2024 FSA Podium and Poster Abstracts
P005: POSTOPERATIVE HYPOVOLEMIC AND OBSTRUCTIVE SHOCK FOLLOWING AN OPEN MITRAL VALVE REPLACEMENT
Emily Chung, DO1; Gordon Hubbell, DO2; Sean Quinn, MD3; Arnaldo Vera-Arroyo, MD3; 1HCA Florida Kendall Hospital; 2HCA Florida Westside Hospital; 3Bruce Carter Department of Veterans Affairs Medical Center
Introduction/Background: Shock in patients following cardiac surgery is a serious complication with a high morbidity and mortality. Identifying the causes and understanding the mechanism at play are crucial for the management of shock. We present a case of postoperative hemorrhagic and obstructive shock following a mitral valve replacement.
Methods: A 73-year-old male with a past medical history of atrial fibrillation, prostate cancer, and endocarditis with vegetations on the mitral valve arrived at the surgical intensive care unit following open mitral valve replacement. The procedure was uneventful and the patient arrived on norepinephrine, epinephrine, and vasopressin drips. A few hours postoperatively, the chest tube had increased output and required additional pressor support. However, after a couple more hours, the output suddenly stopped. The patient then started to become hypotensive with increased pressor support and was unresponsive to fluid resuscitation. The cardiothoracic surgery team (CTS) was notified and called back for resternotomy and chest exploration.
The patient was deemed too unstable to be moved to the OR and the CTS team performed a resternotomy at the bedside. Once the chest was reopened, 6L of blood was found in the chest. Massive transfusion protocol (MTP) was initiated. The CTS team was able to locate the source of the bleeding and control the bleeding. The patient was successfully resuscitated after 16 units of PRBC, 8 units of FFP, 3 units of cryoprecipitate, and 2 units of platelets.
Results: The chest was kept open and later closed on POD 3. The patient had a complicated hospital course, including being unable to wean off the ventilator and requiring a tracheostomy. However, the patient’s condition eventually improved and was weaned off the ventilator. During this time, the patient also completed a course of antibiotics for endocarditis. The patient was transferred to a long-term rehabilitation center on POD 37.
Discussion/Conclusion: Shock in cardiac patients postoperatively is a serious complication with high morbidity and mortality. Early identification of causes and understanding of the mechanism of shock are imperative to formulating a treatment plan. In this case, the patient initially had hemorrhagic shock and became a combination of obstructive and hemorrhagic shock.
The types of shock are cardiogenic, hypovolemic, distributive, and obstructive shock. While cardiogenic and distributive shock require different treatment plans, hypovolemic and obstructive shock have many similarities in goals for treatment. The goals include resuscitation with fluid or blood products to optimize preload, vascular tone, and perfusion pressure, augmentation of myocardial contractility with inotropes, and surgical correction of the problem. In this case, norepinephrine and vasopressin were used to optimize vascular tone and perfusion pressures, epinephrine was used to augment contractility, and MTP was initiated to improve preload. All were in place as the surgery team corrected the underlying cause.