P023: USE OF AN EMERGENCY MANUAL DURING AN INTRAOPERATIVE PULMONARY ARTERIAL RUPTURE, HYPOXEMIA, AND BRADYCARDIA: A CASE REPORT
Shovna Mishra, DO1; Xiaobin Wang, MD1; Xiaofeng Huang, MD2; Yin Guan, MD3; Alejandro Mosquera, MD1; Jeffrey Huang, MD1; 1HCA West Florida Division- Oak Hill Hospital; 2Gansu Provincial Cancer Hospital; 3Lanzhou University Second Hospital MICU
Introduction/Background: The use of an emergency manual (EM) reinforced with simulation training can improve team performance on critical steps during crisis events. Measures of improved performance have so far been captured through survey and simulation data; however, real life case studies showing successful use of the manuals are fewer in number. The case of a patient with an unexpected rupture of the pulmonary artery, hypoxemia, and bradycardia during a Video-Assisted Thoracic Surgery (VATS) lobectomy is described here. It exhibits the purpose of the EM in reducing the reliance on memory, which is prone to human error, especially in situations where information needed may not be used on an everyday basis, as in emergencies.
Case Presentation: An 81-year-old ASA III Chinese male (height 165 cm, weight 74 kg) with history of essential hypertension, coronary artery disease, and tobacco abuse, underwent general anesthesia with left-sided double-lumen endotracheal tube intubation for VATS lobectomy for left upper lobe lung mass. The left pulmonary artery was accidentally torn, and heavy bleeding was noticed immediately. The patient’s vital signs changed immediately (BP: 84/52 mmHg, HR: 121 bpm, SpO2: 94%).
The anesthesiologist lightened the anesthesia, started pressurized infusion, and activated the emergency protocol. As in simulation training, the anesthesiologist asked the circulating nurse to call for help and to retrieve blood and the code cart. An additional anesthesiologist was assigned the role of performing anesthesia procedures. Another team member was designated as the reader and was asked to read aloud the Hemorrhage section of the Stanford University Operating Room Emergency Manuals. The recommendations were reviewed and followed, which included high flow 100% O2, rapid infusion, changing position, using vasopressors, sending a type and cross sample, maintaining normothermia, and monitoring for hypocalcemia. Massive blood transfusion protocol was initiated. 7 units of PRBC and 700 ml FFP were given. After transfusion, the patient’s BP increased to 93/52 mmHg and HR decreased to 113 bpm.
The surgical team started to repair the vessel. However, the patient’s oxygen saturation fell precipitously. The patient became hypoxic, bradycardic, and hypotensive. The reader read aloud the Hypoxemia section of the EM. Each step was checked and executed, fiber optic bronchoscopy was performed, and it was found that the ETT was dislodged. The ETT was repositioned. The patient’s vitals recovered. SpO2 gradually increased from 37% to 93%, HR increased from 45 bpm to 89 bpm, and BP increased from 67/40 mmHg to 110/75 mmHg. He was transported to ICU in stable condition.
Discussion/Conclusion: Although the overall incidence of catastrophic complications during VATS lobectomy is low, there is a higher occurrence of vascular injury during upper lobectomy. Furthermore, double lumen tube displacement usually occurs in surgeries involving traction at the hilum. Reporting the successful usage of the EM in real cases as in this one offers insight on ideal application and integration of EM. EM combined with repeat simulation exercises improved the team’s ability to manage an uncommon series of real life crisis events in the operating room.