CASE PRESENTATION – PATIENT 1:
An 88-year old female was scheduled for a low anterior resection and
end-colostomy formation for a high grade invasive recto-sigmoid
adenocarcinoma. She had suffered an acute kidney injury attributable to
the mass effect of the tumour involving the bladder that required a
rigid cystoscopy and stent insertion prior to laparotomy. Her past
medical history included low body mass index, shingles, recurrent
urinary tract infection, uterine prolapse and a single functioning
kidney. Prior to her admission, she lived at home alone and was fully
independent. She did not take any regular medications and had no known
drug allergies. Her pre-operative bloods results demonstrated an
iron-deficiency anaemia (Haemoglobin 10g/dL), acute kidney injury and
raised inflammatory markers consistent with a contained colonic
perforation. Coagulation studies were normal. She had been receiving a
daily prophylactic dose of enoxaparin (20mg) in the preoperative period.
Prior to induction of anaesthesia, a 20G arterial catheter (Arterial
Leader Cath (PE), Vygon Ref 115.090, 3Fr- L.8 cm-0.9 mm-24 ml/min) was
inserted in the left radial artery using the Seldinger technique. The
first attempt was successful and the arterial catheter was introduced
without resistance. Blood could be withdrawn and a normal pulse tracing
was shown on the monitor. No discoloration of the hand was noted.
General anaesthesia was initiated uneventfully and the patient was
positioned on the surgical table in lithotomy with all necessary padding
and safety straps applied. All pressure areas including venous and
arterial lines were padded and protected. There were no intra-operative
issues with the arterial catheter. The surgery concluded after
approximately five hours without any complications and minimal estimated
blood loss.
At the end of the procedure, progressive dampening of the arterial line
trace was noted on the monitor and blood could not be aspirated through
it. On removal of the surgical drapes, the left hand was noted to be
cold and pale with a prolonged capillary refill time of five seconds.
The arterial catheter was disconnected from the transducer tubing and
there was evidence of thrombus lodged in the catheter. The catheter was
promptly removed and the hand was actively warmed. The patient was
extubated and transferred to the recovery room where an urgent
consultation with a vascular surgeon was obtained. On further
examination, sensation and motor function in the left hand were intact.
Doppler ultrasound examination was unable to detect radial, ulnar or
palmar arch pulsations adequately. The brachial pulse was detectable.
Following on immediate advice from vascular and colorectal surgical
colleagues, treatment with a heparin infusion was not favoured following
major abdominal surgery. CT angiography was contraindicated due to her
acute kidney injury. Surgical intervention was deemed infeasible. After
obtaining consent from the patient, a left-sided stellate ganglion block
was performed by an experienced pain specialist. After two hours, the
patient’s hand colour and temperature improved with a commensurate
reduction in capillary refill time. The patient was transferred to the
high dependency unit for ongoing post-surgical observation and was
reviewed by the vascular team on a daily basis thereafter.
Within 24 hours, doppler signals in the left radial and ulnar branches
were detectable. The fourth and fifth digits remained cold to touch,
with intact sensation, for a further 48 hours. Subsequently there was
full resolution of symptoms with no requirement for further
intervention.