some things in surgery are not taught. you sort of pick them up on the way. the cross clamp was one of those for me.the first time i heard of it was during the m and m meeting after a story i've already told. luckily i was on rotation and was therefore not in the direct line of fire. however the professors grilled my colleague on why he did not open the thorax and cross clamp the aorta before he commenced with the laparotomy. it seems, according to the professors, all would have been just rosy if they had opened the chest first and clamped the aorta, the main artery supplying everything in the abdomen and legs, before they opened the abdomen. i remember thinking the patient looked pretty screwed to me at the time and although conceptually the cross clamp idea sounded good i really doubted it would have changed the outcome. however i made a mental note of it. a while later my time came.
it was a gunshot patient, but he was hit well. however, when i saw him he was not feeling well. in fact he was in exitus. his abdomen was severely distended and his vitals were almost undetectable. i was quite impressed that we got him to theater before he moved to the great hereafter. and then it was time to do something. my mind went back to that m and m and that previous case. if there was ever a case where a cross clamp would be a good idea, then surely this was it.
i opened his chest, a region i'm not overly comfortable in, but a place i can find my way around. i found my way around to the aorta and clamped it off, thereby cutting off all blood flow to everything below the diaphragm. then i went down to my old hunting grounds, the abdomen.
when i opened the abdomen there was blood everywhere but there was very little bleeding. this was obviously because there was no more blood even getting to the abdomen. it may have had something to do with the fact that the patient had very nearly totally bled out. of course it didn't mean everything was fine. things were far from fine. his splenic artery had been shot off about half a centimetre from the aorta. there was also an impressive hole going straight through the liver, ripping a hepatic vein or two to shreds on its way. i sorted the splenic artery problem out (splenectomy in this sort of case for all you budding surgeons out there) and got to work on the liver.
some time in the whole process i asked the anaesthetist how things were going on his side of the drapes.
"the top half of him is fine. just a pitty that we can't just send the top half to icu and hope for the best." the point was at some stage we needed to remove the aorta's cross clamp. we loaded him with fluid and blood and slowly removed the clamp. sure enough once the heart had to supply the whole body and not just the upper half it started struggling. after quite a few tries we finally managed to get the clamp off without the patient crashing. he even made icu where he demised about a day later.
i was quite upset that the outcome was not what it ideally should have been, but the fact of the matter was that if we hadn't cross clamped he would have expired about 30 seconds after opening the abdomen. we gave him the best chance, but, alas, in retrospect he was shot dead.
what instrument do you use to clamp the aorta? something atraumatic i presume?
ReplyDeletehow would the fluid resus be? cyrstalloid -> colloid -> blood products like FFP?
anonymous, one uses a vascular clamp of sorts. i think we might have used a renal artery clamp or even a femoral artery clamp, i can't remember.
ReplyDeletethis guy needed blood, blood and more blood. for his ensuing dic he needed ffp. he was also loaded with both crystaloids and synthetic colloids, more colloids though. they leak out less.
I hate to be a negative commentator here, but usually ischemia like that isn't so healthy 'supratentorally'--as the Germans say. If he was almost already exsanguinated when you started, there was probably already significant damage to the CNS, despite what your anesthesiologist said. The clamp was a heroic effort, and everyone should get a chance to survive, but I wouldn't loose too much sleep over this one. You did the best that you could. That he made it 24 h is amazing.
ReplyDeleteanne, with hypovolemic shock, if they survive they do well supratentorially. i don't know why, but that is just my experience. this guy was is irreversible shock in retrospect which was ... well ... irreversible. we gave it a good go and the experience was worthwhile for me and maybe some day for another patient needing a cross clamp.
ReplyDeleteIt sux for this patient that all your efforts with cross clamping came to naught. However, in learning a new skill, you are better equipped for any future patients. This patient gave you that legacy. So possibly not all bad...although he might disagree ;)
ReplyDeleteI have been on the other side of the drapes with a patient in a near identical situation, and I can tell you, no amount of fluids and inotropes can prepare you for the crash in BP after removal of the clamp!
ReplyDelete