Whipple Surgery is one of the more complex surgeries, and an operation that I have been looking forward to take part in since I started Anaesthesia. Thus, when I joined residency and was bestowed the privilege to partake in one, it was a dream come true and I eagerly prepared for it.
The patient was an elderly lady with complex medical co-morbidities. I discussed the case with my consultant and she informed me of her plans to perform B/L ESP blocks, in addition to the usual set-up of IA, CVP, Animec, BIS, Precedex and Remifentanil infusions.
Leading up to the case, I meticulously read up on special considerations for pancreatic and Whipple surgery, as well as revise the anatomy and techniques for doing an ESP block. I wanted to excel, achieve good outcome for my patient, and leave a positive impression with my consultant. I wanted to make the most out of this precious opportunity. On the op day, I came to OT early to set up all the drugs and equipment, making sure we are built for success. When my consultant arrived, she kindly offered me the chance to do one of the ESP blocks, when all along I was expecting to be just assisting/learning. I thanked her for her trust and performed my first ESP block competently. The induction and subsequent lines-setting were uneventful and soon the operation was smoothly underway. I was excited to done a great job thus far, and was looking forward to ending this complex case on time.
Three hours into the operation, while my consultant was on a short break, the patient suddenly turned hypotensive. Initially I attributed it to the ESP blocks working too well. I cut down on the Remifentanil and gave some vasopressors. While the BP picked up slightly, I checked the suction bottles and noticed that there was a sudden gush/increase in volume of blood loss. Sure enough, surgeons informed me that they had inadvertently nicked a large vein, and were unable to immediately secure the vessel. I sensed the urgency of the matter and asked the Anesthetic nurse to send for bloods. I ran fluids rapidly and did an ISTAT, while at the same time updating my consultant of the development. Subsequently the HCT came back as low, and my consultant agreed with my recommendation for blood transfusion. The team spent the next few hours aggressively replacing the blood loss by running in blood products fast to maintain haemodynamic stability. At the same time the surgeons called in reinforcements to assist in stopping the bleed. Eventually the surgeons repaired the vessel and we caught up with the blood loss. Haemodynamics stabilized and surgery went back on track. Surgery finished around 7pm, we did one last ISTAT prior to extubation and all values were satisfactory (BE -4). She was extubated smoothly, started on PCA Morphine, observed in PACU and discharged to HD in a stable condition.
In the aftermath of this incident, I experienced a great sense of relief. Although it was an unexpected complication, we were thankful we recognized the red flags early and responded swiftly to stabilize the patient. I was happy that we had been thorough in our preparations, ranging from pre-op evaluations/optimizations, preparing all the drugs and equipment, ensuring sufficient blood products on stand-by, and establishing life-saving invasive vascular access post induction. I was thankful that our surgical colleagues called in specialized help from vascular surgeons to help address the issue, and that our AU staff was responsive and calm and carried out our instructions smoothly. For the next few days, I followed up on the patient closely via EMR, and also went down to speak to her in HD. I was relieved she was recovering well from the surgery and kept my senior updated on her progress till discharge to GW.
However, a few days later, while I was doing this reflection, I felt a shudder in retrospect. I was lucky that the bleed was not arterial or torrential, otherwise I might not have been able to handle the situation as calmly without my consultant’s presence. I recalled the moments of panic as the SBP dip to the 70s, while I anxiously waited for the PCT to arrive so as to start the transfusion. Those were heart wrenching moments and I wish to avoid them in my career as much as possible. “Hours of boredom, moments of terror” was an interesting meme about Anaesthesia that I had chuckled about before, but I truly experienced it during this case. All in all I am thankful that I responded appropriately and that the patient did not suffer any untoward consequences from the bleed.
There are many takeaways from this case:
First is the need to train myself to remain calm and rational during crisis situations, which requires mental discipline and clinical experiences.
Secondly, never think your job is done, until it is done. You never know what may happen next, so stay vigilant and be ready to act.
Third is the importance of hard work and preparation. To lay a good foundation is key for the success of any case. I am glad I prepared well for this case, and because I was very familiar with the patient’s condition, I was able to intervene decisively. I was also glad we were meticulous and made all necessary preparations, so that when crisis occurred everything worked well and we were able to deliver the anaesthetic care to the best of our abilities.
Lastly, teamwork and communication can never be understated in crisis management. I thanked the surgical team for informing us of their challenges early, and the AU team for following our plans and performing read-back on every task that was performed. Without good teamwork, the outcome may not have been so positive.