Goals and Plans: Turning Points for Success

Abstract

After emergency surgery, an obese patient with multiple injuries is transferred from the operating room to the surgical intensive care unit (SICU). The patient’s diagnoses include open fractures of the forearm and the femur, blunt chest trauma, a mild head injury, and multiple lacerations. The chest X-ray shows evidence of a lung contusion without any signs of fractured ribs or of a pneumothorax. On admission to the SICU, the patient is adequately ventilated, and his initial hemoglobin concentration is 11.5 g/dL. After 2 h of an uneventful course, the patient suddenly develops increasing peak airway pressure. Despite increasing the inspired oxygen concentration to 70 %, the saturation continues to decrease, and the patient becomes hemodynamically unstable. The resident physician examines the patient, auscultates the lung, and finds decreased chest motion and decreased breath sounds over the right hemithorax. He assumes a diagnosis of pneumothorax without confirming his diagnosis by additional examinations and studies (e.g., chest X-ray). He immediately proceeds to perform a tube thoracostomy through an anterior axillary line incision. Because he has never performed this procedure before and because the anatomy of the patient is less than favorable for an exact identification of anatomical landmarks, he accidentally perforates the liver with the trocar. There is an initial blood return through the chest tube that he interprets as intrapleural bleeding. Despite his intervention, the patient’s oxygenation does not improve, and the peak airway pressures do not normalize. Drawing no further conclusions from these observations, no additional interventions are performed at this time by the resident. Over the next 20 min, 1,500 ml of blood drains from the chest tube and the arterial blood pressure continues to drop. The resident inserts two large-bore intravenous lines and rapidly infuses crystalloid and colloid solutions. At the same time, he asks the nurse to prepare an infusion pump with epinephrine, to check the arterial blood gas, and to request packed red blood cells (PRBCs) and fresh frozen plasma (FFP) from the blood bank. The resident finally calls for his attending physician, but before he arrives in the SICU, the patient goes into cardiac arrest. Cardiopulmonary resuscitation (CPR) is immediately started, and spontaneous circulation returns. From the location of the thoracostomy site and from the clinical course, the attending physician diagnoses intra-abdominal bleeding from a perforated liver and immediately organizes an emergency exploratory laparotomy. Following massive volume resuscitation of blood products and crystalloid, the patient is stabilized and transported to the operating room. Laparotomy confirms the diagnosis of a massive hemorrhage from a laceration to the liver. The surgeons succeed in controlling the bleeding and the blood pressure improves. As a result of the massive transfusion of blood products, the patient develops transfusion-related lung injury (TRALI) and requires mechanical ventilation for several weeks. An intraoperative bronchoscopy reveals a large blood clot, which almost completely obstructs the right mainstem bronchus as the cause for the initial problem. After removing the clot, the saturation and airway pressures normalize rapidly.