Division Corner
A case of elective aortic aneurysm repair with post-operative complications
Matthew H. Gao, DO Jacopo Colombo, MD
A 76-year-old male with a history of hypertension, hyperlipidemia, diabetes mellitus, and heart failure with reduced ejection fraction (HFrEF) underwent an elective open abdominal aortic aneurysm (AAA) repair.
A suprarenal aortic clamp was applied for 30 minutes, and there was significant blood loss of 3.5 liters. The patient received 4 liters of Plasma-Lyte, 4 units of RBCs, 2 units of FFP, and 300 cc from a cell saver, with 350 cc of urine output recorded . Postoperatively, he was extubated without complications, had satisfactory pain control, and was monitored in the PACU overnight with 1200 cc of lactated Ringer’s solution and periodic phenylephrine infusions.
Postoperative Complication:
The following day, he complained of shortness of breath, and his oxygen requirements escalated . To evaluate the cause of his hypoxia and hypotension, a chest X-ray and ultrasound were performed .
Diagnosis:
1.Cardiogenic Pulmonary Edema:
This type is caused by increased pressure in the pulmonary capillaries due to elevated cardiac filling pressures, usually resulting from left ventricular dysfunction (e .g ., heart failure, mitral valve disease, or acute myocardial infarction). The heart’s inability to pump blood effectively leads to fluid backing up into the lungs, causing fluid accumulation in the alveolar spaces.
2. Non-Cardiogenic Pulmonary Edema:
• In this type, fluid leaks into the lungs due to increased permeability of the alveolar-capillary barrier, References: Ralston, S . H ., Penman, I . D ., Strachan, M . W . J ., & Hobson, R . (Eds .) . (2018) . Davidson’s principles and practice of medicine (23rd ed .) . often without elevated cardiac pressures . Common causes include acute respiratory distress syndrome (ARDS), sepsis, trauma, inhalation injury, or severe infections . Unlike cardiogenic pulmonary edema, the heart is usually not the primary culprit in this form of edema . Each type requires different management approaches based on the underlying etiology . The table highlights radiographic differences between cardiogenic and noncardiogenic pulmonary edema.
Treatment in this case would be:
1. Positioning
Sit the patient up to reduce pulmonary congestion and facilitate breathing.
2. Oxygen Therapy:
Administer high-concentration oxygen (e .g ., 60%) to improve oxygenation and alleviate hypoxemia .
3. Monitoring:
Implement continuous monitoring of cardiac rhythm, blood pressure (BP), and oxygen saturation to assess patient status and detect any deterioration . Perform serial cardiac and lung ultrasounds to assess prognosis .
4. Nitrate Therapy:
Administer intravenous (IV) infusion of nitroglycerin . 5. Diuretic Therapy:
Administer a loop diuretic such as furosemide 50–100 mg IV to reduce fluid overload and relieve pulmonary congestion .
6. Noninvasive Ventilation:
Initiate continuous positive airway pressure (CPAP) if respiratory distress persists . 7. Inotropic Agents:
Consider using inotropic agents, especially in patients with hypotension, to improve cardiac output and tissue perfusion .
Mechanical Ventilation:
• Initiate mechanical ventilation if noninvasive ventilation fails, or the patient shows signs of respiratory failure .
Intra-Aortic Balloon Pump (IABP):
• Consider the insertion of an intra-aortic balloon pump, particularly if myocardial ischemia is a contributing factor to the pulmonary edema
References:
Ralston, S . H ., Penman, I . D ., Strachan, M . W . J ., & Hobson, R . (Eds .) . (2018) . Davidson’s principles and practice of medicine (23rd ed .)