Surgical operation of a massive retroperitoneal tumor

Shao-Yan Yang,Yong-Chao He,Meng-Yuan Pei,He Zhang,Xiao-Yu Liu

1The Affiliated Yantai Yuhuangding Hospital of Qingdao University,Yantai 264000, China. 2Northwest Minzu University, Lanzhou 730000, China. 3The Affiliated Children’s Hospital of Shandong University,Jinan 250022,China.

Abstract Summarize the surgical cooperation of a massive retroperitoneal tumor. The main surgical cooperation points include: close observation of the patient's vital signs and condition changes, strengthening the prevention of potential complications, making full preoperative preparation, mastering the coordination points of hand washing, itinerant nurses, and effective massive bleeding treatment plan, etc. Through perfect surgical cooperation and nursing,the patient's condition was stable and discharged smoothly.

Keywords:huge retroperitoneal tumor;acute hemorrhagic shock; surgical cooperation

Background

Bleeding shock, refers to a short period of blood loss caused by large amount of acute circulation. Patients with effective circulating blood mass reduction, blood volume and blood volume do not match, and the existing blood capacity cannot maintain the circulation system to the body tissues and organs transport enough oxygen and other nutrients, tissue and organ perfusion,cell hypoxia,metabolic waste in the body, human metabolism and organ function gradually disorder,eventually cause multiple system organ function damages, and even failure.Usually, when blood loss exceeds 20%of the total body blood.In hemorrhagic shock, acute blood loss is the first preventable and controlled cause of death [1]. Timely and rapid control of blood loss can effectively reduce the occurrence of multiple organ dysfunction syndrome (MODS) and reduce mortality [2]. In December 2021, we admitted a patient with a massive retroperitoneal tumor during surgery. After perfect treatment and care, the patient was discharged smoothly.

Clinical data

Ethical approval

All the participants signed informed consent form. The study was approved by the hospital's ethics committee (YYY‐ETH‐2022001) and signed informed consent was provided by patients or their families.

General information

Patient female, 37 years old, patients 2 years ago, presented to a local hospital, after taking drugs, found abdominal CT hint: see huge mass between liver left lobe and pancreas slightly long T1 T2 signal, DWI(diffusion‐weighted imaging) is the uneven high signal, size about 20.5 cm 15.6 cm, consider cell adenoma, outpatient with "liver lesions"income hospital.

Crisis occurs

At about 90 minutes of surgery, the ultrasonic knife opened the liver and gastric ligament,exposed the tumor,and separated along with the tumor capsule space. Due to the abundant blood supply on the tumor surface, multiple wound bleeding, using 4‐0Prolene suture to stop bleeding. As such a procedure, the patient's blood pressure began to fall, giving accelerated rehydration and intermittent interstitial hydroxylamin, the maintain the blood pressure at 90‐100/50‐60 mmHg, also enable autologous blood return transfusion.CConsidering the larger tumor body and its rich blood,we separated the right side of the tumor and the mesenteric vein may rupture, with rapid bleeding and a sharp drop in blood pressure. A few minutes later, the blood pressure dropped to 40/20 mmHg, heart rate of 116 beats/min, the SpO2is undetected,CVP (central venous pressure)0 cmH2O,PETCO2,8 mmHg, blood gas analysis showed no hemoglobin or hematocrit(below the lower limit),rescue it immediately.

Rescue after

Call help immediately, multichannel pressure to speed up transfusion,infusion, adjust the anesthesia machine breathing parameters,increase 8 cmH2O PEEP, give suspended red blood cells 7.5 U, plasma 1,780 mL, cryoprecipitate 10 U, platelet 10 U, hydroxyethyl starch 1,500 mL, 2,500 mL rapid infusion, intermittent high dose hydroxylamine, pump bead noradrenaline, intermittent blood review,supplement sodium bicarbonate, calcium gluconate according to the blood gas results. The vascular surgeon was invited for a stage consultation, and the superior mesenteric vein was repaired with 4‐0Prolene wire and polyester heart repair materials. After about 20 minutes, the patient's blood pressure was stable and the PETCO2increased to 35 mmHg.

Crisis turns

The patient accumulated bleeding over 3,000 mL, fed 1,500 mL of suspended red blood cells, 1,780 mL of fresh frozen plasma, 10 U of cryoprecipitation, 10 U of platelets, 2,000 mL of colloid fluid and 3,500 mL of crystalloid.After surgery,the patient's blood pressure was 96/50 mmHg,heart rate 90 beats/min,SpO2100%,PETCO232 mmHg,CVP 3 cmH2O, and endotracheal catheter into the ICU for mechanical ventilation and hemostasis and liver preservation. Later, the patient was transferred to general disease and was discharged smoothly.

Observation of potential complications

Large vascular injury and massive bleeding

The most common and serious problems in retroperitoneal tumor surgery are large vessel injuries and massive bleeding.Due to the large size and deep location of the tumor, the blood vessels are pushed and squeezed, and limited by the insufficient size of the incision during separation, the compressed blood vessels are often not easily exposed,so they may be injured if you pay little attention. Veins are more vulnerable to injury than arteries.

Adjacent organ injury

Anatomical range of the retroperitoneal space, front: the retroperitoneum, nude, mesenteric root, and the right hepatic lobe,duodenal, ascending colon, descending colon, and rectum. With the growth of retroperitoneal volume, the retroperitoneal tumor squeethe surrounding tissue, and it is easy to cause damage to adjacent organs and tissues during surgery.

Risk of retroperitoneal space infection

The retroperitoneal space is a huge loose space, with no obvious septum,through up and down.Once the infection occurs,it can cause extensive retroperitoneal space infection.

Bleeding and hemorrhagic shock

When the intraoperative bleeding volume is large during the retroperitoneal tumor, the patient will have blood shock symptoms such as decreased blood pressure and accelerated heart rate due to insufficient circulating blood volume.

Hypothermia

Hypothermia is the most common body temperature disorder caused by anesthesia and surgery. During anesthesia, hypothermia often occurs because anesthetics and methods inhibit thermoregulation or patients are exposed to cold environment or input a large amount of hypothermic liquid and blood products. The incidence rate is 50% to 90%. In addition, patients with hemorrhagic shock often present with hypothermia, the incidence rate is as high as 10% to 65% [3]. Heat preservation should be performed as early as possible to reduce heat loss..

Thrombosis formation

Bleeding shock is prone to disseminated disseminated intravascular coagulation (DIC), large surgery, due to a long supine and anesthesia,lower limb muscles complete paralysis, lost normal contraction function, muscle relaxation, venous relaxation; lower limb muscles in a relaxed state,and lower limb deep vein blood flow slows down,thus creating conditions for thrombosis.

Drug extravasation

Angioactive drugs are one of the high‐risk drugs for intravenous infusion, especially vasoconstrictors with pH ＜4.0 (such as adding epinephrine, dopamine, phenylephrine, etc.), which are easy to cause vascular intima damage, increase of vascular wall permeability, and a large number of transfusion infusion is easy to cause extravasation[4].

Coagulation dysfunction

Hythermia and massive fluid infusion and massive accumulation of sodium citrate in stock blood affect coagulation function [1].

Nursing

Preoperative preparation

Patient preparation. Nurses visited patients one day before the surgery to understand the patients' enhanced CT examination results,introduce the operating room environment, anesthesia methods and basic operation process, reduce patients' fear, encourage patients'family members to carry out family care, timely encourage and comfort patients, and establish a positive and healthy treatment attitude.

Item preparation. Routine preparation: abdominal opening instruments, vascular instruments, abdominal hook, dressing,disposable items; special preparation: vascular slide line, hemostatic materials, ultrasonic knife, etc.; instruments and equipment preparation: electric knife, attractor, ultrasonic knife, autologous blood return instrument; drug preparation: preoperative antibiotics,hemostatic drugs, sodium bicarbonate, etc.

Preparation of anesthesia. The patient was monitored by ECG(electrocardiogram) oxygen, invasive arterial blood pressure,endotracheal intubation after induction of intravenous anesthesia,and then catheterization by right internal jugular venipuncture.

Intraoperative cooperation

Cooperation of itinerant nurses. (1) Establish the venous channels.The upper limb vein (green trocar) and deep jugular vein are usually established to ensure intraoperative transfusion,blood transfusion and central venous pressure measurement, restore effective blood volume,maintain MAP (manifold absolute pressure) at around 60 mmHg, and ensure the perfusion of important organs[5].

(2) Position positioning and catheterization. According to the surgical position according to the operation, pay attention to maintaining the patient's physiological position, so as not to damage joints, nerves and muscles, and maintain smooth breathing and circulation. Preoperative catheterization is conducive to timely emptying of the bladder, exposing the surgical field, and facilitating timely observation of urine volume, which can not only reflect the blood volume and kidney function, but also have great significance to monitor the changes of the patient's condition.When the urine volume was greater than 30 mL/h, the shock condition of the patient was improved [6].

(3) Check the items on the table carefully with the equipment nurse. Due to the intraoperative bleeding, the itinerant nurses'work is tight and fast. Therefore, it is very important to carefully count the items on the stage and record them clearly. If items need to be added during the operation,they should be recorded in time to avoid missing due to busy work.

(4) Carefully check the blood transfusion and timely warm up.Before blood transfusion, carefully check the patient's name, bed number, hospitalization number, blood type, cross‐matching results,blood volume, blood composition, blood date and other information with the anesthesiologist, strictly make three checks and eight pairs,and conduct infusion before the information is accurate.

(5) Prevention of hypothermia. The occurrence of hypothermia is often accompanied by acidosis and coagulation dysfunction, which is called the "death triad," which is the main cause of death in shock patients, so it is particularly important to prevent hypothermia early[7]. Song RY et al. pointed out in their research that the main measures to prevent hypothermia included core body temperature monitoring, appropriately increasing the temperature in the operating room,liquid warming, and skin heat preservation measures [8].

(6) Prevention of deep venous thrombosis in the lower limbs. The patient's physical condition was evaluated preoperatively to see whether the patient had blood hypercoagulability due to dehydration or other diseases, and it was supplemented with enough body fluid to improve the blood hypercoagulability. Avoid lower limb puncture during surgery and select upper limb veins; adjust appropriate temperature and humidity, cover insulation blanket and insulation,warm fluid, and avoid gravity on both lower limbs. Others:prophylactic application of anticoagulant drugs; give patients to wear elastic socks; intermittent pneumatic pressure pump treatment.

(7) Brain protection. Brain injury caused by ischemia can activate multiple physiological channels, and reperfusion, reactive oxygen species (ROS) release, inflammation, and cell death can cause blood‐brain barrier damage and brain edema [9].Protective measures include using an ice cap on the head, applying osmotic diuretics,applying hormones,and applying sedation agents.

(8) Prevention of drug extravasation. When using vasoactive drugs and massive blood transfusion,observe the puncture site,improve risk awareness, and prevent adverse events in time.

(9) Assess the bleeding volume. When severe bleeding is found,the attractor waste liquid bag should be replaced immediately, and check the amount of washing water during the operation and the number of gauze and gauze pads used with the washing nurse, to facilitate the statistics of acute blood loss.

(10) Circuit nurses must fully master the routine operation and use of high‐frequency electric knife, defibrillator, autologous blood transfusion machine and other instruments, and efficiently cooperate with the surgeon to complete the operation.

Hand washing nurses should cooperate. (1) The hand washing nurse washed her hands 30 minutes in advance, arranged the sterile table, assessed the risk of the operation, and prepared adequate supplies. Check the items carefully together with the itinerant nurse,and pay special attention to checking the integrity of various instruments and whether the screws are loose.

(2) Strictly implement the inspection system. When the intraoperative instrument is added, carefully count with the itinerant nurse, and try not to shift during the operation. Before and after closing the abdominal cavity,all the instruments and materials should be counted again with the circuit nurse.

(3) Strictly implement the aseptic operation principle, and supervise the aseptic operation of the participating operators.

(4) Keep the attractor unobstructed and stop the bleeding in time.Soak the field blood at any time, keep the field clear, wipe the electrocoagulation head with gauze in time, so as not to affect the hemostasis effect because of the scab.

(5) The coordination of large blood vessel injury. Immediately inform the anesthesiologist and the circuit nurse, found the large blood vessel rupture bleeding, the doctor will immediately compress the bleeding, the nurse immediately pass dry gauze compress the bleeding site, attractor suction surrounding blood, see the operation field, to identify the large blood vessel bleeding site, immediately handed no damage clamp, control the ruptured blood vessels. After controlling the bleeding, vascular repair was performed with direct vision under the Prolene‐ray.

(6) Cooperate with the rescue and manage the operating instruments and items on the operating table. Needle to keep the eye from the needle, fill in the position and quantity of the gauze for stopping bleeding should be known.

(7) The operation is difficult, and the operation rhythm is fast.Therefore,nurses are required to be calm and master the key points of preoperative and intraoperative nursing cooperation, which is conducive to the smooth progress of the operation.

Treatment protocol for major bleeding

(1) Anesthesiologist should immediately absorb oxygen to the patient,improve oxygen flow and inhaled oxygen concentration (FiO2),quickly check blood pressure, heart rate, pulse, blood oxygen saturation, and immediately call for help, prepare ice cap to protect brain tissue, and heater to protect body temperature.

(2) The anesthesiologist should inform the severity of bleeding, the operator should be performed as soon as possible to stop bleeding or slow down bleeding measures, such as: endoscopic surgery bleeding can be changed to open surgery, clamp bleeding vessels or gauze compression slow bleeding drugs, call experienced surgeons, if necessary exploration surgery, the first task is to stop bleeding, blood loss statistics.

(3) Establish more than two emergency venous routes (preferably 22 G). Anesthesiologists should also establish invasive blood pressure monitoring and consider the placement of a central venous catheter.

(4) Immediately rapid infusion to replenish blood volume. It is expected that when the fluid volume is large, the liquid should be heated and infused, and insulation measures should be taken.

(5) Re‐evaluate important vital signs and peripheral perfusion situation, patients with general anesthesia can consider superficial anesthesia or stop anesthesia, use vasoactive drugs to maintain MAP 60 mmHg, and noradrenaline and noxepinephrine should be given priority in severe bleeding.If the effect is poor,positive inotropic drug dobutamine can be considered. Dose of common vasoactive drugs:ephedrine 5‐50 mg intravenous, deaerobic epinephrine 50‐200 ug intravenous, adrenaline 10‐100 ug intravenous, norepinephrine 0.1‐0.5 ug/(kg·min).

(6) Immediately call blood products, consider starting a large number of blood transfusion program (massive transfusion protocol,MTP): using plasma, red blood cells, platelets 1:1:1 resuscitation plan[1], recommended every 6 U plasma suspension 10 U, 1 treatment amount (10 U) platelets as a group, inform the occurrence of blood transfusiondepartment,and requirefurtherpreparation,anesthesiologists can consider for autologous blood recovery device.

(7) Conduct blood gas analysis as soon as possible, correct metabolic acidosis and electrolyte disorders, master the patient's current Hb (hemoglobin)and HcT（Hematocrit）,and pay attention to review to evaluate the effect of transfusion treatment. Severe metabolic acidosis can be given 100‐200 mL of 5% sodium bicarbonate injection, intravenous infusion within 30 minutes, but should pay attention to the possibility of hypokalemia. Consider administering the hemostatic drug tranexamic acid for at least 10 minutes, followed by an additional 1 g of infusion for at least 8 h[2].

Discussion

Bleeding shock is a complex pathophysiological process and untreated management can cause serious complications[10].The overall goal of the treatment of patients with hemorrhagic shock is to control bleeding actively, take personalized measures to improve microcirculation and oxygen utilization disorders,and restore internal environmental stability [2]. Patients with hemorrhagic shock change rapidly and develop rapidly,and the median time from shock onset to death was only 2 h [3], time is life, timely rescue patients, formulate effective first aid measures, is of great significance to improve the rescue rate. Operating room nursing staff need to master the whole operation procedures and procedures, early rapid identification of massive bleeding, when general anesthesia patients, heart rate,arterial blood pressure(invasive/noninvasive),arterial waveform base widening, continuous positive airway pressure ventilation pulse variation, arterial oxygen saturation, unexplained urine volume, and the damage of arteriovenous vessels, through intraoperative, suction attract sound fluid rapid increase, drainage bottle,should consider the potential bleeding point or infiltration of massive bleeding. Nursing staff should strengthen the prevention of intraoperative potential complications, adequate preoperative preparation, skilled hand washing, circuit, effective bleeding treatment, can improve the operation condition, make the operation with more smooth and tacit understanding, can effectively shorten the operation time, create conditions for patient rescue, improve the success rate of rescue.Through continuous accumulation and summary, the hospital has initially formed the procedural procedure of our hospital, which is of great practical significance to guide the nursing work in the operating room. I hope to provide a reference for improving the quality of nursing service and standardizing the clinical pathway in the future.