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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

  • 16g, 18g, 18g

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

Antibiotic Redosing

Calcium Gluconate

Calcium Chloride

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

Anesthetic Plan

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

Intra-Op Labs

Indications:

Experience vs. Textbook

Benumof, 1059

Indications:

Contraindications

Advantages

Edwards Quick Guide to Cardiopulmonary Care (2nd ed.)

Risks

Physics and YOU!

2x 3cm 18g = 424 ml/min

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...

CALL FOR HELP!

(early)

References

(should give centrally/slowly)

(may give via PIV)

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