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