A 22-year-old previously healthy female was the unrestrained passenger in a highway MVA. Upon impact, a mailbox penetrated the passenger front windshield and struck the patient's face, resulting in severe facial trauma. The patient was intubated in the field for a Glasgow Coma Scale score of 5. She was emergently airlifted to the hospital and, en route, was resuscitated with crystalloid and two units of whole blood.\nThe patient arrived hemodynamically unstable—tachycardic and hypotensive complicated by severe metabolic acidosis (lactate 3.42 mmol/L, reference range: 0.6–2.3 mmol/L). Her right eye was ruptured, and her left pupil was dilated to 5 mm and minimally responsive to light. Three additional units of packed red blood cells (pRBCs) and two units of fresh frozen plasma (FFP) were rapidly administered via a Level 1 rapid infuser in the right 18-gauge antecubital intravenous catheter with stabilization of her hemodynamic status. Trauma series computerized tomography (CT) revealed facial trauma with ruptured right globe, temporal bone fracture, temporomandibular joint-line fractures, and mixed subdural and epidural hematomas with an 8 mm midline shift and effacement of the anterior horn of the right lateral cerebral ventricle. A large amount of air within the right ventricle (RV) extended to the right axillary vein (Figures and ) with air collection under the pulmonary valves () but no immediate RV outflow tract obstruction. The air entrainment was thought to be due to transfusion of products through the Level 1 rapid infuser given that there were no pneumothoraces or air in the superior and inferior vena cava.\nA multispecialty conference was held between the trauma surgery, neurosurgical, cardiac intensive care, and anesthesia teams regarding the optimal treatment plan. The concern was RV air burden may risk embolization and would compound hemodynamic collapse during emergent craniotomy. Aspiration of air via a central line was considered, but the impending risk of brain damage expedited the decision to proceed emergently to the OR for intracranial decompression. While the patient was in the CT scanner, vital signs included bradycardia (50s–60s) and occasional hypertension (systolic blood pressure reaching 150s–160s mm Hg), indicating presence of Cushing's triad. These vital signs along with physical exam findings of left dilated pupil and imaging evidence of an 8 mm cerebral midline shift were consistent with possible critically elevated intracranial pressures. With relatively stable hemodynamics but critical cerebral herniation risk, the decision was made to proceed with emergent craniotomy.\nThe patient arrived to the OR directly from diagnostic radiology, with heart rates between 80 and 90 beats/min and mild hypotension with systolic blood pressures of 90–100 mm Hg without any vasopressor support. She was maintained on inhaled sevoflurane at a minimum alveolar concentration <1.0 with nondepolarizing muscle relaxant. A right radial arterial line was placed. For access, the patient had a previously placed 18-gauge peripheral intravenous and intraosseous catheters. The patient was positioned in pins in the reverse Trendelenburg position. The degree of reverse Trendelenburg position was small (about 10–15 degrees) and was performed to decrease intracranial pressure and for optimum surgical visualization.\nTwenty-five grams (200 mg/kg) of intravenous mannitol was administered. At this point, the patient had approximately 2–2.5 L of estimated blood loss and had received four units of red blood cells (two whole blood, two pRBCs) and four units of FFP. Since intraoperative hemoglobin (9.7 g/dl), coagulation panel, and lactate (normalized to 2.0 mmol/L) were normal, further transfusions were deferred.\nApproximately 28 minutes after incision, end-expiratory CO2 (EtCO2) and mean arterial pressure abruptly fell concomitantly with loss of pulse oximetry waveform. She maintained an organized rhythm but distal pulses could not be palpated. The neurosurgeons were able to palpate intracranial pulsation; therefore, chest compressions were not initiated. Obstructive VAE physiology was assumed, and repeated intravenous epinephrine doses (10 mcg per injection) and 1 L fluid bolus were administered. After the first 30 mcg of epinephrine was administered over approximately 30 seconds, EtCO2 and blood pressure increased and the pulse oximetry waveform returned. An epinephrine infusion was initiated to maintain hemodynamic stability. In aggregate with hemodynamic resuscitation, the patient was immediately placed on 100% inspired oxygen and taken out of reverse Trendelenburg position to a more neutral position.\nThe patient remained hemodynamically stable on the epinephrine infusion and did not have a recurrence of such an event for the rest of the procedure. At the conclusion of the right hemicraniectomy and hematoma evacuation, intraoperative transesophageal echocardiography (TEE) showed hyperdynamic contractility and persistent, though nonobstructive air in the right ventricle. The intracardiac air burden was substantially less compared to the amount visualized on preoperative CT scan. There was no patent foramen ovale or regional wall abnormalities. At this point, the patient had displayed normal and stable vital signs for two hours. Thus, in the presence of hemodynamic stability in a patient without cardiac or other major comorbidities, the decision was made to proceed with the remainder of planned surgery. Furthermore, the ophthalmology and plastic surgery teams indicated that urgent surgical intervention may potentially preserve function of the patient's right eye while decreasing chance of infection.\nOnce the TEE probe was removed, the ophthalmology and plastic surgery teams performed a right eye enucleation, repair of brow and facial lacerations, complex repair of nasal laceration and cartilage, repair of upper and lower eyelid lacerations and reduction and fixation of numerous, complex frontozygomatic fractures, and irrigation and debridement of open wound, which collectively took 90 minutes of additional operating time.\nTotal OR time totaled 569 minutes. Using a goal-directed transfusion threshold of 8.0 g/dL, the patient received a total of two units of pRBCs and two units of FFP intraoperatively. Additionally, a total of 5,000 cc of crystalloid and two grams of intravenous calcium chloride were administered. Estimated blood loss for the procedure was 300 mL with 4000 mL of urine output. The epinephrine infusion was weaned off by the end of the procedure (highest dose 0.1 mcg/kg/min).\nA postoperative head CT revealed expected postoperative changes with complete resolution of midline shift. The patient was then transported to the neurological intensive care unit intubated for ongoing cares. Given her age, lack of preexisting cardiac comorbidities, and resolution of her hemodynamic instability, further cardiac evaluation was deferred. She remained intubated for airway protection but was extubated within 36 hours of admission. The patient exhibited no gross neurological deficits and was able to verbally communicate shortly after extubation. She continues to progress with traumatic brain rehabilitation in the outpatient setting.
A 37-year-old 70 kg male patient with chronic hepatitis B- and C-induced liver cirrhosis (MELD score of 28 and Child-Pugh of 11) presenting with mild jaundice and abdominal distension was admitted for orthotropic liver transplantation (OLT) to the Hospital of Lithuanian University of Health Sciences Kaunas Clinics. There was no clinical evidence of cardiopulmonary decompensation in physical examination or clinical history. CT CAP showed ground glass opacity (GCO) findings in the right lung. Arterial blood gas (ABG) values, electrocardiogram (ECG), spirometry, and transthoracic cardiac echo prior to surgery revealed no significant abnormalities. However, the coagulation profile was deranged: PT 43.6 s, APTT 60 s, fibrinogen 122 mg/dl, and platelets 36 × 109/l. In the anticipation of a high risk of bleeding group and save as well as crossmatch were requested prior operation. In the operation theatre standard anesthesia was induced with 2.8 mcg/kg fentanyl, 2.5 mg/kg propofol, and 0.14 mg/kg cisatracurium. The patient was intubated with standard endotracheal tube no. 7.5 using direct laryngoscopy and MAC blade no.3, and ventilation was started using PRVC mode with Vt of 6–8 ml/kg IBW, 12 bpm, aiming for a moderately lower EtCO2 of 35 mmHg, a peak not exceeding 25 cm H2O and a positive end-expiratory pressure (PEEP) of 4 cm H2O. Sevoflurane (2.2–2.5% EtSEV) in an air-oxygen mixture, fentanyl on requirement and cisatracurium infusion were used for anesthesia maintenance. Central venous pressure, invasive arterial blood pressure and BIS monitoring were used together with all standard anesthesia monitoring. The ABG test was performed every hour. Rotational thromboelastometry (ROTEM) was used to guide blood product transfusion. According to scientific sources, ROTEM has proven to be more appropriate for the assessment of coagulation in liver diseases than conventional coagulation tests and it can reduce perioperative blood loss and blood product transfusion rates [, ]. Based on a local transplantation protocol, a rapid infusion system (The Belmont® Rapid Infuser (FMS 2000)) is routinely used in this transplantation center. Additionally, in anticipation of massive blood loss, the Hemonetics® Cell Saver Autologous Blood Recovery System is used unless contraindicated [].\nThere was no hemodynamic instability during the initial portion of the procedure. During the recipient hepatectomy (hour mark two), the patient had a sudden decrease in arterial blood pressure, heart rate, oxygen saturation and end-tidal carbon dioxide level. In high suspicion of air embolism, the oxygen fraction (FiO2) was instantly increased to 100% following immediate chest compressions and 1 mg of IV adrenaline. Mechanical ventilation was converted to manual ventilation to ensure adequate oxygenation. The resuscitation protocol was carried out for less than 2 min, proper asystole was never truly observed, and cardiovascular function was preserved. The surgeons confirmed the presence of a defect in the inferior vena cava at its junction with hepatic veins, proving the preliminary diagnosis of venous air embolism. After an unsuccessful attempt to aspirate air through the central venous catheter (CVC) and re-establishment of mechanical ventilation with a PEEP of 8 cm H2O, TEE was performed that revealed air bubbles in both the right and left heart chambers confirming the diagnosis (Fig. ). Although adequate ventilation with a high inspired oxygen fraction was maintained, saturation remained low during the remaining portions of the surgical procedure. There were no additional episodes which represented VAE; however, further problems were more closely related to various coagulation issues which led to massive allogenic blood products and autologous blood transfusion and the development of DIC. Repeated viscoelastic coagulation tests revealed that CT, CFT in intrinsic and CFT in extrinsic coagulation pathways were severely prolonged due to significant deficiency of fibrinogen (MCF 5 mm). The urgent call of blood products was indicated – the total amount of transfused blood during the surgery was 10,955 ml (49 units) alongside 14,000 ml of fluids to maintain volemia. ROTEM and TEG both indicated severe coagulopathy with especially low fibrinogen levels (Fig. ). The patient was transfused continuously using various blood products according to local transfusion protocols and viscoelastic blood coagulation test results (Fig. and Table ). The total amount of blood loss was 4000 ml. Intraoperative blood salvage (Cell Saver) was extremely beneficial as it allowed us to limit the amount of autologous blood transfusions and return 3500 ml of salvaged blood. Fibrinogen concentration was restored using cryoprecipitate, which may not have been as efficient or effective as compared to human fibrinogen concentrate, but was the only available agent at the time. Despite all interventions thrombocytopenia occurred (after VAE episode platelets decreased: 36- > 28 × 109/l) due to the lack of fibrinogen, and proper clot formation could not be achieved (Fig. ).\nDuring the other phases of the surgery, the patient received protective lung ventilation (Vt of 6–8 ml/kg IBW and PEEP at 8 cm H2O) with a high inspired oxygen fraction and 0.3 mcg/kg/min noradrenaline to maintain adequate ABP. The patient remained in a critical condition and was transferred to the ICU for further treatment. Repeated TTE revealed small ventricles with normal systolic function indicating consequences of hypovolemia secondary to severe bleeding.\nDiffuse bleeding almost immediately after transplantation, on first postoperative day, from the upper abdomen and thrombosis of the hepatic artery were suspected as the patient’s anaemia worsened and transaminase levels increased. A computerized tomography (CT) scan demonstrated that the left hepatic artery was only partially filled with contrast leading us to suspect partial thrombosis as well as a large subhepatic heterogenic mass (6.5 cm × 7.5 cm) representing a possible hematoma. Contrast extravasation was also noted in the venous phase. The decision was made to perform emergency relaparotomy. Due to unstable hemodynamics caused by severe bleeding, coagulopathy and acidosis, noradrenaline was continuously given by reducing the dosage in a manner dependent on the requirement until complete cessation. Cryoprecipitate, prothrombin complex concentrate (PCC), platelets and packed red blood cells (PRBCs) were constantly given. Patient remained stable for 2 days before hypotension and anaemia worsened. The patient was taken back to the Operating Theatre for exploration which demonstrated 3000 ml of blood (fresh and clotted). Clotted blood was found suprahepatically around the caval anastomosis as well as porta hepatis. After the patient’s second laparotomy, he continued to deteriorate and required increasing doses of vasopressors to maintain adequate blood pressure and tissue perfusion. He continued to deteriorate becoming increasingly hypotensive, acidotic and eventually went into multisystem organ failure and died.