO4
- 500cc FFP
- 2L NS, 2L LR
- 4U PRBCs
- MAP 50-75 mmHg
- HR 90-110
- Smooth induction, central line & art line placed uneventfully
- Surgical team "overkill?"
- 1st Hour:
- EBL ~ 400cc
- IVF: 1200cc
- UOP: adequate
- 2nd Hour:
- EBL: ~2000cc
- IVF: 3800cc
- PRBC: 6u
- Colloid: 1L 5% Albumin
- UOP: adequate
- HOTN tx with phenylephrine boluses
Indications:
Experience vs. Textbook
Edwards Quick Guide to Cardiopulmonary Care (2nd ed.)
Physics and YOU!
Introducer = 8.5F = 594 ml/min
Brown et. al "Normal Saline Flow Rates Through Peripheral Catheters" (2008)
Hardy "Inserting peripheral intravenous canulae- tips and tricks" p. 22.
5
4
2
Cell Saver
Final Thoughts
Marino "The ICU Book" p. 227
Perhaps Most important...
References
(should give centrally/slowly)