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Table 1 Summary of clinical presentations of seven patients with circulatory collapse and unknown etiologies during or shortly after wound closure in spine surgery

From: Circulatory collapse during wound closure in spine surgery with an unknown cause: a possible adverse effect of topical application of vancomycin?

Case Demographic information Initial signs/symptoms of shock and management Hemoglobin value (g/L),
fluid resuscitation and blood product infusion
VCM administration
and Postoperative sequelae
1 Female; 68-yr; 160 cm/60 kg
BMI: 23.4
Diagnosis:
Lumbar stenosis (L3-S1)
Surgery:
Posterior decompression, fixation and fusion of lumbar spine.
Medical and allergy history:
Hypertension
History of retina surgery
Time of occurrence:
Subcutaneous layer closure, 30 min after initiation of wound closure.
Signs and symptoms:
ABP: 30/20 mmHg
SpO2: undetectable
ECG: tarchycardia with elevated ST segment
Skin and airway symptoms: none.
Management:
Boluses and continuous infusion of noradrenaline (0.01–0.04 μg/kg/min) for 45 min. Fluid resuscitation and blood transfusion.
Preoperative HGB value: 124
Intraoperative minimum value of HGB: 73
Blood loss: 600 ml
Urine: 850 ml
Fluid and blood product infusion:
Crystalloid: 3450 ml
Colloid: 500 ml
PRBC infusion: 1200 ml
Infused autologous blood: 210 ml
VCM administration:
0.5 g mixed with bone debris into the cage and 0.5 g spraying on the dura mater and into the mascularis layer.
Postoperative sequelae:
Proceeded with surgery and the patient was extubated uneventfully.
2 Male; 74-yr; 171 cm/67 kg
BMI: 23.9
Diagnosis:
lumbar stenosis (L3–5)
Surgery:
Posterior decompression, fixation and fusion of lumbar spine.
Medical and allergy history:
nil relevant.
Time of occurrence:
Subcutaneous layer closure, 30 min after initiation of wound closure.
Signs and symptoms:
NBP: 45/15 mmHg
SpO2: undetectable
ECG: tachycardia with ST segment depression
Skin and airway symptoms: none.
Management:
Boluses and continuous infusion of noradrenaline (0.05–0.4 μg/kg/min) and adrenaline (0.5–0.15 μg/kg/min) for 4 h.
Preoperative HGB value:135
Intraoperative minimum value of HGB: 79
Blood loss: 600 ml
Urine: 1950 ml
Fluid and blood product infusion:
Crystalloid: 6300 ml
Colloid: 500 ml
PRBC infusion: 1200 ml
Plasma: 800 ml
Infused autologous blood: 254 ml
VCM administration:
0.5 g mixed with bone debris into the cage and 0.5 g spraying on the dura mater and into the mascularis layer.
Postoperative sequelae:
The patient was extubated and transferred to ICU due to neurological symptoms (unable to follow instructions).
Postoperative imaging: intracranial minor hemorrhage at subdural and subarachnoid space.
The patient was discharged from hospital without neurological deficit.
3 Male; 63-yr; 169 cm/70 kg
BMI: 24.5
Diagnosis:
Lumbar stenosis (L3–5)
Surgery:
Posterior decompression, fixation and fusion of lumbar spine.
Medical and allergy history:
Lacunar infarction;
Bilateral carotid atherosclerotic plaque formation
Time of occurrence:
50 min after initiation of wound closure and 20 min post-extubation in the PACU.
Signs and symptoms:
NBP: 60/25 mmHg
SpO2: 96%
HR:sudden elevation from 60 to 90 bpm
Postoperative agitation
Skin and airway symptoms: none.
Management:
Boluses of ephedrine, phenylephrine and fluid resuscitation.
Preoperative HGB value: 176
Intraoperative minimum value of HGB:123
Blood loss: 800 ml
Urine: 800 ml
Fluid and blood product infusion:
Crystalloid: 2350 ml
Colloid: 1000 ml
PRBC infusion: 400 ml
VCM administration:
Topical spraying of vancomycin (1 g) on the dura mater and into the mascularis.
Postoperative sequelae:
Uneventful.
4 Female; 70-yr; 160 cm/65 kg
BMI:25.4
Diagnosis:
Lumbar stenosis (L4-S1)
Surgery:
Posterior decompression, fixation and fusion of lumbar spine.
Hypertension
Diabetes Mellitus
Time of occurrence:
Subcutaneous layer closure, 30 min after initiation of wound closure.
Signs and symptoms:
NBP: 45/15 mmHg
SpO2: undetectable
Persistent tachycardia
Skin and airway symptoms: none.
Management:
Boluses of phenylephrine for treating severe hypotension and esmolol for tachycardia
Fluid resuscitation and blood transfusion.
Preoperative HGB value: 150
Intraoperative minimum value of HGB: 92
Blood loss: 1500 ml
Urine: 1800 ml
Fluid and blood product infusion:
Crystalloid: 3100 ml
Colloid: 1500 ml
PRBC infusion: 1200 ml
Infused autologous blood: 450 ml
VCM administration:
0.5 g mixed with bone debris into the cage and 0.5 g spraying on the dura mater and into the mascularis layer.
Postoperative sequelae:
The patient was extubated after surgery and transferred to ICU due to tachycardia after sufficient fluid resuscitation.
Recovered uneventfully.
5 Female;48-yr; 170 cm/75 kg
BMI: 26.0
Diagnosis:
Thoracic spinal canal stenosis (T6-T11)
Surgery:
Posterior decompression, fixation and fusion of thoracic spine.
Medical and allergy history:
nil relevant.
Time of occurrence:
Subcutaneous layer closure, 30 min after initiation of wound closure.
Signs and symptoms:
NBP: 40/30 mmHg to undetectable
HR: 120 bpm to 40 bpm
SpO2: undetectable
Cardiac arrest
Skin and airway symptoms: none.
Management:
Extracardiac compression
Boluses of noradrenaline (200 μg) and adrenaline (1 g)
Continuous infusion of noradrenaline (0.02–0.08 μg/kg/min) for 50 min
Fluid resuscitation and blood transfusion.
Preoperative HGB value: 132
Intraoperative minimum value of HGB: 74
Blood loss: 2500 ml
Urine: 1300 ml
Fluid and blood product infusion:
Crystalloid: 4000 ml
Colloid: 500 ml
PRBC infusion: 2400 ml
VCM administration:
Topical spraying of vancomycin (1 g) on the dura mater and into the mascularis layer.
Postoperative sequelae:
The patient was extubated after surgery, and discharged from hospital uneventfully.
6 Male; 66-yr; 175 cm/ 80 kg
BMI: 26.1
Diagnosis:
Lumbar stenosis (L3–5)
Surgery:
Posterior decompression, fixation and fusion of lumbar spine.
Medical and allergy history:
Carotid artery stenosis
Diabetes Mellitus
Time of occurrence:
Sudden cardiac arrest 10 min after extubation (approximately 45 min after initiation of wound closure) with full recovery from anesthesia and without any discomfort complaint.
Signs and symptoms:
Cardiac arrest and persistent VF
Skin and airway symptoms: none.
Management:
Continuous CPR
Persistent VF was treated with repeated defibrillation
Boluses of adrenaline (a total of 6 mg) and amiodarone.
Fluid resuscitation and blood transfusion.
Preoperative HGB value: 143
Intraoperative minimum value of HGB: 78
Blood loss: 1000 ml
Urine: 850 ml
Fluid and blood product infusion:
Crystalloid: 4400 ml
Colloid: 1000 ml
PRBC infusion: 1200 ml
Infused autologous blood: 600 ml
VCM administration:
Topical spraying of vancomycin (3 g) on the dura mater and into the mascularis.
Postoperative sequelae:
The patient was reintubated and transferred to ICU after ROSC. The patient was diagnosed as hypoxic encephalopathy and remained in a coma state. Tracheotomy was performed 2 weeks after surgery, and the patient was transferred to a nursing home for rehabilitation 1 month after orthopedic surgery.
7 Female; 43-yr; 155 cm / 54 kg
BMI: 22.4
Diagnosis:
Thoracic kyphosis (T7-T8)
Surgery:
Osteotomy for kyphosis of thoracic spine (T7-T8).
Medical and allergy history:
nil relevant.
Time of occurrence:
subcutaneous layer closure, 30 min after initiation of wound closure.
Signs and symptoms:
HR:tachycardia
NBP: 60/30 mmHg
SpO2 82%
Skin and airway symptoms: none.
Management:
Boluses of phenylephrine and ephedrine;
Continuous infusion of noradrenaline (0.05–0.1 μg/kg/min)
Fluid resuscitation and blood transfusion.
Preoperative HGB value: 138
Intraoperative minimum value of HGB: 95
Blood loss: 1200 ml
Urine: 1900 ml
Fluid and blood product infusion:
Crystalloid: 4700 ml
Colloid: 1000 ml
PRBC infusion: 1200 ml
Infused autologous blood: 470 ml
VCM administration:
Topical spraying of vancomycin (1 g) on the dura mater and into the mascularis layer.
Postoperative sequelae:
The patient was transferred to ICU for optimal monitoring and recovered uneventfully.
  1. Abbreviations: NBP Non-invasive blood pressure; ABP Arterial blood pressure; (NBP is noted when ABP is not available.) VF Ventricular fibrillation; CPR Cardiopulmonary Resuscitation; HGB Hemoglobin; VCM Vancomycin; PRBC Packed red blood cell; ROSC Return of spontaneous circulation