A case of abdominal aortic aneurysm posted for artificial aortic grafting with intra-operative hemorrhagic shock

1. Acase of abdominal aortic
aneurysm posted for artificial
aortic grafting with intra-
operative hemorrhagic shock
Dr Zikrullah

2. • NAME - Sehdev Varshney
• AGE/SEX - 73 years / Male
• ADDRESS - S/O Ramdev Varshney,
R/O Tiraha Prav Dubey,
Aligarh
• CADS NO - 45260/16
•DOA - 08/12/16
•C/I - Prof. M.H. Beg
•Surgery Planned: Resection of aneurysm &
artificial aorta grafting

3. CHIEF COMPLAIN:
• FEELING OF PULSATION ON UPPER
ABDOMEN-6 MONTHS

4. History of Present Illness
• According to pt, He was apparantly well 6
month back, when He accidentally felt
the feeling of pulsation over upper
abdomen.
• It was insidious in onset & progressive in
nature.

5. • There is no H/O pain in upper abdomen or
any swelling, Haemetemesis, loss of appetite

6. PERSONALHISTORY
Bowel/bladder - Regular
Appetite - Normal
Sleep - Adequate
Diet - Mixed
Addiction - alcoholic and chronic
smoker

7. GENERALEXAMINATION:
• Pt was an average built male well oriented
to time, place and person
 Pallor - absent
 icterus - absent
 Clubbing - absent

8.  Cyanosis - absent
 Lymphadenopathy - absent
 Oedema - absent

9. VITALS:
 PR - 86/min, regular, normal
volume
 BP - 128/82 mm Hg
 RR - 20/min , regular
 Temperature - Afebrile

10. SYSTEMIC EXAMINATION
PER ABDOMEN EXAMINATION:-
INSPECTION-
 Umblicus central & inverted
No scar mark
Prominent abdominal pulsation seen in
epigastric region.

11. PALPATION-
Pulsation felt on upper abdomen
Soft & non tender abdomen
No organomegaly
AUSCULTATION-
Bowel sound +nt

12. CARDIOVASCULAR SYSTEM
 S1 and S2 normal, no added sounds

13. CENTRAL NERVOUS SYSTEM
Higher functions – intact
Cranial nerves – intact
No sensory / motor deficits
Pupil – B/L NSNR

14. RESPIRATORYSYSTEM
B/L clear & equal air entry
No added sound

15. PRE-ANAESTHETIC EVALUATION
Date : 08/12/2016
Diagnosis : abdominal aortic aneurysm
Proposed surgery : resection of aneurysm &
artificial aortic grafting
Present History :No H/O cough, fever, dyspnoea,
palpitation, convulsion or any
drug reaction

16. Past history-
 H/O Pulmonary koch’s 3 yrs back
took ATT for 6 months
 H/O Hypertension (tab Metolar
12.5mg,Amlopres 5mg) since 2 years
 H/O chest pain (Angina ?) in 1988 &
managed conservatively
 No H/O: DM, Jaundice

17. Personal history-
Appetite- Normal
B/B- Regular
Sleep- Adequate
Addiction : alcoholic and chronic smoker
Family history- Nothing significant history

18. ANAESTHESIA HISTORY-
No previous Anaesthesia exposure

19. Examination-
Weight - 72 kg
Pulse - 88/min, Regular
BP - 146/90 mmHg
Pallor - absent
Dyspnea - absent
Cyanosis - absent
Icterus - absent
Edema - absent

20.  Chest- shape normal, trachea central
B/L equal A/E
CVS – WNL
CNS - WNL

21. Airway examination:
 Mallampatti grading : III
 Neck movement : Adequate
 Mouth opening : Adequate
 False/loose teeth : Edentulous,Removable
Denture (upper & lower jaw)

22. Investigations
•Hb -11.8 gm%
•TLC- 11000 cells/mm3
•DLC- P76L21.8M1.7
•Platelet-3,59,000/mm3
•Blood sugar- 86 mg%
•Blood urea- 14 mg%
•S.creatinine- 1.65 mg%

23. •Na- 134 mEq/L
•K- 4.0 mEq/L
•ECG – RBBB
•Chest X-ray :shows ill defined
patches of opacification with
adjacent bronchiectasis

24. •ECHO – Concentric LVH, mild AR, Gr
I LVDD, EF 65%
•PT – 13.5
•INR – 1.19
•CT angiography- aneurysm of
abdominal aorta (size 13 x 9.5 cm
location suprarenal , distal to
origin of SMA with renal artery
involved)

25. CXR CT ANGIO

26. ECG

27. RSR’pattern in V1

28. Advice-
 kindly get nephrology reference done
for derange RFT/SE
Kindly continue Antihypertensive
(Amlopres 5mg, Metolar 12.5mg )
medication as advised by ROC medicine.
Kindly consult concerned
anesthesiologist 1day prior to surgery

29. Review PAC done on next day.
Nephrology reference done and no active
intervention required except to avoid
nephrotoxic drug.
Kindly continue tab. Amlopress 5mg & take
tab. Clonazipam 0.5mg night prior to surgery
as advised by ROC medicine.
Arrange for GA.
Kindly arrange at least 3unit PRBC & 2unit
FFP.
High risk of surgery to be explained to the pt.
NPO for 8 hours prior to surgery.

30. PRE–OPERATIVE PREPARATION
• All preparation done in OT.
• 2 large bore Arterial cannulation done.
• Epidural catheter placed through T9
T10 space
• Foley’s catheter inserted.
• Monitors attached - Pulse oximeter
,NIBP, IBP, 12 Lead ECG

31. • PRE-OP VITALS:
PR:-78/min
B.P.:-124/76 mmHg
SpO2:-99% on Hudson
Chest : B/L clear
CNS: EMV=15/15
Pupils : B/L NSNR
• TECHNIQUE :- GA

32. PRE-MEDICATION:
Inj. Midazolam 2 mg iv
Inj. Dexamethasone 8mg iv
Inj. Fentanyl 140 mcg iv

33. PROCEDURE
 Pre/Oxy & De-Nitrogenation with 100% O2
for 3 min
 I/w Inj. Etomidate 14 mg iv
 R/w Inj. Succinylcholine 100 mg iv
OTI done with cuffed ETT of 8.0mm i.d
M/W O2 , N2O, vecuronium , isoflurane

34. Time PR BP SPO2 IVF IVD Remarks
10:45 am 92 130/70 100 RL1 CVP line
secured
11:00 am 88 128/70 100 RL2 Surgical
incission given
@11:10am
11:15 am 102 90/56 99 U/O 150mL
11:30am 99 100/74 99 ABG done
11:45 am 98 128/68 100
12:00 pm 96 118/56 99 RL3
12:15 pm 90 120/50 99 RL4

35. Time PR BP sPO2 IVF IVD Remarks
12:30 pm 88 110/58 100 U/O
300mL
12:45 pm 84 100/52 100
RL5
Epidural
top-up given
1:00 pm 89 102/62 99
RL6
1:15pm 94 108/60 98 PRBC1
1:30pm 88 100/76 98
1:45pm 93 112/78 99 Inj.
Calcium
10mL
Inj. HCO3
100mL
2:00pm 94 102/74 99 U/O
400mL

36. Time PR BP sPO2 IVF IVD Remarks
2:10 pm 92 100/70 100
RL7
2:15 pm 92 98/72 100 HEPARIN
5000 U
2:20 pm 93 96/72 100
2:25 pm 90 96/68 100
2:30pm 87 90/58 99 Arterial
clamping
done
2:35 pm 89 94/60 99
2:40 pm 88 90/60 100

37. 2:45 pm 112 86/54 98 PRBC2 PRBC 3 NORAD @
20mL/hr
After clamping,
incision given
Massive bleeding
with 4L in drain
stat
Inj calcium 10mL
ACT 93
3:00 pm 124 62/50 98 DOPAMINE
@ 10mL/hr
3:15 pm 116 44/28 99 PRBC4
PRBC 5
RL8
ABG done
Inj. HCO3 100
3:30 pm 112 32/12 98 FFP1 20mL/hr
3:45 pm 102 30/10 99 FFP2 FFP3
VOLUVEN1
Adrenaline
@10mL/hr
4:00 pm 112 48/22 98 PRBC6
VOLUVEN2
-NORAD
@30mL/Hr --
DOPA
@30mL/hr
Adr @ 30
U/O 400mL
ACT 153

38. Time PR BP sPO2 IVF IVD Remark
s
4:15
pm
98 56/48 98 RL9
4:30pm 102 84/42 99 20mL/hr
20mL/hr
ADR. stop
U/O
410mL
4:45
pm
106 90/56 100
VOLUVEN 3
5:00
pm
104 86/58 99 Epidural top-up
given
U/O
450mL
5:05
pm
103 60/40 99 PLATELETE
CONCENTRATE
5:15
pm
102 72/50 99 RL10
5:30
pm
112 90/46 100 10mL/hr ABG
done
U/O

39. Time PR BP sPO2 IVF IVD Remark
s
5:45 pm 106 100/50 100 Inj. HCO3 50mL
Inj. NTG 5 mcg/hr
DOPA. Tappered
& stop
U/O
500mL
6:00 pm 102 88/72 99 NORAD
@5mL/hr
Inj. Protamine
50mg over 30 min
ACT
253
6:15 pm 112 82/54 99 RL11
6:30 pm 102 94/58 100 RL12
6:45 pm 112 96/58 100 Inj lasix 5+5 mg iv
7:00 pm 104 102/76 100
7:15 pm 108 100/74 100 U/O
700mL
ACT

40. ABG @ 11:35 AM Fio2=40%)
• pH : 7.36
• pO2 : 147 mmHg
• pCO2 : 42 mmHg
• Glucose : 98 mg/dL
• Lactate : 0.7
• Ca : 1.15
• HCO3 : 23.7
• SpO2 : 99%
• S Na : 138
• S k : 4.1

41. ABG@ 3:15pm Fio2=40%)
• pH : 7.14
• pO2 : 301 mmHg
• pCO2 : 45 mmHg
• Glucose : 314 mg/dL
• Lactate : 6.3
• Ca : 0.88
• HCO3 : 15.3
• SpO2 : 100%
• S.Na : 137
• S.k : 4.6

42. ABG @ 4:30 pm Fio2=40%)
• pH : 7.23
• pO2 : 88 mmHg
• pCO2 : 45 mmHg
• Glucose : 292 mg/dL
• Lactate : 7.5
• S.Na : 140
• S. k :4.2
• Ca : 1.19
• HCO3 : 18.8
• SpO2 : 95%

43. ABG@ 5:30PM Fio2=40%)
• pH : 7.19
• pO2 : 222 mmHg
• pCO2 : 41 mmHg
• Glucose : 258 mg/dL
• Lactate : 7.8
• Ca : 1.02
• Na : 142
• K :3.6
• HCO3 : 15.7
• SpO2 : 100%

44. Extubation trial was not taken and pt shifted to
ICU on manual bagging at 7:30 pm
Vitals in ICU on 14/12/2016 :-
PR : 102/min
BP : 136/84mm Hg
sPO2 : 100%
CHEST : B/L clear
CVS : S1 S2 audible
CNS : E1M1VT

45. • VENTILATORYPARAMETERS
Mode: PCV
FiO2 : 50%
Pins : 16
Frequency :16
I:E : 1:2.5
PEEP: 6

46. pH : 7.24
pO2 : 194 mmHg
pCO2 : 42 mmHg
Glucose : 228 mg/dL
Lactate : 5.7
Ca : 0.90
Na : 142
K : 3.8
HCO3 : 18
SpO2 : 100%
ABG @ 7:38 pm in ICU(Fio2=50%

47. Tretament in ICU :- 14/12/2016
•Inj NORAD 2 ampule in 50 ml NS
•Inj NTG 2 amp in 50 ml NS
•Inj Tazotis 4.5 gm in 100 ml NS
•Inj Metron 100 ml
•1 unit FFP A+ve
•1 unit PRBC A+ve
•Inj fentanyl 1 amp in 50 ml NS
•Inj Neovac 20 mg with 30 ml NS

48. ICU DAY 1 15/12/2016
• BP : 115/70 -98/62 mm Hg (ON vasopressor –
NORAD 2amp in 500ml NS )
• PR : 116/min - 73/min
• SPO2 : 100%
• CHEST : B/L clear
• CVS : s1,s2 audible
• CNS :E1M1Vt ( INTERMITTENT SEDATION )
pupil :NSNR
• URINE : input 3100 ml
Output : 1405 ml

49. TREATMENT in ICU (15/12)
• Inj NORAD 2 ampule in 50 ml NS
• Inj VASOPRESSIN 2 amp in 50 ml NS
• Inj NTG 2 amp in 50 ml NS
• Inj Tazotis 4.5 gm in 100 ml NS
• Inj Metron 100 ml
• 1 unit PRBC A+ve
• PLATELET transfusion started at 11:00pm
• Inj fentanyl 1 amp in 50 ml NS

50. DAY-1 INVESTIGATION
Hb - 10.6 gm%
TLC- 12000 cells/mm3
DLC- P89L8M3
Platelet- 84 X 103 /mm3
Blood sugar- 582mg%
Blood urea- 24 mg%
S.creatinine- 1.94 mg%
S.Na+ – 134meq/l
S.k+ – 3.9meq/l

51. DAY-1 ABG’s (FIO2-50%)
6 PM 9 PM
pH 7.22 7.15
pCO2 56 mmhg 76
pO2 144 mmhg 119
glucose 116 mg/dL 141
lactate 1.3 mmol/L 1.6
Bicarb 22.9 mmol/l 26.5
Serum Na 143 mmol/L 141
Serum K 4.7mmol/L 5.2
Serum Ca 0.77 mmol/L 0.95

52. CXR 15/12/2016

53. ICU day-2 16/12/2016
•BP : 102/74 – 148/87 mm Hg (on
vasopressors NORAD)
•PR : 85/min – 120/min (regular)
•SPO2 : 100%
•CHEST : B/L clear
•CVS : s1,s2 audible
• CNS : E1M1Vt…pupil: NSNR
•URINE : input –2050 ml
output – 2045 ml
• PATIENT WAS EXTUBATED @ 2:45 pm
• Nephrology reference done for deranged RFT (advised to stop
Metolar and continue vasopressor)

54. Hb – 10.6 gm%
TLC- 15.2 X 103 cells/mm3
DLC- P94.5 L5.1M0.4
Platelet-97 x103 /mm3
Blood sugar- 150 mg%
Blood urea- 42 mg%
S.creatinine- 3.32 mg%
S.Na+ - 132
S.k+ -4.9 Trop T : -Ve
DAY-2 INVESTIGATION

55. TREATMENT IN ICU (16/12)
Inj NORAD 2 ampule in 50 ml NS
Inj VASOPRESSIN 2 amp in 50 ml
NS
Inj Tazotis 4.5 gm in 100 ml NS
Inj Metron 100 ml
INJ MEROPENEM 500mg BD
INJ LINZOMAC 30ml BD
1 unit PRBC A+ve @4:45 PM

56. DAY-2 ABG
13:26 PM ( before extub) 17:57 PM (After extub)
pH 7.30 7.32
pCO2 44mmhg 47
pO2 178 mmhg 69
glucose 114 mg/dl 132
lactate 1.2 mmol/L 1.0
bicarb 21.6 24.2
Serum Na 139 mmol/L 141
Serum K 4.3mmol/L 4.7
Serum Ca 0.61 mmol/L 0.88

57. ICU day-3 17/12/2016
• BP : 110/78 -135/82 mm Hg ( 0n vasopressor –NORAD)
• PR : 100/min – 71/min
• SPO2 : 88% -97%
• CHEST : B/L clear
• CVS : s1,s2 audible
• CNS : EMV-15/15
• URINE : INPUT – 2050 ml
OUTPUT – 1805 ml
*Orally water allowed

58. DAY-3 INVESTIGATIONS
Hb – 10.8 gm%
TLC- 19 x 103cells/mm3
DLC- P93.5L6.1M0.4
Platelet-101 x 103 /mm3
Blood sugar- 144mg%
Blood urea- 37 mg%
S.creatinine- 2.81 mg%

59. DAY-3 ABG (Room air)
00:42 AM 06:38 AM
pH 7.31 7.32
pCO2 44 mmhg 53
pO2 98 mmhg 83
glucose 97 mg/dl 126
lactate 0.7 mmol/L 1.0
Bicarb 22.2 mmol/l 27.3 mmol/l
Serum Na 139 mmol/L 138
Serum K 3.6 mmol/L 4.4
Serum Ca 0.75 mmol/L 0.95

60. ICU day -4 18/12/2016
• BP : 127/77 mm Hg (vasopressor stopped )
• PR : 90/min – 128/min
• SPO2 : 86% - 97%
• CHEST : B/L clear
• CVS : s1,s2 audible
• CNS : EMV-15/15
• URINE : INPUT – 1650 ml
OUTPUT – 1250 ml

61. DAY-4 INVESTIGATION
•Hb – 10.2 gm%
TLC- 8.1 x 103 cells/mm3
DLC- P 84.7 L 13.6 M1.7
Platelet- 85 x 103/mm3
Blood sugar- 99 mg%
Blood urea- 32 mg%
S.creatinine- 2.07 mg%

62. DAY-4 ABG (Room air)
6:54 AM 18:15 PM
pH 7.42 7.52
pCO2 39 mmhg 26
pO2 51 mmhg 70
glucose 96 mg/dl 94
lactate 0.9 mmol/L 1.3
Bicarb 25.3 mmol/l 21.2
Serum Na 140 mmol/L
Serum K 3.9 mmol/L
Serum Ca 1.08 mmol/L

63. ICU day-5 19/12/2016
•BP : 155/82 – 118/72 mm Hg
•PR : 93/min – 106/min
•SPO2 : 96% -98% on Hudson
•CHEST : B/L clear
•CVS : s1,s2 audible
• CNS : WNL

64. DAY-5 INVESTIGATION
•Hb – 10.4 gm%
TLC- 9 X103 cells/mm3
DLC- P 84.5 L 14.6 M 0.9
Platelet- 90 x103/mm3

65. DAY-5 ABG(Room air)
• pH : 7.45
•pCO2 : 39 mmhg
•pO2 : 82 mmhg
•Glucose : 97 mg/dl
•Lactate : 0.9 mmol/L
•Bicarb : 27.1 mmol/L
•Serum Na : 136 mmol/L
•Serum K : 3.2 mmol/L
•Serum Ca : 1 mmol/L

66. • Pt shifted to HDU in satisfactory condition.
• Discharged from HDU later on and doing
well as per follow up report.

67. THANK YOU