Recognition and management of hemorrhaging in combination with emerging enterogenic sepsis during a hepatectomy: a case report

Our subject is a 56-year-old male weighing 53 KG and 160 cm tall who had a history of multiple cholelithiasis, as well as multiple choledochotomies over the past 30 years. He was admitted to the hospital complaining of recurrent right upper abdominal pain over the span of one week and abdominal CT showed varying degrees of intrahepatic bile duct dilatation with multiple stones.Preoperatively diagnosed with the following: (1) intrahepatic bile duct stones with cholangitis; and (2) biliary cirrhosis. The patient had been treated with anti-infective therapy at a lower hospital prior to admission, and continued with ertapenem for one week after admission.The treatment plan of an elective right hepatectomy with bile-intestinal anastomosis and reconstruction was decided. The preoperative examination showed approximately normal results, except for a mild increase in transaminases.

The patient entered the operating room at 10:40 on the day of surgery. Considering the patient’s history of multiple biliary surgeries and the likelihood of finding a large number of adhesions in the abdominal cavity, the operation was much more difficult than usual. In addition to routine monitoring, we quickly established internal jugular venous access and parallel radial artery puncture. We also monitored the patient’s blood pressure and cardiac function using Vantage Flow. Subsequently, esketamine, propofol, etomidate, sufentanil, and rocuronium were chosen for the anaesthetic induction protocol, and the patient’s vital signs were observed to be stable after the induction.

At 14:50, a hemorrhage occurred during resection of the right half of the liver. In response, the patient’s blood pressure dropped rapidly to 70/52 mmHg, while the heart rate rose to 91 bpm. The rapid estimate of total bleeding volume of 2000 ml was made and an immediate intravenous infusion of 4 U of packed red blood cells and a rapid infusion of crystalloid was administered. Norepinephrine and meprobamate were used to maintain circulatory stability. In the following 4 h, the surgical wound continued to bleed (roughly 6000 ml), during which time we administered vasoactive drugs and goal-directed fluid therapy, including 4000 ml of lactated Ringer’s solution, 7 U of suspended red blood cells, and 900 ml of fresh frozen plasma. However, the patient’s hemodynamics neither improved significantly nor worsened. Meanwhile, systolic blood pressure fell to a minimum of 58 mmHg, a blood gas analysis suggested severe hyperlactatemia, and the patient’s urine output was significantly lower than before. All these evidence suggested that the patient remained in a state of severe water deprivation and tissue perfusion deficit during this time. We suspect that the severe hemorrhagic shock may have led to a pathophysiological alteration of sepsis with vasodilation, thus increasing endothelial permeability due to an intestinal barrier dysfunction, translocation of intestinal flora and endotoxins. The subsequent reduction in peripheral vascular resistance also supported our idea. We then accelerated the rate of rehydration and administered imipenem anti-infective therapy and corticosteroids supplementations. Following this, the patient’s circulation improved significantly, the systolic blood pressure stabilized at around 90 mmHg, and their urine output increased compared to before (The variation of Vigileo’s parameters is shown in Fig. 1). After the patient’s condition improved, we retained a bacteriological blood culture specimen.

Fig. 1figure 1

The variation of Vigileo’s parameters

Almost immediately following the above treatment, a second difficulty arose. At 20:30, as the surgeon was preparing to suture, the patient’s heart rate increased gradually, soon developing into supraventricular tachycardia (see supplemental material for details). To make matters worse, ventricular tachycardia with severe hypotension also occurred one minute later. The arterial blood gases measured at this time suggested the development of metabolic acidosis combined with hyperkalemia. We immediately corrected the arrhythmia with amiodarone and lidocaine, then administered glucose, insulin, sodium bicarbonate, and calcium gluconate via intravenous infusion. The assistant also prepared a defibrillator for use if necessary. Fortunately, the ventricular tachycardia soon returned to sinus and the blood pressure returned to normal. By 23:00, the operation was complete and the patient was safely admitted to the ICU. In total, 8600 ml of blood was lost, while a total of 19 U of suspended red blood cells, 1300 ml of fresh frozen plasma, 5500 ml of crystalloid. and 6500 ml of colloids were transfused.

Postoperatively, the patient showed a significant increase in inflammatory markers compared to that of the preoperative period as well as intraoperative blood culture specimen results for Enterococcus faecalis (See Fig. 2 for further details). The patient’s troponin, creatinine, liver function, and coagulation indexes were also elevated for a short period of time after surgery(see Table 1), suggesting combined heart, liver, kidney, and other multi-organ failure, which was considered a severe infection. Initially, anti-infective treatment with imipenem was given, and after the blood culture results returned, anti-infective treatment with vancomycin was switched. Polyene Phosphatidylcholine Capsules and glutathione were used for liver function protection. The patient was slightly irritable postoperatively and had mildly elevated blood ammonia. Therefore, we administered ornithine menthylate injection to improve blood ammonia metabolism and Semtex Transmetil to improve cholestasis. Postoperative coagulation indexes were significantly abnormal and platelets were significantly decreased, which was considered to be dilutional coagulopathy caused by massive fluid replacement after massive blood loss in a short period of time. We performed supplementation of coagulation factors and platelets. The rest of the treatment included sedation, analgesia, circulatory support, and nutritional support therapy.After these treatments,the patient was successfully transferred back to the general ward on the seventh post-operative day.

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Postoperative trends in pct and blood culture results

Table 1 Laboratory parameters in the preoperative and postoperative periods

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