Component blood transfusion used to treat massive postoperative hemorrhage after resection of a thoracic tumor: a case report : IJS Global Health

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Component blood transfusion used to treat massive postoperative hemorrhage after resection of a thoracic tumor: a case report

Zou, Bin MD; Fan, Haiyin MM; Guo, Changying MD

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International Journal of Surgery: Global Health: September 2022 - Volume 5 - Issue 5 - p e80
doi: 10.1097/GH9.0000000000000080
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Abstract

Surgical resection of large tumors from the thoracic cavity is inherently challenging. The surgery often results in perioperative massive thoracic hemorrhage, resulting in high morbidity and mortality. It is not always easy to distinguish an oozing surgical wound from active vascular bleeding. Here, we report a patient who developed massive hemorrhage after resection of a large thoracic tumor. The hemorrhage was successfully treated with blood transfusion without secondary thoracotomy. Such a massive hemorrhage has not been performed with secondary thoracotomy, which has not been reported yet.

The work has been reported in line with the SCARE 2020 criteria1.

Case presentation

A 76-year-old man suffering from chest pain was diagnosed with a left thoracic space-occupying lesion. Chest computed tomography (CT) showed a large thoracic tumor with a maximum diameter of ~160 mm. The tumor had caused displacement of the heart and mediastinum to the right side (Fig. 1). Tumor puncture cytology showed no cancer cells, but histopathologic examination revealed a large amount of necrotic tissue. General anesthesia was induced uneventfully. The surgery was initiated by performing posterolateral thoracotomy. Because of the large size of the tumor, the sixth rib was resected to access the pleural cavity. The tumor was totally encapsulated. The capsule was thickened and partially calcified, reaching the top of the pleura and descending to the diaphragm, as well as extending posteriorly to the spine and laterally to the mediastinum. The tumor was too large to be removed entirely. Therefore, we decided to cut the tumor. The tumor contained a large amount of red necrotic tissue that looked like bean curd residue. The tumor capsule was removed after evacuation of the tumor contents. The lung was significantly compressed, and the visceral pleura was thickened; therefore, we decided to peel off part of the visceral pleura. To facilitate quick removal of the tumor, we used a hot gauze to pack the surgical wound, but did not wait for the achievement of complete hemostasis. After removal of the tumor, there was incessant bleeding from the surgical wound, which required use of electrospray mode to stop the bleeding. The total intraoperative blood loss was 4200 mL. Because of the unstable hemodynamics, the patient received 8 units of concentrated red blood cells and 600 mL of plasma during the surgery. The anesthesiologist maintained the blood pressure with use of a vasopressor and a large volume of crystalloids and colloids.

F1
Figure 1:
Preoperative chest computed tomography showing a huge thoracic tumor, which has displaced the heart and mediastinum to the contralateral side.

Postoperatively, the patient was transferred to the intensive care unit and was kept intubated. One hour after the operation, the thoracic drainage volume was 550 mL. The blood pressure dropped to 55/37 mm Hg. Approximately 5 hours later, the amount of pleural hemorrhage had reached 1400 mL. At 6 hours, the thoracic cavity drainage volume showed a sudden increase, and the amount of bleeding reached 820 mL within one hour. The red blood cell count was 1.39×1012/L, hemoglobin had dropped to 42 g/L, and there was a failure of the coagulation system. Prothrombin time and activated partial thromboplastin time were significantly prolonged (20.9 and 68.7 s, respectively), while fibrinogen level was significantly decreased (0.55 g/L). Concentrated red blood cells, plasma, and cryoprecipitate were administered, and continuous IV infusion of norepinephrine was initiated (up to 2.13 µg/kg/min). The thoracic hemorrhage gradually stopped within 10 hours after the operation after enough coagulation factors had been infused. Approximately 6 hours later (ie, 16 h after the operation), the amount of pleural bleeding was 4800 mL. The patient received 8 units of concentrated red blood cells, 24 units of cryoprecipitate, and 950 mL of plasma. The coagulation function showed gradual recovery, and there was partial alleviation of hypofibrinogenemia (1.43 g/L). On the first day after the operation, pleural drainage showed a gradual decrease along with stabilization of the hemodynamics. Postoperative posteroanterior chest radiographs showed restoration of the heart position to normal, and no effusion in the pleural cavity (Fig. 2). The patient was extubated on the third day after the operation. On postoperative day 5, the patient was moved to the general ward. He was then discharged on postoperative day 16. Postoperative pathology showed fibrous tissue hyperplasia with massive necrosis.

F2
Figure 2:
Postoperative chest radiography showing restoration of the heart to normal position; no obvious effusion is seen in the pleural cavity.

Discussion

Perioperative bleeding is a common complication of thoracic surgery. Generally, postoperative bleeding is more dangerous than intraoperative bleeding and is associated with a higher mortality rate2. Secondary thoracotomy is required in 1.25%–1.95% of cases to stop postoperative bleeding. Postoperative bleeding can lead to shock, disseminated intravascular coagulation (DIC), multiple organ dysfunction syndromes, and even death3,4. Perioperative bleeding could be related to systemic factors (such as oral anticoagulant therapy, chronic liver disease, coagulation dysfunction) or local factors (such as tumors adjacent to large vessels, anatomic variation, and local inflammation). The surgeon’s skills can also impact the probability of occurrence of perioperative bleeding5,6. In the present case, perioperative bleeding was mainly attributable to the massive surgical wound and loss of a large number of coagulation factors.

The indications for secondary thoracotomy in postoperative massive thoracic hemorrhage include: (1) blood loss of 300 mL/h within 3 hours after operation; (2) thoracic drainage volume >1000 mL within 5 hours after operation; (3) hemoglobin volume of thoracic drainage equal to 6 g/100 mL7. In this case, the amount of postoperative blood loss was far more than the indication for secondary thoracotomy. The main causes of postoperative bleeding in our case were massive surgical wound and the loss of coagulation factors. During removal of the tumor and peeling of the thickened pleura, there was continuous bleeding on the wound surface. In order to remove the tumor as quickly as possible, we did not stop bleeding immediately. Instead, we used hot gauze to pack and compress the oozing of blood from the wound surface. However, due to the large wound surface and the longer operation time, intraoperative blood loss reached 4800 mL. A large number of coagulation factors were lost which led to coagulation failure after surgery. After infusion of enough coagulation factors, the thoracic hemorrhage gradually stopped. There is no doubt that the key to the patient’s successful rescue lies in the infusion of many cryoprecipitates. Cryoprecipitate contains fibrinogen, factor VIII, factor XIII, vWF, and fibronectin, all of which play an important role in coagulation8. In patients showing hypofibrinogenemia (ie, <1.50 g/L) during surgery, administration of cryoprecipitate or fibrinogen concentrate is usually effective in achieving hemostasis and in reducing the required number of transfusion units9. We were prudent in not performing secondary thoracotomy to stop bleeding. If we had performed secondary thoracotomy to stop bleeding according to the above indications, we probably would not have found obvious bleeding points and the patient’s outcome would have been uncertain.

Conclusions

The following lessons can be gained from this case report: (1) although hot gauze can have a hemostatic effect, this method may not always work. Once bleeding occurs, prompt stoppage of bleeding should take precedence. (2) Large amounts of coagulation factors can be lost due to massive intraoperative bleeding. Timely supplementation of coagulation factors during the operation can reduce the risk of postoperative bleeding. (3) Postoperative intrathoracic hemorrhage does not always require a second thoracotomy for hemostasis. The key point is determining whether the hemorrhage is due to oozing from surgical wound or an active vascular bleed.

Ethical approval

None.

Sources of funding

This work was supported by National Natural Science Foundation of China (81560382).

Authors contribution

All authors participated in surgery and postoperative management. Z.B. and F.H. reviewed and edited the manuscript. Z.B. and G.C. contributed to discussion.

Conflicts of interest disclosure

The authors declare that they have no financial conflict of interest with regard to the content of this report.

Research registration unique identifying number (UIN)

None.

Guarantor

Bin Zou and Changying Guo.

References

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4. Sirbu H, Busch T, Aleksic I, et al. Chest re-exploration for complications after lung surgery. Thorac Cardiovasc Surg 1999;47:73–6.
5. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA 1998;280:1569–75.
6. Villa M, Sarkaria IS. Great vessel injury in thoracic surgery. Thorac Surg Clin 2015;25:261–78.
7. Department of Thoracic and Cardiovascular Surgery of Chinese Medical Association. Consensus on prevention and management of perioperative bleeding in thoracic surgery. Chin J Thorac Cardiovasc Surg 2018;34:321–30.
8. Lozano M, Badawi M. Indications for transfusion of blood components. ISBT Sci Series 2020;15:320–30.
9. Yamamoto K. Required laboratory examination and blood transfusion therapy in massive hemorrhage during surgery. Rinsho Byori 2011;59:678–83.
Keywords:

Blood transfusion; Hemorrhage; Thoracic tumor; Coagulation factors; Secondary thoracotomy; Case report

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