2024 FSA Podium and Poster Abstracts
P026: ANESTHETIC MANAGEMENT OF OPEN REPAIR OF AN ABDOMINAL AORTIC ANEURYSM RESULTING IN SPLENIC LACERATION AND MASSIVE HEMORRHAGE
Evan Maisel, MD1; Garrison S Kohler1; Emily Chung, DO1; James Bolduc, DO1; Ryan Shienbaum, MD2; 1HCA Kendall Hospital; 2HCA Aventura Hospital
Introduction: Surgical management of abdominal aortic aneurysms were historically repaired via the open approach, but are now mostly performed through endovascular methods for numerous reasons, including a large decrease in mortality rates. In more rare instances, the open approach is still performed. This report aims to discuss a complicated open abdominal aortic aneurysm procedure with massive hemorrhage stemming from incidental splenic injury, as well as measures to address it.
Methods: The patient is a 71 one year old male who is a former smoker with history of hypertension, hyperlipidemia, COPD, obesity, who presented to the hospital for repair of an infra-renal abdominal aortic aneurysm. The decision to perform the surgery open was made as anatomy made the patient a poor candidate for an endovascular approach. An arterial line and central line were established in addition to 2 large bore peripheral IV’s prior to the start of surgery. Additional monitoring included cerebral oximetry. Aside from some anticipated blood loss, the surgery was relatively uneventful until the repair was determined to be complete and the aorta was unclamped. At this time, the surgeon notified the OR team of massive bleeding from an unidentifiable source which resulted in almost immediate hemodynamic instability. It was later determined that the patient suffered an injury to the spleen during aneurysm repair.
Results: The anesthesia team immediately activated the facility’s massive transfusion protocol and started resuscitation with the remaining blood products that were already in the room, as well as with crystalloids and vasopressors until more blood products arrived. The surgery team re-clamped the aorta to allow time to find the source of the bleed. This allowed enough time for resuscitation and the patient was able to regain hemodynamic stability. The surgery team identified the source of the bleed to be from a splenic laceration, which resulted in splenectomy, and allowed the surgery to be completed without any further intra-operative complications.
Discussion/Conclusion: Open abdominal aortic aneurysm repairs pose a challenge from both the surgical aspect and anesthetic aspect. There are a wide range of complications that can occur during an open abdominal aortic aneurysm repair. The incidence of splenic injury/incidental splenectomy is not extremely common, however certainly possible with the site of surgery. Massive hemorrhage can occur, requiring significant administration of blood products and prevention of coagulopathy. Prompt recognition and intervention by both the anesthesia and surgical team are crucial to minimizing the risk of complications and improving patient outcomes. Post operative monitoring and supportive measures are also critical to successfully managing patients after such a complication, as there is potential for systemic effects after such an extensive procedure and in the setting of large hemodynamic swings.