VCU DEATH AND COMPLICATIONS CONFERENCE Sihong SuyApril 5, 2012.
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Transcript of VCU DEATH AND COMPLICATIONS CONFERENCE Sihong SuyApril 5, 2012.
VCUVCUDEATH AND DEATH AND COMPLICATIONS COMPLICATIONS CONFERENCECONFERENCE
Sihong Suy April 5, 2012
Brief Overview of CaseBrief Overview of Case
Diagnosis:Diagnosis: Presacral schwannomaPresacral schwannoma
Procedure:Procedure: Resection of presacral mass Resection of presacral mass
Complication:Complication: Intraoperative hemorrhageIntraoperative hemorrhage
Clinical History
HPI: 64 yo woman with no signifcant PMH
Presented to her PCP with vague abdominal pain, urinary frequency and some degree of vaginal prolapse
Underwent CT scan which revealed a heterogenous mass measuring 10 x 28 x 12.6 cm
CT guided biopsy was performed with pathology consistent with schwannoma
Referred to Surgical Oncology for evaluation for possible resection
Medical History
PMH: Chronic back pain Hypercholesterolemia Uterine bleeding
SurgHx: TAH with BSO
Meds: Celebrex Simvastatin
Allergies: Codeine
Labs: WBC 3.6 Hemoglobin 13.3 Platelet 265
SocHx: Nephrolithiasis Parathyroidectomy GM, GGM
Hospital Course
March 14th : To OR for ex lap and resection of presacral mass
Mass was noted to be deep in pelvis Partially dissected it out anteriorly and sidewalls Difficulty exposing the posterior plane so dissected out using finger fracture
technique Hemorrhage was not excessive > irrigate for closure > pooling of venous
blood was noted > presacral packing was performed > presacral space continued to well up with venous bleeding
No obvious large source of bleeding was identified Patient was hemodynamically stable SBP 90-120’s, HR 60-90’s, UOP 65
ml/2 hours Intraoperative CBC obtained showed hemoglobin 6.5 > repeat 5.3
2 units PRBC given
Hospital Course
March 14th - POD 0 : Patient became hemodynamically unstable
Massive transfusion protocol initiated Cell saver called into room
Intraoperative Vascular Consult Continued packing and waited for anesthesia to catch up with resuscitation Upon removal of packing 1 side branch from left common iliac vein and two
presacral sidewall branches were noted to be bleeding controlled with 3-0/4-0 prolene
Patient continued to ooze from presacral area Decision was made to pack the abdomen, place wound vac transfer pt to ICU for
resuscitation/monitoring Intraoperative resuscitation
7400 ml crystalloid/500 albumin/ 10 units PRBC/10 FFP/2 Platelets/ 1630 cell saver EBL 2300/UOP 100 Factor VII administered in STICU
Hospital Course
POD 1 : Patient was hemodynamically stable
700 ml serosanguinous fluid from abdominal wound drain 1 Unit PRBC
POD 2: Taken back to OR for exploration Packs removed – No surgical bleeding Abdominal closed
POD 12: Uneventful course Discharged home
Analysis of Complication
• Was the complication potentially avoidable?– Maybe.
– Pre-operative angiography – possible pre-operative embolization
– However would have been difficult to embolize small side branch and presacral veins
• Would avoiding the complication change the outcome for the patient?– Yes. Limited transfusion. Second operation and long
hospital course • What factors contributed the
complication?– Patient’s disease process. Difficult exposure