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