Page 7 - CASA Bulletin of Anesthesiology 2022; 9(3)-1 (1)

Vol. 9, No 3, 2022

and rocuronium, and maintained with sevoflurane, IV fentanyl and rocuronium. Two 16 G
cannulas were placed for venous access. In addition to ASA standard monitors, a left radial
catheter was placed for monitoring of arterial blood pressure, and for serial blood sampling for
arterial blood gas, hematocrit, electrolytes and thromboelastogram (TEG) analysis. A left internal
jugular (IJ) Cordis catheter (9 Fr, Teleflex) was inserted for rapid transfusion of blood products
and CVP measurement. A cardiac output (CO) monitor (Argos CO monitor, Retia Medical) was
employed for continuous intraoperative monitoring. A second right IJ and right femoral venous
catheter were cannulated for intraoperative VVB. A Belmont rapid transfusion system (Belmont
Medical Technology) was connected to a Cordis catheter for intraoperative blood transfusion.

The surgeon made a midline incision from the xiphoid process to just below the umbilicus.
The liver was extremely bulky with metastatic disease predominantly in the right liver. Seven
tumors were removed from the liver segment 2, 3 and 4B without much difficulty. Up to this
time, patient BP, HR, oxygenation, cardiac output (CO) and pulse pressure variation (PPV)
remained stable. A low CVP was maintained (2 mmHg) and ABG, TEG and Hb and electrolytes
results were within the normal range despite an estimated blood loss (EBL) of 3400ml.

When the tumor in segment 4A was dissected and resected, there was a large amount of
bleeding from the backside of the lesion that was believed to be portions of the middle hepatic
vein plastered to the backside of the tumor. Massive transfusion of blood products, including red
blood cells, cell savior, FFP, platelets were initiated using the Belmond rapid transfusion system
to resuscitate the patient. IV vasopressin was bolused, and phenylephrine and norepinephrine
infusions were used to maintain the BP. As surgeons began to trace down these vessel branches,
the patient went to sudden pulseless VT cardiac arrest. Her vital signs changed: mBP decreased
from 75 to 20⁓30mmHg, ECO2 from 30 to 9 mmHg, EKG changed from sinus rhythm to
ventricular tachycardia and CVP from 2 to 12mmHg. ABG showed severe metabolic acidosis,
potassium 6.2-8mmol/L, Calcium 0.47-0.65mmol/L, Hb 6-9g/dL. The anesthesia provider
immediately notified surgeons and called for assistance. Cardiopulmonary resuscitation with
chest compression was initiated as the patient was in pulseless electrical activity. The fraction of
inspired oxygen (FiO2) was increased to 100%, and IV boluses of epinephrine 1mg IV were
administered every 3 minutes. Additionally, calcium, sodium bicarbonate, infusion of
norepinephrine and dextrose/insulin for hyperkalemia were administered.
While the Cardiorespiratory resuscitation and massive blood products transfusion continued,
surgeons encircled the portal inflow and pulled up on the Pringle Maneuver to stop all hepatic
inflow stopping the bleeding. Surgeons at this point also found small perforating holes in the
middle hepatic vein enabling air to enter into the side branches of the middle hepatic vein when
the tumor was resected and veins manipulated. An anesthesia team members immediately
withdrew 10 ml of air from the central line, ultrasonography imaging of the patient’s heart
showed a large amount of air in the right atrium and ventricle. A needle was placed into the right
ventricle and a significant volume of air withdrawn. Despite these measures, EtCO2 continued to
fall to 10 mmHg and mBP to 30mmHg. The resuscitation attempts had been going on for 45
minutes without any return of spontaneous circulation and the resuscitation effort was
discontinued.

The patient estimated blood loss during the surgery was 10,000 ml, and urine output was 300
ml. The patient received 7,000 ml IV crystalloid, 800 ml 25% albumin, 31 units of PRBC, 15

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