The Crash Course I Received in the Stabilization and Treatment of Post Pancreaticoduodenectomy Bleeding
My Entire Knowledge of the Whipple Surgical Procedure prior to this Transport
I knew Whipple Surgeries are a huge surgical intervention. I knew that the surgery has something to do with the pancreas. In a passing conversation with a surgical fellow in our Adult Emergency Department (ED), we discussed that the kits for Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) were actually implemented at Michigan Medicine “Not for trauma, but because we do a large volume of Whipple surgeries…when patients that come with post Whipple bleeding they do not do well!” As we can now learn just about “everything” from YouTube (except maybe the step-by-step on how to actually perform the procedure), the following video provides an excellent and brief overview:
The Transport that Changed My Level of Knowledge
Almost three decades ago when I took my initial Basic EMT class, my EMS educator stressed basic physiology: “Air Goes in and Out and Blood Goes Round and Round”. He also frequently spoke of the “Pathway to Death”. He would call out, “How do people die?” The class would answer, “Seizure>Coma>Death.”
Although my hair is grey and I am a bit more “seasoned” than I was in 1994, the rules I learned in Basic EMT School about “Life and Death” are clearly demonstrated in this case. While my general surgical knowledge is still a bit suspect, recognizing “basic needs” allowed us to stabilize and safely transport this patient to definitive care. Details of this case are loosely based on actual events; patient identifiers have been altered to protect privacy and enhance educational impact.
We were called to a small, critical access ED for a 41-year-old patient with a “GI Bleed”. Before we launched, we had the discussion of taking blood products from our stock. We carry 2 units of Packed Red Blood Cells (universal donor) and 2 units of Thawed Plasma at each base. While the referring ED “should” have blood products available, it was fortunate for us that we took ours.
Clinical History and “HPI”
The patient presented to the ED via EMS at 01:10 am. He was experiencing generalized, “full body seizures,” bright red blood emesis and bright red stool. While per family report, he has no significant Allergies, has “an antibody” that makes, “matching blood products difficult.” At home, he takes Lovenox, Aspirin, MS Contin, Flagyl, Zofran, Compazine, Reglan and Senekot. He has a significant history of Type II diabetes, obesity and was diagnosed with “Pancreatic Cancer” 6 months ago.
He was discharged from the tertiary hospital post-Whipple procedure 2 weeks prior. His baseline Hemoglobin was 8.9 mg/dl. He had received his Aspirin and Lovenox by a home health aide on an ordered schedule (within 6 hours of ED admission). His post-operative course was complicated by a bile leak, fever (questionable sepsis) and hepatic venous thrombosis. He was discharged from the tertiary hospital after readmission for his bile leak 30 hours prior to presenting to the local ED with the aforementioned symptoms.
Upon our arrival, the referring staff indicated that the patient has received 4 liters of crystalloid because their blood bank would not release any blood. The reasoning? “He has antibodies.” His vital signs included an oral temperature of 35.1 C, a heart rate of 134 bpm (sinus), a blood pressure of 75/40, and an oxygen saturation on room air 96%. Significant laboratory studies included a WBC count of 47.4 x 103/mm3, Hemoglobin of 4.3 mg/dl, an INR of 1.8, a serum lactate of 14.8 mmol/L and a serum potassium of 3.9 mEq/L.
Our clinical assessment included a declining neurologic status (somnolent and slow to respond to basic verbal commands), grey cold skin with absent peripheral pulses and thready central pulse quality, ongoing active bleeding of bright red blood from the nasogastric (NG) tube and rectum, and patient report of increasing right upper quadrant pain at rest and with palpation.
Our Priorities of Care
Intubate the patient due to risk of airway compromise (hemodynamic instability/failure to protect airway/expected clinical course).
“Give every bit of blood you can get your hands on” following receiving physician consultation. The risk of death due to hemorrhage outweighed “antibodies.”
Initiate a TXA bolus and drip.
Time from treatment plan to endotracheal tube placement was 31 minutes. To improve oxygen carrying capacity, hemodynamic stability and attempt to reverse shock, the crew made the decision to resuscitate prior to intubation. High-low oxygen (via a nasal cannula at 10 lpm and a non-rebreather mask) was initiated. Likewise, the crew initiated volume resuscitation with the Emergency Release Blood Products that they brought with them. While the local blood bank was reluctant to release blood products due to “antibodies,” death due to anemia and hemorrhage was imminent. Consent was obtained from the patient’s spouse and emergency resuscitation was initiated. Due to ongoing hemorrhage and coagulopathy, 1 gram of Tranexamic Acid (TXA) was also initiated per transport team protocols for hemorrhagic shock. Additionally, 1 gram of Calcium Chloride (CaCl2) was administered due to documented hypocalcemia.
Patient Transport and Disposition
Following hemodynamic resuscitation with 2 units of thawed plasma and 2 units of packed red blood cells, intubation and TXA, the patient’s vital signs included a heart rate of 116 bpm, blood pressure of 116/62 and an oxygen saturation of 97%. His skin color was pale / pink with stronger central pulses but still lacked palpable peripheral pulses. An abdominal ultrasound revealed a large amount of bowel gas, preventing any useful images.
The referring hospital finally issued a cooler of blood products to us for transport as we walked to the helicopter. After we lifted off, we opened the cooler to find 6 units of O negative blood and 2 units of Thawed Plasma (AB -) with the patient’s name on the blood tag…but NO PAPERWORK was issued with the blood. As we were not sure if we could even administer these products, we decided to hold on administering unless the patient had life threatening hemodynamic compromise (we were not going to administer any more crystalloid).
Upon arrival to the ED, the patient had a heart rate and rhythm of sinus in the 120-bpm range, a blood pressure of 106/72, and an oxygen saturation of 99% with a waveform capnography reading of 30 mmHg. He was immediately taken to interventional radiology where he was found to have a suspected pseudoaneurysm of the gastroduodenal artery (GDA). The GDA is a terminal branch of the common hepatic artery which mainly supplies the pylorus of the stomach, proximal duodenum, and the head of the pancreas.
An angiogram revealed the location of the pseudoaneurysm and stenting of the common hepatic artery to exclude GDA pseudoaneurysm ensued. Following the stenting, there was no further evidence of bleeding. The patient was extubated within 8 hours of transport without complication. He was restarted on Lovenox day 1 following the procedure to due to the history of Portal Vein Thrombosis and was discharged home (with a Hospice Consult) day 3 post procedure.
Take Home Points
- Sometimes, there is little room for error when establishing treatment priorities. Dr. Weingart often calls a laryngoscope a “murder weapon” for a reason. While this patient clearly needed intubation, the induction and subsequent laryngoscopy has the potential to carry grave consequences for a patient in refractory shock. There was a reason that we spent 31 minutes resuscitating this patient prior to placing the C-Mac in his mouth.
- Minimizing ground / bedside time is a “moving target.” Refer to the previous bullet point. Many flight services scrutinize bedside times. This is understandable for “STEMIs” and Strokes. However, it is important to understand that while the resources you have in a critical access hospital are limited, those in the cabin of a helicopter or ambulance are even more so. Think about how easy it is to do CPR in the cabin of your aircraft. A few extra minutes at the bedside can prevent that.
- Can the flight team give blood without clear confirmation of patient identity and proper/standard blood verification checks? While not standard practice, the benefits outweigh the risks in a crashing patient in hemorrhagic shock. After consultation with our blood bank, we had a plan should the need to administer the products be required. The referring blood bank would not release products without some semblance of oversight. It is recommended that if the need to administer these products arose, we keep the packaging / bags that the products were in and give them to the blood bank. It is also important to be accurate in documentation including product, donor unit number on the packaging, time administered and clinical assessment before and after administration. The patient would automatically receive close follow up and consultation with hematology.
References
Castillo CF et al. Overview of surgery in the treatment of exocrine pancreatic cancer and prognosis. UptoDate. Last updated May 4th, 2002
Mann, B. D., Heath, C. M., Gracely, E., Seidman, A., Nieman, L. Z., & Sachdeva, A. K. (1998). Use of a paper-cut as an adjunct to teaching the Whipple procedure by video. The American journal of surgery, 176(4), 379-383.
Puppala, S., Patel, J., McPherson, S., Nicholson, A., & Kessel, D. (2011). Hemorrhagic complications after Whipple surgery: imaging and radiologic intervention. American Journal of Roentgenology, 196(1), 192-197.
Whipple, A. O., Parsons, W. B., & Mullins, C. R. (1935). Treatment of carcinoma of the ampulla of Vater. Annals of surgery, 102(4), 763.