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         HOW I AVOIDED A «RE-OPERATION» IN AN AORTIC DISSECTION SURGERY
Dimitris Bliamplias1, Athanasios Mitsokapas2, Georgios Anagnostou2, Euaggelia Gkoutziomitrou3
Anesthesiology Department, «Papageorgiou» General Hospital,Thessaloniki Greece 1 Consultant,
2 Resident,
3 Director
     Introduction-Purpose: Ascending aortic dissection is a condition with high mortality and morbidity. Ideally, the patient should be taken to the operating room before complications such as hemopericardium or dissection of the right coronary artery occur. The following is the clinical course of a young patient with an emphasis on coagulation disorders and their correction.
Case Presentation: A patient in the middle of the 5th decade of his life, came to the hospital because of a fainting episode and precardiac pain. He underwent a chest CT scan almost immediately, dissection of the ascending aorta was documented, he was taken directly to the operating room. Both transthoracic and transesophageal ultrasound showed severe aortic valve insufficiency. It was decided to repair according to Bentall procedure with a metal valve implant. The duration of the extracorporeal circulation was close to three and a half hours and the total hypothermic arrest 30 minutes. The first thromboelastometric study before starting extracorporeal circulation weaning procedure, when the patient was completely heparinized, showed very low levels of fibrinogen (A5 FIBTEM 4 mm) and prolonged CT at EXTEM 152 sec. After extracorporeal circulation was disconnected successfully, 250 mg of protamine sulfate, 5 grams of fibrinogen concentrate, and 1500 IU of prothrombin factor concentrate were administered. Repeated thromboelastometry showed A5 FIBTEM 16 mm, CT EXTEM 79 sec, CT INTEM> 3000 sec, CT HEPTEM 235 sec, A5 EXTEM 30 mm. ACT> 900 sec. From blood gases Hb 8.2 mg / dl. Severe endogenous pathway insufficiency was evident from the above results, given that the ratio CT INTEM/CT HEPTEM> 1.25 and was treated with repeated doses of protamine (50 mg x 3) until the ACT became less than 130 sec (close to baseline). A bag of platelets was also given due to the small width of elastographic diagrams in INTEM/EXTEM. A new thromboelastometric study showed CT EXTEM 100 sec with A5 FIBTEM 14 mm and A5 EXTEM 41 mm. 1500 IU PCCs were re-administered and after the surgical sites of bleeding were checked, 2 units of concentrated red. The final (4th) elastographic study showed a normal endogenous pathway. The patient was taken to the ICU intubated.
Discussion: Repair of ascending aorta separation using extracorporeal circulation, total hypothermic arrest, causes the coagulation mechanism to deregulate to some other degree. Tissue damage, blood loss from large surgical surfaces under complete heparinization, and possible hemostasis also contribute. The result is severe coagulation disorders at the end of surgery. In this instance use of ROTEM significantly helped to immediate recognition-treatment of “residual” coagulation disorder (prolongation of EXTEM) despite that all other “primary” disorders were corrected. In another setting, this situation would be perceived in the intensive care unit at least 60 minutes later after the first laboratory tests would be available. It is possible that despite initiation of delayed treatment (after almost 2 hours), reoperation to investigate postoperative bleeding could not be avoided. Along with the use of coagulation factor concentrates, it was possible to reduce transfusions and reduce the reoperation of these patients to investigate postoperative bleeding.
ΒΙΒΛΙΟΓΡΑΦΙΑ
1. N. Rahe-Meyer / Thrombosis Research 128 (2011) S17–S19 2. Liu et al. Journal of Cardiothoracic Surgery (2017) 12:50
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