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?
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?