Blood loss and left ventricular failure

[Cherrypicker999]

I would appreciate a view on this:

A 76 year old man has elective surgery to remove gall stones using laproscopic surgery.
He has no history of heart problems.

Haemoglobin levels are as follows:

9:30am 13.6 (surgery started at 9:30 and ends at 11:30am)
2pm 4.4
3pm 3.2

Estimated blood loss during surgery = 500ml

Can one conclude (1 or 2):

A. The patient suffered modest post-operative blood loss
B. The patient suffered severe post-operative blood loss

Is the answer obvious?

The patient suffers left ventricular failure at 3pm and pronounced dead
at 3:50pm.

Would such a degree of blood loss result in left ventricular failure?


Can one conclude (1 or 2):

1. Given that he had little evidence of significant pre-existing heart disease and given that fluid/blood loss was modest post-operatively, the severity of his heart problems are difficult to account for.”

2. Given that he had little evidence of significant pre-existing heart disease and given that fluid/blood loss was severe post-operatively, the severity of his heart problems can be explained by the severe blood loss.

Is the answer obvious?


The operation took 2 hours and blood loss was estimated to be 500ml
(higher than expected).
This patient was hyoptensive upon being transferred to recovery.
His blood pressure could not be maintained by gelofusin.

Should such blood loss have been diagnosed by the anaethetist
or could he really claim it could not be diagnosed.

What would cause such a massive blood loss?
Eg a clip coming off, "nicking" a vessel etc?

Regards

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[P Diddy]

I would appreciate a view on this:

{awful scenario}

a Hct drop from ~50 to ~7 constitutes severe blood loss.

that much blood loss would put the pt at risk for myocardial ischemia by reducing the oxygen carrying capacity of the blood (depriving myocardial cells of oxygen) and placing excessive strain on the heart (increased cardiac workload necessary to deliver adequate oxygen/nutrients to the rest of the body). this elderly pt almost certainly exhibited some degree of occult atherosclerosis given his age and probably had less ability to compensate for such an insult (less contractility, lower maximum heart rate), compounding the degree of injury. the hypotension caused by such massive blood loss ( ~ 11 units of blood!) would damage not only the heart but also the brain and kidneys. even a younger person would be hard pressed to compensate for such a loss of blood volume.

i'm interested when you state the pt died from 'LV failure'. how was that diagnosis made? do you mean the pt died from MI? did arrhythmia play a role? why wouldn't you say the pt died from severe blood loss?

usually lap choles (choleys?) go well, but this one seems to have bit the big one. unless the man hemorrhaged from another site, i think you'd have to say the surgery caused the blood loss. if the pt was not hypotensive during surgery, the anesthesiologist would not necessarily have known the pt was losing so much (unless he/she was pumping massive amount of fluids and titrating pressors during the surgery).

are they doing an autopsy? they should.

p diddy

 

[Cherrypicker999]

I agree with that you say.

Sit down and be shocked.

An autopsy was undertaken.
The pathologist made a point in his report that there was no evidence of poor surgical technique.

He also stated the op began at 11:30. Really? That is when it ended.
He could not even get this correct.
It is the way he interpreted it.

He also stated modest-post operative blood/fluid loss.
Really? He seems the only one who said that.


Internal Examination

Pericardial cavity contained 150ml of blood stained fluid.
Some haemorrhage into the pericardial fat on the anterior surface of the left ventricle. Sectioning of heart muscle reveals 2 foci of intramuscular haemorrhage each 0.5cm across and in the interventricualar septum and one in the anterior left ventricle.

Respiratory System.
The larynx, trachea and main bronchi contains blood stained fluid.
Lungs congested and heavy in keeping with pulmonary oedema.
Pulmonary arteries contain no thromboemboli.

GI System

50ml blood clot collected in lesser sac.
100ml bloodstained fluid within right side of abdominal cavity.
Liver essentially normal, A 10x6cm diameter raw granular area corresponding to the gall bladder bed. No adherent blood clot to suggest chronic ooze or untoward bleeding
Occasional surgical clips noted in this area.
Clips across cystic duct.
No adherent blood clot to this area and no apparent significant blood loss relating to this area of autopsy. Slicing of liver - no evidence of trauma.


GI System

Very small insignificant right sided haemorrhage in perinephric fat.
Small amount of blood is present in the collecting system of both kidneys.
Urinary catheter noted in situ


CNS

Brain normal, On section, no evidence of haemorrhage or stroke.


HISTOLOGY

Heart - Recent haemorrhage is confirmed between myocardial fibres, but there is no associated acute myocardial ischaemia and no myocartis or vascualitis

Lungs – acute vascular congestion and pulmonary oedema only

Comments

Gall baldder tightly stuck to underside of liver by dense fibrous adhesions.
Thus operation technically difficult.
After operation, episodes of intra-abdominal bleed or cardiac malfunction.


CONCLUSION

This man suffered acute left ventricular failure precipitated by a laproscopic cholecystectomy. Although the operation was technically difficult there are no features to suggest poor or careless surgical technique has contributed to the outcome. Given that he had little evidence of significant pre-existing heart condition, and given that fluid/blood loss was relatively modest post operatively, the severity of his heart problems are difficult to account for.

Cause of death

Death in my opinion was due to:

1. Acute left ventricular failure
2. Complicating laproscopic cholecystectomy


Is this reasonable?
How can he state fluid/blood loss was relatively modest post operatively?

Surely, the correct cause of death was acute left ventricular failure due to excessive blood loss.

Please note the hospital admit to have losing a blood sample taken at 1:15.
No blood transfusion until Hg was < 4.2
Blood loss not diagnosed even though extremely hypotensive and bp could not be maintained. Blood loss is the primary complication.

 

[P Diddy]

I agree with that you say.

Sit down and be shocked.

An autopsy was undertaken.
The pathologist made a point in his report that there was no evidence of poor surgical technique.

He also stated modest-post operative blood/fluid loss.
Really? He seems the only one who said that.

that's pretty crazy. where did all of the blood go? 11 units of blood must have gone somewhere. seems like it should be an M&M.

p diddy

 

[Cherrypicker999]

that's pretty crazy. where did all of the blood go? 11 units of blood must have gone somewhere. seems like it should be an M&M.

p diddy

If during the second operation there was 2 litres of actual blood from the abdomen (it was distended so they opened up), and 500ml was lost in the first operation (2.5 litres in total), that leaves 1 litre unaccounted for. Thus, perhaps the blood loss during the first operation was much higher, i.e. 1.5 litres, wholly consistent with low blood pressure and temperature.

The rest, who knows!

Sorry for the ignorance, what exactly do you mean by M&M
(Morality and Morbidity?) I'm from the UK!

 

[P Diddy]

If during the second operation there was 2 litres of actual blood from the abdomen (it was distended so they opened up), and 500ml was lost in the first operation (2.5 litres in total), that leaves 1 litre unaccounted for. Thus, perhaps the blood loss during the first operation was much higher, i.e. 1.5 litres, wholly consistent with low blood pressure and temperature.

The rest, who knows!

Sorry for the ignorance, what exactly do you mean by M&M
(Morality and Morbidity?) I'm from the UK!

second operation? when did you write about that?

M&M is morbidity and mortality conference. in the US some departments (like Internal Medicine and Surgery) will have weekly conferences based upon a case where something went wrong. then everyone argues about what should have been done and yells at each other. ideally such conferences lead to improvements in hospital policies and/or patient care. often they merely provide entertainment for the disgruntled masses.

p diddy

 

[DrMom]

Since the OP has posted multiple threads on this same topic & has no other posts here, it really appears to be someone coming here for medical advice. Because of this I am closing the threads.

To the OP: SDN is not for medical advice. Please do not post similar topics in the future.