Perioperative management of a patient with polycythemia who developed massive hemorrhage

A 34-year-old man, 170 cm in height and 70 kg in weight, was scheduled for emergency operation because of gastric perforation due to gastric cancer under general anesthesia. His preoperative blood analysis showed 5.2 x 10(3) mm(-3) of red blood cell, 18 g x dl(-1) of hemoglobin and 48% of hematocrit. Based on this and other data, he was diagnosed as having polycythemia caused by stress. Anesthesia was induced with thiopental and maintained with O2-N2O-sevoflurane. The intraoperative blood loss reached approximately 7,000 ml. Although we administered only 4 units of fresh-frozen plasma (FFP) and 9,150 ml of fluid with no red cell concentrated, his hemodynamic state was stable during surgery. After the surgery, we administered the minimum amount of FFP according to his blood analysis. Although red cell concentrated was not administered in the perioperative period, his general condition remained stable.     

Therapeutic management of massive hemorrhage caused by gastroduodenal ulcer

Based on 103 patients the authors discussed policy of therapeutic management in gastric and duodenal ulcer disease complicated by massive hemorrhage. In the surgical treatment of such patients the authors prefer resection procedures aimed at simultaneous control of bleeding, prevention of its relapse and radical treatment of peptic ulcer disease.     

Evaluation and management of massive lower gastrointestinal hemorrhage.

Sixty-eight patients with massive lower gastrointestinal (G.I.) hemorrhage underwent emergency arteriography. Patients were transfused an average of six units of packed red blood cells within 24 hours of admission. The bleeding source was localized arteriographically in 27 (40%), with a sensitivity of 65% among patients requiring emergency resection. However, twelve of the 41 patients with a negative arteriogram still required emergency intestinal resection for continued hemorrhage. Radionuclide bleeding scans had a sensitivity of 86%. The right colon was the most common site of bleeding (35%). Diverticulosis and arteriovenous malformation were the most common etiologies. Selective intra-arterial infusion of vasopressin and embolization were successful in 36% of cases in which they were employed and contributed to fatality in two patients. Twenty-three patients underwent segmental resection, whereas seven patients required subtotal colectomy for multiple bleeding sites or negative studies in the face continued hemorrhage. Intraoperative infusion of methylene blue via angiographic catheters allowed successful localization and resection of bleeding small bowel segments in three patients. Overall mortality was 21%. The mortality for patients without a malignancy, with a positive preoperative arteriogram, and emergency segmental resection was 13%.     

Anesthetic management of massive endobronchial hemorrhage after pulmonary embolectomy

We report a case of massive endobronchial hemorrhage after pulmonary embolectomy. A 63-year-old woman underwent emergency pulmonary embolectomy with cardiopulmonary bypass (CPB). During partial CPB, we found massive blood gushing out from the endotracheal tube. Approximately 2,000 ml of blood was aspirated in 10 minutes. To ensure adequate oxygenation, emergent percutaneous cardiopulmonary support system (PCPS) was started. After neutralization of heparin and the institution of 10 cmH2O of positive end-expiratory pressure, the bleeding diminished. Institution of PCPS allows performance of unhurried bronchoscopy to identify the actual bleeding point and to lavage the airway. In addition to this management, we administrated steroids and neutrophil elastase inhibitor to stabilize pulmonary capillary membrane. Without complications, the patient was extubated 2 days after operation and the following course was uneventful. Immediate institution of PEEP and pharmacological interventions to reduce pulmonary blood pressure were beneficial in arresting hemorrhage. The bleeding begins usually at the time of discontinuation of CPB. We should recognize the possible occurrence of endobronchial bleeding after pulmonary embolectomy and prepare to protect the airway and to maintain oxygenation and cardiac function.     

介入诊疗急性动脉性消化道大出血

目的探讨急性动脉性消化道大出血介入诊疗的临床应用价值。方法对39例急性动脉性消化道大出血患者行DSA检查,对38例出血征象阳性的患者中37例采用明胶海绵颗粒配合微弹簧圈进行介入栓塞治疗。结果 39例动脉造影中38例出血征象阳性,主要表现为对比剂外溢。接受栓塞治疗的37例中,止血成功36例(其中3例行第2次栓塞),均未发生与介入栓塞相关的严重并发症。最终2例患者转剖腹探查手术。结论介入技术是急性动脉性消化道大出血安全、有效的诊疗手段,能快速明确出血动脉及部位,并迅速有效控制出血。     

Liver packing for uncontrolled hemorrhage: a reappraisal

The efficacy of liver packing for uncontrolled hemorrhage was assessed in 345 patients with hepatic injuries divided into two groups: Group I (1977-1980; n = 177), when packing was not used and Group II (1981-1985; n = 168) when the technique was employed. Despite similar clinical details, mortality from bleeding was unchanged (19.2% and 19.4% overall, and 63.7% and 61.7% for Grade IV, V, VI liver injuries). Packing was used in 14 patients who were in clinical coagulopathy after debridement-resection of the injured liver: eight patients (57%) expired from continued bleeding; five of the six survivors (83.3%) developed intra-abdominal abscesses despite early removal of the pack. The incidence of sepsis was significantly (p less than 0.002) increased as compared to that of 15 similar patients who had debridement-resection without packing. Liver packing, in our experience, has not altered the mortality from major hepatic trauma and appeared to increase the incidence of abdominal sepsis.     

Surgical management of acute variceal hemorrhage

The advent of more effective nonoperative therapies, mainly endoscopic variceal sclerosis, has decreased the need for emergency surgery for control of acute variceal hemorrhage. In centers where it is available, nonoperative portal decompression by transjugular intrahepatic portosystemic shunting (TIPS) is likely to have a further impact. When acute or chronic sclerotherapy fails or when bleeding is secondary to gastric varices or portal hypertensive gastropathy, emergency surgery may be life-saving and should be done promptly before worsening hepatic functional decompensation develops. Child's class C liver disease is not a contraindication to emergency surgery; many patients who fail nonoperative attempts at control of bleeding are of this risk status. The most commonly utilized emergency procedures are portacaval and interposition mesocaval shunts, both of which are effective, and esophageal transection, which is associated with a higher incidence of late rebleeding. An emergency distal splenorenal shunt is appropriate for selected patients who are not actively bleeding at the time of surgery. TIPS is the preferred alternative for acute or chronic endoscopic sclerotherapy failures who are candidates for liver transplantation within the succeeding 6 to 12 months.

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Resumen El advenimiento de nuevas y más efectivas terapias no operatorias, principalmente la esclerosis endoscópica de la várices, ha disminuído la necesidad de realizar cirugía de emergencia para el control de la hemorragia varicosa aguda. En algunos centros, donde ya está disponsible la descompresión portal no operatoria (TIPS) probablemente habrá de significar aún un impacto mayor.Cuando la escleroterapia aguda o crónica falla o cuando el sangrado es secundario a várices gástricas o a gastropatía hipertensiva portal, la cirugía de urgencia puede ser salvadora y debe ser realizada prontamente, antes de que se desarrolle el empeoramiento y descompensación de la función hepática. La enfermedad hepática Child Clase C no significa contraindicación para cirugía de emergencia; muchos de los pacientes que fallan bajo terapias no operatorias se encuentran en esta categoría de riesgo. Los procedimientos quirúrgicos de urgencia más utilizados son los shunts portacava y de interposición mesocava, los cuales son eficaces, y la transección esofágica, la cual se asocia con una mayor incidencia de resangrado tardío. Un shunt espleno-renal de emergencia aparece apropiado en pacientes seleccionados que no presentan sangrado activo en el momento de la cirugía. El TIPS es la alternativa de preferencia para pacientes en quienes falla de la escleroterapia aguda o crónica y que sean candidatos para transplante hepático en los próximos seis a doce meses.

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Résumé L'utilisation de thérapeutiques non opératoires efficaces, essentiellement la sclérothérapie endoscopique, a diminué le nombre de cas opérés en urgence pour le contrôle d'hémorragie par rupture aiguë des varices oesophagiennes. Dans les centres où cela est disponible, la shunt intrahépatique nonopératoire (SIHN) est destiné à avoir un impact à l'avenir. Lorsque la sclérothérapie, pratiquée de façon urgente ou en plusieurs séances, ne réussit pas à contrôler l'hémorragie, ou lorsque l'hémorragie est secondaire à des varices gastriques ou à une gastropathie hypertensive, la chirurgie garde un rôle essentiel et doit être envisagée avant que la fonction hépatique ne se détériore. Le patient ayant une insuffisance hépatique du stade C de Child n'est pas forcément une contre-indication à la chirurgie d'urgence, car beaucoup de ces cas, menaçant de toutes façons le pronostic vital, sont également des échecs de la thérapeutique nonopératoire. Les interventions les plus souvent utilisées sont l'anastomose portocave et l'anastomose mésentérico-cave par prothèse interposée, efficaces toutes deux, et la transsection oesophagienne, dont l'incidence de récidive hémorragique tardive est plus élevée. Une anstomose splénorénale distale peut être proposée pour le patient qui ne saigne plus activement au moment de la chirurgie. Le SIHN est par contre l'alternative à préférer pour les échecs de la sclérothérapie endoscopique qui deviennent des candidats à la transplantation hépatique dans les six à douze mois après.