A 91-year-old man with coronary artery disease
was taken to the operating room (OR) for semi-elective repair of a
10-cm abdominal aortic aneurysm (AAA). The procedure was relatively
uneventful, and the infrarenal aneurysm was repaired. The
patient’s estimated blood loss was more than 1000 cc, and he
received 2-3 units of cell saver blood. As the fascia was being
closed, the surgeon noted pooling of blood in the surgical field.
The patient’s abdomen was re-explored, at which time he began
bleeding profusely from multiple sites, including the surgical
wound, endotracheal tube, nasogastric tube, and intravenous
catheter sites, all consistent with the development of disseminated
intravascular coagulation (DIC).
The surgeon mechanically reinforced the
anastomosis sites, but they continued to bleed. Surgeons assisting
with the case, as well as the anesthesiologist, recommended packing
and closing the abdomen to tamponade the bleeding and transferring
the patient to the ICU for further medical management. The
attending surgeon opted to give blood products and continued to
attempt local control of the bleeding with little success. The
patient was finally closed and transferred to the ICU 6 hours after
the DIC was first noted. He had received more than 20 units of
blood products and was acidotic on multiple pressors. At this time,
the attending surgeon left the hospital, and the patient was
managed primarily by the chief resident.
The next morning, the patient continued to
require multiple pressors and a bicarbonate drip and had fixed
pupils. The attending surgeon opted to bring the patient back to
the OR for a second look. He found clotted blood but no treatable
lesions; no interventions were undertaken. The patient subsequently
had progressive hypotension, did not respond to resuscitative
measures, and died.
The attending surgeon was known to have had
multiple surgical complications in previous cases, and had been
formally investigated twice for inability to meet the standard of
care. Given his seniority, longevity, and respected position in the
medical center, his credentials were never formally restricted;
rather, it was informally requested that he not perform certain
procedures, including AAA repair.
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