GA4-83
Prone chest compressions and massive blood transfusion during a Cesarean section-to-resection of a fetal sacrococcygeal teratoma: when "perfect" truly was the enemy of "good".
1Jivan K, 2Jivan K, 2Simpao A
1Georgetown University Hospital, Washington, DC, USA; 2The Children's Hospital of Philadelphia, Philadelphia, PA, USA
Case Description: A 32-week gestational age male fetus with an estimated fetal weight of 1.7 kg was scheduled for an immediate resection and/or debulking of a large, mostly cystic sacrococcygeal teratoma (SCT) after Cesarean delivery from a healthy mother. The procedure’s urgency was due to a increase in SCT growth and risks of cardiac compromise—an increase in dilation of the inferior vena cava had been noted on fetal echocardiogram.
After an uneventful Cesarean delivery, the neonate was intubated immediately after birth. Peripheral IVs, umbilical venous and arterial catheters were placed by the neonatology team followed by transfer to the fetal OR for debulking of the SCT. Prior availability of emergency medications, fresh/washed blood and blood products was confirmed. The patient’s initial potassium level was 4 mg/dL and hematocrit (Hct) was 31%.
Intraoperative Course: The patient was placed in the prone position and the umbilical lines were checked. The anesthesia team administered fentanyl, vecuronium boluses and isoflurane was increased gradually. A slow transfusion of packed red blood cells (PRBCs) was initiated as surgery commenced. A tourniquet was used to help achieve hemostasis, yet heavy blood loss ensued and the patient’s mean arterial pressure dropped to 20mmHg. Epinephrine 10mcg/kg, calcium gluconate 30mg/kg, and PRBCs, platelets, and fresh frozen plasma (FFP) were given followed by prompt resolution of the hypotension. The patient remained fairly stable throughout the remainder of the case, with transient but reversible hypotension and hypoxia whenever the surgeons lifted the patient’s lower body off of the OR table.
The patient had received 200mL PRBCs, 100mL platelets, and 100mL FFP and the patient was hemodynamically stable—yet the Hgb was only 8.5mg/dL. The decision was made to transfuse 10 ml/kg PRBCs from a second unit. .
The patient became hypotensive. The arterial waveform went flat and peaked T-waves were seen on the electrocardiogram (ECG). IV epinephrine was given and the ventilator rate was increased. Prone chest compressions were administered with prompt return of spontaneous circulation. The PRBC transfusion was stopped. Calcium, insulin and bicarbonate were given, and the T-waves decreased in amplitude. An iStat showed the potassium level had risen to 6.1 mg/dL.
The patient was stable throughout the remainder of the closure, The potassium level was 5.8 mg/dL and Hb was 10.7 mg/dL before transport to the Neonatal intensive care unit from where he was eventually discharged.
Discussion:
SCT resections immediately following delivery are challenging cases with vulnerable patients. Anesthesiologists must be prepared for transient hypotension and hypoxia whenever the surgeons lift the patient to expose the SCT. Blood products must be available. Unit doses of epinephrine, bicarbonate, and calcium, dextrose and insulin infusions should be immediately available to treat hyperkalemia. Verifying the securement and patency of umbilical lines in the prone position and during position changes and transportation is crucial.
References:
Isserman, RS. Risk factors for perioperative mortality and transfusion in sacrococcygeal teratoma resections.Ped. anesth 2017 Jul;27(7) 726-732
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