1. VCU DEATH AND COMPLICATIONS CONFERENCE

2. Introduction  Complication  Death, coagulopathy  Procedure  Partial resection of massive intraabdominal tumor  Primary Diagnosis  Sarcoma NOS

3. Clinical History  2 yo girl from Honduras  Large intraabdominal tumor  PMH seizure disorder  Mass diagnosed at age 6 months  s/p 2 resections/biopsies, 6 cycles chemo  Multiple working tumor diagnoses, multiple pathologists  Admitted 3/1 for imaging, hyperalimentation  Stepdown status for refeeding syndrome  Heme-onc and nutrition consults  Outside path specimens reviewed at MCV

4. Timeline of Key Events  3/2  To OR for R brachial PICC line, CT abdomen  3/5  PICC adjustment by IR, placement of R IJ PICC  CTA abdomen/pelvis  MRI head  3/6  OR for resection

9. Intraoperative events  Transverse abdominal incision made over mass  Transverse colon mesentery dramatically stretched  Anatomy grossly distorted  Dissection proceeded on left lobule  Left sided masses removed x 2 after reduction of transverse colon  Perforation noted near pylorus, mass origin  Distal gastrectomy, cholecystectomy

11. Intraoperative events  Intraoperative TEE  Sinus bradycardia @ 1209  Loss of pulse @ 1219, chest compressions  Ventricular fibrillation 1247, shock x 2 (30J, 50J)  Intraoperative TEE revealed collapsed RV  Decision made to close abdomen and transfer to ICU for rewarming, resuscitation and correction of coagulopathy

12. Postoperative events  Transferred to ICU hyperkalemic (6.8), temp of 35, coagulopathic, anemic (5.6), lactate 11.4, acidotic (7.08)  Coded again within 1 hour of arrival to PICU  ACLS again initiated, ultimately pupils fixed and dilated, continued hemorrhage from abdomen

14. Facts and failures  Platelets checked at 1125 (45) with coags (INR 3), fibrinogen ( 20)  Intraoperative temperature range 30.8 – 36.8 C  Bair hugger reportedly on 43 deg C  TEG done at 1125 revealed DIC with low platelet function/count and low fibrinogen  Coags and fibrinogen unchanged on arrival to PICU 3 hours later  Massive transfusion protocol never initiated

15. Facts  Totals for case  EBL 800 cc  1850 cc PRBC  1100 cc NaCl 0.9%  583 FFP  100 U cryoprecipitate  500 cc albumin  200 cc TPN

16. Analysis of Complication Was the complication potentially avoidable? – Yes. Could have elected not to resect, or simply to biopsy for additional stains/markers. Could have had better communication with anesthesia regarding intraoperative resuscitation status. Would avoiding the complication change the outcome for the patient? – Yes. What factors contributed the complication? – Lack of communication between surgery and anesthesia, size of tumor, extensive dissection and distortion of anatomy, release of inflammatory mediators, nutritional status.

17. Contributing problems  Poor planning  Distorted anatomy  Grossly disturbed physiology  Inadequate resuscitation  Factor deficiencies, hemodilution  Ineffective communication

18. Final Pathology