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?
Q1, the patient looks oliguric, with metabolic acidosis after prolonged renal ischemia and blood loss, it seems acute renal failure, so I should involve renal team and discuss the possibility of hemodialysis. I will also examine the abdomen for if it is tense or not, and check both lower limbs vascularity
Q2, prolonged clamping, massive blood loss, also, I should put in mind ischemic colitis
Q3, based on the data above, I may request abdominal and pelvis US to rule out any collection or active bleeding plus to comment about both kidneys. if clinically meets ischemic colitis, colonoscopy should be requested
Q4, patient condition is still unstable, i will clarify ever thing to them, and all what happened is listed complication with such a complex operation, also I will keep them updated with any new events
Q1, the patient looks oliguric, with metabolic acidosis after prolonged renal ischemia and blood loss, it seems acute renal failure, so I should involve renal team and discuss the possibility of hemodialysis. I will also examine the abdomen for if it is tense or not, and check both lower limbs vascularity
Q2, prolonged clamping, massive blood loss, also, I should put in mind ischemic colitis
Q3, based on the data above, I may request abdominal and pelvis US to rule out any collection or active bleeding plus to comment about both kidneys. if clinically meets ischemic colitis, colonoscopy should be requested
Q4, patient condition is still unstable, i will clarify ever thing to them, and all what happened is listed complication with such a complex operation, also I will keep them updated with any new events
Based on the clinical finding & investigation, I put AKI and intestinal ischemia as DD.
So, I Will order full labs,
PA/US : to detect any collection or AKI.
Abdominal X-ray: for intestinal ischemia (thumbprint sign).
also, if the condition of the patient is stable, I will order sigmoidoscopy for colon ischemia.
If the patient is unstable and intestinal ischemia is highly suspecting, transfer him to OR for second look.
I will talk to his family about hazarrds of his condition and possibility to transfer the patient again to OR and this step carry many serious complication with mortality rate about 40 to 50%.
Q1
by examination
_full abdominal examination
_ lower limb perfusion
_urine output and fluid chart
Investigation :ECG changes ,pelvi abdominal U/s
Q2
prolonged operation time
,prolonged inter renal clamping Blood loss,
inotropic and vasopressor support ,post operative bowel ischemia
Acute myocardial infarction
Q3
_ CT abdomen with contrast
Q4
I will talk to them about obstacles that we faced during the operation,post operative updates,the morbidity that may occur such as renal failure, bowel ischemia and the need for re entry to the operative theatre
Thank you all for your answers and comments.
Looking at the intraoperative events you will notice some operative challenges including inter-renal clamp, significant blood loss and prolonged clamping time which all raises the risk of AKI and intestinal ischaemia amongst other less likely possibilities
.
While in ITU, you can see that he is still suffering metabolic acidosis with rising serum lactate BUT the creatinine level started decreasing which points to improving AKI so you must think of another cause where INTESTINAL ISCHAEMIA becomes the most dangerous possibility to exclude.
Contrast enhanced CT is the investigation of choice in this situation (Don’t worry about kidney functions)
Conversation with the family should be centred around the need for laparotomy, intestinal resection, temporary or permanent colostomy, possibility of more interventions and obviously the higher mortality risk and prolonged ITU stay.
Q1: i will make abdominal exam, take vital signs and do full labs and US.
q2: I think the cause is acute kidney injury from prolonged inter-renal clamping.
q3: i will request abdominal US.
Q1
Firstly by examination
_Abdominal distension, decrease intestinal sounds
_ lower limb coldness ,pulseless
_urine out put and fluid chart
Labs : CBC , s.creat, cardiac enzymes
Investigation :ECG changes ,pelvi abdominal U/s
Q2
prolonged operation time,prolonged inter renal clamping time, Blood loss,inotropic and vasopressor support ,post operative bowel ischemia
Acute myocardial infarction
Q3
_ pelvi abdominal U/s to detect any collections
_Renal artery duplex
_ CT abdomen without contrast
_ECG
Q4
I will talk to them about obstacles that we faced during the operation,post operative updates,the morbidity that may occur such as renal failure, bowel ischemia and the need for re entry to the operative theatre
I will inform them that mortality rate in first 30 days post OSR is 25_40%
Thanks Ahmed for your answer.
A2: why do you think MI is a differential? I agree with the rest but I would definitely put Bowel ischaemia and AKI on the top of the list.
A3: US is of very limited benefit at this stage so does the duplex. I agree with CT but I go for contrast enhanced as you want to check perfusion of the intestine.
A4: Excellent answer
1- I will start by clinical assessment
*Abdominal distention and decrease bowel sound that indicate paralytic iliues or mesentric ischemia
*Abdominal distention and flank ecchymosis that could indicate retroperotineal hematoma
*lower limb examination for peripheral pulsation to detect possible graft thrombosis
*fluid chart and urine output that could indicate acute kidney injury
*Amount of fluid inside the Drains and the type of that fluid indicate anastomosis leakage
*Surgical site early iflamation
–> I will go for Lab investigation
*if there’s Hb drop it could indicate anastomosis leakage
*If there’s increased Creat level Decreased eGFR and increased K it could indicate acute kidney injury
*If there’s increased Cardiac enzymes with or without ECG changes it could indicate MI
*If there’s decreased Platlet count with increased D-dimer and PT may indicate DIC.
2- Acute kidney injury.
3- I will ask for Urgent U/S to detect any possible hematoma and to assess both kidneys and to assess bowel movement.
4- I will explain to the family the possible complication that could happen, I will till them that the whole team are doing their best to treat these complication and I will clearly state that there’s increased mortality rate especially with increased ITU stay, inotropes and intubation.
Thanks Mina for your answer.
A1: Agree with your assessment, if you are thinking of bleeding ITU would have highlighted this in the first few hours postoperatively as the haemodynamic deterioration will be much faster.
A2: Totally agree with AKI. Would you consider intestinal ischaemia as a differential?
A3: U/S is of very limited benefit at this point, not the best to detect retroperitoneal collection, renal parenchyma in the context of acute ischaemic nor it is accurate with bowel movements.
A4:if you consider AKI then I would bring up the possibility of hemofiltration (and dialysis if kidneys doesn’t recover)
Q1: local abdominal examination for surgical abdomine, intestinal sounds to exclude IO, labs as CBC checking for hb drop
Q2: MI, bleeding, AKI or bowel ischemia
Q3: CTA to exclude bleeding or occlusion of visceral arteries, erect abdominal XRay to exclude IO, sigmoidoscopy to exclude bowel ischemia, ECG to exclude MI and renal US
Q4: i will reassure them and tell them the possible cause and what we going to do
Thanks, would you consider discussing with the family the scenarios and mortality risk for each?
Q1.
assessment first by clinical examination
abdominal examination, bowel sounds, revision of fluid charts and measuing the intake and the output
lab investigations.
especially kidney function tests and ABG
Q2.
possible causes
prolonged inter renal clamping time
blood loss
prolonged operative time
inotropic and vasopressor support
differential diagnosis
metabolic acidosis and elevated lactate indicates possibility of organ injury plus elevated kidney functions and low urine output
Acute kidney injury
ischemic colitis
myocardial ischemia
abdominal compartmental syndrome
hypovolemic shock
Q3.
renal ultrasound
CT abdomen with contrast
Q4.
I will explain to the family the intraoperative challenges and the need for prolonged inter renal clamping, and the amount of blood loss and the effect of these events on his systems
I will explain to them the post operative plan and investigations needed in this time and the possibility of urgent exploration if needed
Thanks, good answer. Would you like to extend the discussion with the family about possible morbidity and mortality risk?
Yes, I will explain and clarify recent condition of the patient and discuss the possible morbidity and mortality risk
Q1
Assessment the condition by:
Examinations
Abdominal ex. (distention, tenderness), auscultation bowel sounds, measure IAP by measuring bladder pressure.
Distal pulses
Surgical drains
Input/output chart
Investigations
Hb,Tlc, guaiac positive stool s.urea, electrolytes, eGFR
ECG
Q2
Causes
Possible differential diagnosis
1.Ischemic colitis
2.Post-oprative AKI
3.Abdominal compartment syndrome
Q3
At this stage pt. Developed metabolic acidosis, rised lactate 2.8 and tachycardia HR 130 bpm so , flexible sigmoidoscopy needed (to evaluate the colonic mucosa) to exclude Ischemic colitis.
Kidney ultrasound to exclude AKI.
Q4
I will clarify the condition of their patient ( he is still in ITU, needs medical and breathing support, explain to them briefly about the surgery challenges that led to prolongation clamping time, and we are now requesting some investigations to evaluate the colon condition and ,i will inform them that the complications probably to happen are treatable, put in sever situation may need return to OR for resection ischemic part of colon with high rate of mortality).
Thanks for your answer, I like the way you think regarding differential diagnosis
Do you think there is any form of imaging modality can give you more objective assessment for the current complication?
Just regarding surgical drains, we usually do not place drains post AAA surgical repair
Contrast-enhanced abdominal CT scan
(ideally with an arterial phase):
findings in IC
Bowel wall findings
Peritoneal/retroperitoneal cavity findings
Vascular findings
Thanks for your answers, I would recommend to have the source cited for benefit of the group and to keep copyrights please
1.Iacobellis F, Berritto D, Fleischmann D et al. CT Findings in Acute, Subacute, and Chronic Ischemic Colitis: Suggestions for Diagnosis. Biomed Res Int. 2014;2014:895248. doi:10.1155/2014/895248 – Pubmed
https://pubmed.ncbi.nlm.nih.gov/25247191/
2.Brandt L, Feuerstadt P, Longstreth G, Boley S, Boley S. ACG Clinical Guideline: Epidemiology, Risk Factors, Patterns of Presentation, Diagnosis, and Management of Colon Ischemia (CI). Am J Gastroenterol. 2015;110(1):18-44; quiz 45. doi:10.1038/ajg.2014.395
I think the main cause of his clinical situation is Type A lactic acidosis due to hypovolemic shock as a result of intraoperative blood loss. On the other hand I would consider colonic ischemia as well that may occur as a consequence of hypo perfusion, prolonged clamping and ongoing vasopressors.
Assessment should include blood tests results, vital signs, fluid chart, pelvi-abdominal US for possible ongoing blood leaking, bedside colonoscopy for colon assessment
I would discuss the patient situation with his family frankly that he is still shocked and needs cardiac support. More investigations are required to check other body organs that could be affected due to shock.
Would you think any other modality of investigation would help in such situation to give more objective assessment please?
contrast enhanced CT is another helpful diagnostic tool
Good answer, thanks. I would appreciate if that can be supported by citation or source from literature. Thanks
Q1 clinical ex. Temp. Abd girth tenderness ask about early bowel empty and bloody diarrhea
CBC search for leukocytosis anemia
CRP KFT LFT serum lactate ABG stool analysis
Intra abdominal pressure meaurement IAP
Q2
Prolonged clamping
Blood loss
Inotropics support
Prolonged operation time
Q3 yes
Flexible sigmidoscopy to confirme or exclude ischemic colitis
CT with IV contrast to search for
Thromboembolism in the mesenteric vessels
Intramural or portal venous gas
Segmental thickening of the bowel wall
Absence of bowel wall enhancement with
contrast-enhanced CT
Irregular narrowing of the bowel lumen as a
result of mucosal edema (thumbprinting
Possible bowel dilatation proximal to the
ischemic segment of the bowel
Nonspecific signs of bowel ischemia, including
bowel obstruction, mesenteric edema mesenteric vascular engagement, and ascites
Round-belly sign: Abdominal distention with an increased ratio of anteroposterior-to-transverse abdominal diameter (ratio >0.80)
Collapse of the vena cava.
Q4
Pt day 2 with no improving as u know the operation was difficult and we take long time due to bad aortic wall we suspected some ischemia at bowel ?? and we will do some Ix to confirm that and mostly is mild to moderate and can managed conservatively and this problem occur in 2% of people post OSR
If it sever we need to re explore with possibility for resection of bowel with mortility about 40%
Thanks a lot for your answer
Any other possible differential diagnosis ?
Ischemic colitis
Abd. Compartmental syndrome
Mesenteric vascular occlusion
Acute kidney injury
Myocardial injury
Hypovelamic shock
Very good
thanks for your answer
1- firstly, I will examin wounds carefully with full abdominal examination ,assessing distal pulsations,
Pelvi-abd US to exclude any intraabdominal complications
2-most probably intestinal ischemia , may also as consequence of declamping
3-yes, pelvi-abd US and may need CT abdomen with double contrast if possible regarding illeus and renal function
4-frank talking about possible complications as renal ischemia and intestinal ischemia (sholud be mentioned before surgery) also possibility of effects of declamping
Thanks a lot for your answer
Any other possible differential diagnosis ?
1-full examination-full labs abg u&e
2-prolonged ischemia time -vasopressors-blood loss
3-ctabdomen e contrast
4-ptn is stable but no improving as excepectedmay need exploration and either reimplantation of ima or resection anastomosis or colostomy or 2nd look
Good start , what do you think could be possible diagnosis or differential diagnosis
Regarding labs , you mentioned ABG which shows metabolic acidosis and rising lactate , what do you think the reflections of the ABG result on your diagnosis
And what should be the main points to mention during your discussion with the family please?
Current state of patient, what will l do, possible cause may need intervention possible results of intervention
* acidosis may aki_ischemic colitis mi hypo perfusion
Good answer, would you consider discussing morbidity and mortality risks with the family?
yes
i would 40%