Patient from scenario 1 underwent OSR. Aortic wall was considerably friable necessitating prolonged inter-renal clamp for 40 minutes , blood loss was 1800ml. Revised distal end twice to land on CIA rather than the aortic bifurcation.
Day 2 Postop while in ITU and while being adequately resuscitated he remains on inotropic support with a BP 110/70 HR 130 bpm, urine output of 30 ml/hr and creatinine of 180 ummol/L (200 the day before), ABG showed ongoing metabolic acidosis with lactate 2.8 (was 2.0 the day before)
1- How to assess?
2- What do you think is the cause(s) of this clinical situation?
3- Would you request any radiological investigation at this stage based on the above? If yes then What And why?
4- Patient is still intubated, Family asks about updates and prognosis, what information would you give them at this stage?
19 Comments
Yasmin Mosbah
1-Serial labs especially ABG , Creat , vital signs , UOP / hr , bowel sounds & passing of flatus , abdomen tender or lax
2- Most probably renal ischemia or/& bowel ischemia
3-Ct abdomen & pelvis to assess hypoperfusion , may begin with PAUS , easier apply with immobile intubated patients
4-I will retell them about the complications of such major operation & that the patient may need longer stay in the ICU & even may need reintervention if he is not improved generally in addition of risk of dialysis & even death
N.B. theses complications should have been explained to the patients & his relatives before consenting to the operation
1- How to assess?
I will revise the Labs and the CVP to assess dehydration, also I will consult nephrology for assessing kidney function and I will ask for abdominal ultrasound to detect any intra peritoneal collection. Also I will ask about intestinal function including passing gases or stool.
2- What do you think is the cause(s) of this clinical situation?
Maybe renal ischemia or intestinal ischemia.
3- Would you request any radiological investigation at this stage based on the above? If yes then What And why?
Abdominal ultrasound for detecting collection commenting on renal ecogenicity or back pressure. Any suspicion from ultrasound may lead us to ask for CT abdomen and pelvis.
Renal artery duplex may help in detecting any thrombosis.
X-ray maybe helpful if intestinal obstruction was there.
4- Patient is still intubated, Family asks about updates and prognosis, what information would you give them at this stage?
We are now working on Labs and investigations to detect the cause of being non-intubated we will search for kidney affection or intestinal problems.
Kidney problem may need dialysis through help kidney to overcome the ischemia and we hope that to be transient.
Consider that reintervention may be done this day or one day after if the investigation suspects intestinal ischemia specially.
Our aim in reintervention is to improve the general condition of him and to repair the ischemia as possible. This will help him to be better.
A1- examination by vitals and cvp
examination of abdomen is it tender or distended
and check peristalsis and any change of stool colour
examination of LL limb for any signs of hypo perfusion
A2 -it is mainly due to hypo perfusion either a acute kidney injury due to prolonged clamping or ischemic bowel
A3- yes , I will order urgent CT scan and us abdomen and Doppler renal arteries
A4 – it is a major operation and it may developed complications
and it is a major complications that might need urgent intervention either laparotomy and exploration .or may need dialysis
Reperfusion → inflammation, vasodilation, capillary leak, transient organ dysfunction.
B. Ongoing Hypoperfusion or Vasoplegia
Need for inotropes + high HR suggests persistent vasodilation, likely due to:
Systemic inflammatory response (SIRS)
Blood loss + resuscitation (1800ml + ?transfusions)
Capillary leak
C. Acute Kidney Injury (AKI)
Pre-renal due to hypoperfusion
Possible acute tubular necrosis from ischemia
Contributing to acidosis and oliguria
D. Bowel Ischemia
Early clue = rising lactate (now 2.8), ongoing metabolic acidosis
Possibly from:
Hypoperfusion
Graft-related complication (e.g. IMA ligation without adequate collaterals)
Prolonged clamp time affecting mesenteric perfusion
———————————————
Q3 US/ CT with contrast comment on bowl/garft
———————————
i would assure the patients family but giving them the whole truth about possible re intervention and the mortality probablity
Q1
Post op assessment
Monitoring of
Cvp
Map
Urine output
O2 saturation
HR , rhythm
Body temp
Lap :
Abg
Lactate level
Cbc
Creat
Q2
Metabolic acidosis post OSR most propably due to organ ischemia especially with prolonged inter renal clamping
Bowel ischemia is the most common cause
Renal ischemia
Limb ischemia reperfusion injury
Q3
Us commment on bowel motility and vascularity , renal doppler , graft patency
Ct abd pelvis with contrast for detecting bowl ischemia,graft thrombosis
Q4
Clearly informing them with risk of major operation,risk of prolonged interclamping , risk of wall friability distal thrombosis
Propability of re intervention, surgical exploration and resection anastomosid of bowl and stomy
• I would assess clinical status (heart rate, BP trend, capillary refill), fluid balance, central venous pressure, urine output, labs (ABG, lactate, renal function), and repeat bloods regularly. Also check limb perfusion and bowel signs.
• Likely causes: ongoing hypoperfusion or early organ dysfunction. Could be due to prolonged clamp time, ischemia-reperfusion injury, or possible bleeding or graft-related complication. Early acute kidney injury and lactic acidosis suggest poor tissue perfusion.
• Yes, I would request an urgent CTA abdomen and pelvis. Purpose: rule out graft-related complication (e.g. thrombosis, bleeding, distal embolization) or bowel ischemia. It helps guide further management quickly.
• I would tell the family:
“He had a major surgery with some intraoperative challenges. He is still in a critical phase and needs strong medications to support his blood pressure. We are closely monitoring his organs, especially the kidneys. The next 24–48 hours are important, and we’ve requested a scan to check for any issues. While he’s stable for now, recovery will take time, and we’ll keep you updated regularly.”
I beleive most of the findings can be checked without CTA
I think according to provided information the list of DD could be thinner
I beleive more aggressive intervention and more conclusive discussion with the family needed at this point
(please try to avoid using AI in rephrasing or answering questions)
A1.
I will assess by vital sings BP Hr temp Rr rbs
Bowel sound
Amount of urine
Cvp
And it seems intros that there is problem
……..
A2.
May be Dt aki or Ischemic Bowel
Or leakage
…..
A3.
I think pt condition is critical so I need to take him to theater as soon as possible
Although ct abd and pelvis with iv would be helpful
…….
A4.
I will discus ever point with family clearly
That intra op it was very difucult
And pt now on introp and we will go for further intervention (exploration)
Perfusion: Mottling, peripheral temperature, mental status (if sedatives lightened)
Urine analysis: check for hematuria or proteinuria
B. Monitoring:
• Arterial line (already likely in place)
• CVP / ScvO2 if central line present
• Lactate trend
• ABGs with anion gap and base deficit
C. Laboratory Investigations:
• Daily U&E, creatinine, and lactate
• Liver function (to rule out ischemic hepatitis)
• Coagulation profile (DIC screen)
• Troponin / ECG / cardiac enzymes (rule out myocardial injury)
• CK / Myoglobin (check for rhabdomyolysis)
⸻
2. What Do You Think is the Cause(s)?
Multifactorial Acute Kidney Injury (AKI)
due to:
• Ischemia-reperfusion injury (prolonged inter-renal clamp)
• Hypoperfusion despite resuscitation (low UOP, on inotropes)
• Possible atheroembolism (friable aorta = showering of emboli)
• Rhabdomyolysis from prolonged hypotension or ischemic muscles
• Nephrotoxic exposure (e.g., contrast if used pre-op)
⸻
3. Would You Request Any Radiological Investigation?
Yes – if stable enough:
A. Renal Ultrasound with Doppler:
• Purpose: Assess renal perfusion, exclude obstruction or renal artery thrombosis
• Bedside feasible, non-invasive
B. CT Angiography (CTA): (if renal function permits)
• Evaluate:Graft patency, Renal artery flow, Anastomotic integrity
• Evidence of ischemic bowel or embolic phenomena
⸻
4. What Would You Tell the Family? (Prognosis and Update)
# uptodate:
He underwent a major, high-risk vascular surgery which involved prolonged clamping above the kidneys
Currently, his blood pressure is supported with medication and he remains intubated and sedated
The kidney function is impaired but is being monitored and supported
There are signs of reduced blood flow to organs (suggested by low urine and raised lactate)
He is being monitored round the clock in ICU
#Prognosis:
This is a serious but not uncommon complication after this type of surgery
We are doing everything possible to support him
His next 48–72 hours are critical to assess how his body recovers
If kidney function does not improve, renal replacement therapy (dialysis) may be needed temporarily
Thanks for your answer
What about other organs malperfusion, would you consider doing other investigations
Would you consider 2nd opinion or MDT discussion for the case?
A1:
Regarding the intra op event with the post op data it seems that we have a problem in this case that would be assessed via vital signs cvp uop cbc abg kft bowel movement and sound abdominal wall laxity or rigidity
A2:
AKI bowel ishemia are the most expected complications in this situation due to prolonged interrenal clamping with blood loss and prologed time of surgery with 3 rd space loss
A3:
If bowel ischemia was suspected and other causer excluded so there would be no time for investigations specially the patient is still intubated and it is very critical to be moved and it’s recommended to be re explored asap
ct abdomen and pelvis would be helpful for bowel ishemia
PAUS and renal artery duplex might help in AKI
A4:
Everything should be discussed clearly with the relatives regarding the intra op difficulties and the expected complications according to the recent situation including the probability for re exploration for checking the bowel viability and it might need resection with stoma creation
Increasing mortality in case we delay the decision or to less extent with re expolration
A1..Based on intraoperative finding and post operative results, as we now the rate of peri-operative morbidity and mortality increases with higher levels of aortic clamping so in this patient I will keep him resuscitated in ICU with prompt care of post operative complication and for the increased urea level and decreased urine output mannitol could be beneficial together with prompt resuscitation
Daily full lab is essential to detect any deterioration
Beta blockers to reduce peri-operative cardiac risks all are crucial in that situation
A2..
I think renal ischemia and colonic ischemia are the causes of that continued un improvement of the patient despite proper resuscitation together with acidosis and elevated lactate level all increase the suspicious of bowel ischemia that require immediate management
A3..
Yes , I will ask for endoscopy to diagnose bowel is hemia and to now the level of ischemia mucosa only or the whole thickness of the wall is affected
A4..
I will discuss with them the suspected complications as AKI and bowel ischemia and bowel ischemia incidence is rare with elective repaire of AAA but when it occurs it’s mortality is high if not properly treated and that their father might need reexploration and possible bowel resection and stoma creation to save his life ,however that may carry an increased risk of graft infection
Thanks a lot for your input
I appreciate your insight of needing immediate management in such situation
Would you think endoscopy would be the ideal investigation of choice for this patient?
Would any other imaging modality (if the patient clinical condition stable enough for having imaging) could give some information and wouldn’t be invasive as endoscopy?
Would you consider further surgical intervention and if considered what is the timing and preparation including discussion with the patient and or family please?
1-Serial labs especially ABG , Creat , vital signs , UOP / hr , bowel sounds & passing of flatus , abdomen tender or lax
2- Most probably renal ischemia or/& bowel ischemia
3-Ct abdomen & pelvis to assess hypoperfusion , may begin with PAUS , easier apply with immobile intubated patients
4-I will retell them about the complications of such major operation & that the patient may need longer stay in the ICU & even may need reintervention if he is not improved generally in addition of risk of dialysis & even death
N.B. theses complications should have been explained to the patients & his relatives before consenting to the operation
1- How to assess?
I will revise the Labs and the CVP to assess dehydration, also I will consult nephrology for assessing kidney function and I will ask for abdominal ultrasound to detect any intra peritoneal collection. Also I will ask about intestinal function including passing gases or stool.
2- What do you think is the cause(s) of this clinical situation?
Maybe renal ischemia or intestinal ischemia.
3- Would you request any radiological investigation at this stage based on the above? If yes then What And why?
Abdominal ultrasound for detecting collection commenting on renal ecogenicity or back pressure. Any suspicion from ultrasound may lead us to ask for CT abdomen and pelvis.
Renal artery duplex may help in detecting any thrombosis.
X-ray maybe helpful if intestinal obstruction was there.
4- Patient is still intubated, Family asks about updates and prognosis, what information would you give them at this stage?
We are now working on Labs and investigations to detect the cause of being non-intubated we will search for kidney affection or intestinal problems.
Kidney problem may need dialysis through help kidney to overcome the ischemia and we hope that to be transient.
Consider that reintervention may be done this day or one day after if the investigation suspects intestinal ischemia specially.
Our aim in reintervention is to improve the general condition of him and to repair the ischemia as possible. This will help him to be better.
A1- examination by vitals and cvp
examination of abdomen is it tender or distended
and check peristalsis and any change of stool colour
examination of LL limb for any signs of hypo perfusion
A2 -it is mainly due to hypo perfusion either a acute kidney injury due to prolonged clamping or ischemic bowel
A3- yes , I will order urgent CT scan and us abdomen and Doppler renal arteries
A4 – it is a major operation and it may developed complications
and it is a major complications that might need urgent intervention either laparotomy and exploration .or may need dialysis
A1: Vital signs, CVP, O2 sat, urine output, Lab investigations (ABG, Lactate, CBC, Creatinine)
A2: Metabolic acidosis post OSR due to organ ischemia (Bowel or renal)
A3: CT abdomen and pelves
A4: I would discuss prognosis, possible reintervention and possible mortality with the patient
Thanks, good approach
q1- CVP -UOP-O2 sat – HR
LAB : LFT – KFT – CBC – ABG – Lactate
q2 multifactorial causes:A. Ischemia-Reperfusion Injury
B. Ongoing Hypoperfusion or Vasoplegia
C. Acute Kidney Injury (AKI)
D. Bowel Ischemia
———————————————
Q3 US/ CT with contrast comment on bowl/garft
———————————
i would assure the patients family but giving them the whole truth about possible re intervention and the mortality probablity
Thanks for your answer
I would really appreciate more concise answer showing the scheme of your approach
Please avoid using AI for input or an answer
Q1
Post op assessment
Monitoring of
Cvp
Map
Urine output
O2 saturation
HR , rhythm
Body temp
Lap :
Abg
Lactate level
Cbc
Creat
Q2
Metabolic acidosis post OSR most propably due to organ ischemia especially with prolonged inter renal clamping
Bowel ischemia is the most common cause
Renal ischemia
Limb ischemia reperfusion injury
Q3
Us commment on bowel motility and vascularity , renal doppler , graft patency
Ct abd pelvis with contrast for detecting bowl ischemia,graft thrombosis
Q4
Clearly informing them with risk of major operation,risk of prolonged interclamping , risk of wall friability distal thrombosis
Propability of re intervention, surgical exploration and resection anastomosid of bowl and stomy
Very reasonable approach and methodical thinking
Would you consider discuss mortality with the family?
• I would assess clinical status (heart rate, BP trend, capillary refill), fluid balance, central venous pressure, urine output, labs (ABG, lactate, renal function), and repeat bloods regularly. Also check limb perfusion and bowel signs.
• Likely causes: ongoing hypoperfusion or early organ dysfunction. Could be due to prolonged clamp time, ischemia-reperfusion injury, or possible bleeding or graft-related complication. Early acute kidney injury and lactic acidosis suggest poor tissue perfusion.
• Yes, I would request an urgent CTA abdomen and pelvis. Purpose: rule out graft-related complication (e.g. thrombosis, bleeding, distal embolization) or bowel ischemia. It helps guide further management quickly.
• I would tell the family:
“He had a major surgery with some intraoperative challenges. He is still in a critical phase and needs strong medications to support his blood pressure. We are closely monitoring his organs, especially the kidneys. The next 24–48 hours are important, and we’ve requested a scan to check for any issues. While he’s stable for now, recovery will take time, and we’ll keep you updated regularly.”
I beleive most of the findings can be checked without CTA
I think according to provided information the list of DD could be thinner
I beleive more aggressive intervention and more conclusive discussion with the family needed at this point
(please try to avoid using AI in rephrasing or answering questions)
A1.
I will assess by vital sings BP Hr temp Rr rbs
Bowel sound
Amount of urine
Cvp
And it seems intros that there is problem
……..
A2.
May be Dt aki or Ischemic Bowel
Or leakage
…..
A3.
I think pt condition is critical so I need to take him to theater as soon as possible
Although ct abd and pelvis with iv would be helpful
…….
A4.
I will discus ever point with family clearly
That intra op it was very difucult
And pt now on introp and we will go for further intervention (exploration)
Reasonable approach
I would like to know what are the complications that will be included in your discussion with the family please
A1. How to Assess?
A. Clinical Examination:
B. Monitoring:
• Arterial line (already likely in place)
• CVP / ScvO2 if central line present
• Lactate trend
• ABGs with anion gap and base deficit
C. Laboratory Investigations:
• Daily U&E, creatinine, and lactate
• Liver function (to rule out ischemic hepatitis)
• Coagulation profile (DIC screen)
• Troponin / ECG / cardiac enzymes (rule out myocardial injury)
• CK / Myoglobin (check for rhabdomyolysis)
⸻
2. What Do You Think is the Cause(s)?
Multifactorial Acute Kidney Injury (AKI)
due to:
• Ischemia-reperfusion injury (prolonged inter-renal clamp)
• Hypoperfusion despite resuscitation (low UOP, on inotropes)
• Possible atheroembolism (friable aorta = showering of emboli)
• Rhabdomyolysis from prolonged hypotension or ischemic muscles
• Nephrotoxic exposure (e.g., contrast if used pre-op)
⸻
3. Would You Request Any Radiological Investigation?
Yes – if stable enough:
A. Renal Ultrasound with Doppler:
• Purpose: Assess renal perfusion, exclude obstruction or renal artery thrombosis
• Bedside feasible, non-invasive
B. CT Angiography (CTA): (if renal function permits)
• Evaluate:Graft patency, Renal artery flow, Anastomotic integrity
• Evidence of ischemic bowel or embolic phenomena
⸻
4. What Would You Tell the Family? (Prognosis and Update)
# uptodate:
#Prognosis:
Thanks for your answer
What about other organs malperfusion, would you consider doing other investigations
Would you consider 2nd opinion or MDT discussion for the case?
A1:
Regarding the intra op event with the post op data it seems that we have a problem in this case that would be assessed via vital signs cvp uop cbc abg kft bowel movement and sound abdominal wall laxity or rigidity
A2:
AKI bowel ishemia are the most expected complications in this situation due to prolonged interrenal clamping with blood loss and prologed time of surgery with 3 rd space loss
A3:
If bowel ischemia was suspected and other causer excluded so there would be no time for investigations specially the patient is still intubated and it is very critical to be moved and it’s recommended to be re explored asap
ct abdomen and pelvis would be helpful for bowel ishemia
PAUS and renal artery duplex might help in AKI
A4:
Everything should be discussed clearly with the relatives regarding the intra op difficulties and the expected complications according to the recent situation including the probability for re exploration for checking the bowel viability and it might need resection with stoma creation
Increasing mortality in case we delay the decision or to less extent with re expolration
Very good and methodical approach
A1..Based on intraoperative finding and post operative results, as we now the rate of peri-operative morbidity and mortality increases with higher levels of aortic clamping so in this patient I will keep him resuscitated in ICU with prompt care of post operative complication and for the increased urea level and decreased urine output mannitol could be beneficial together with prompt resuscitation
Daily full lab is essential to detect any deterioration
Beta blockers to reduce peri-operative cardiac risks all are crucial in that situation
A2..
I think renal ischemia and colonic ischemia are the causes of that continued un improvement of the patient despite proper resuscitation together with acidosis and elevated lactate level all increase the suspicious of bowel ischemia that require immediate management
A3..
Yes , I will ask for endoscopy to diagnose bowel is hemia and to now the level of ischemia mucosa only or the whole thickness of the wall is affected
A4..
I will discuss with them the suspected complications as AKI and bowel ischemia and bowel ischemia incidence is rare with elective repaire of AAA but when it occurs it’s mortality is high if not properly treated and that their father might need reexploration and possible bowel resection and stoma creation to save his life ,however that may carry an increased risk of graft infection
Thanks a lot for your input
I appreciate your insight of needing immediate management in such situation
Would you think endoscopy would be the ideal investigation of choice for this patient?
Would any other imaging modality (if the patient clinical condition stable enough for having imaging) could give some information and wouldn’t be invasive as endoscopy?
Would you consider further surgical intervention and if considered what is the timing and preparation including discussion with the patient and or family please?