1. VCU DEATH AND COMPLICATIONS CONFERENCE

2. Brief Overview of Case  MVC, hemoperitoneum, cirrhosis  Withdraw care, death, variceal bleed

3. Introduction for Every Case  Complication  death  Procedure  2/25 – exlap, splenectomy, transverse colectomy, packing of abd, VAC  2/25 – reopening abd, control of bleeding from diaphragm lac, packing  2/28 – removal of packs  3/1 – banding of 5 esophageal varices  3/2 - TIPS  Primary Diagnosis  MVC – splenic laceration, transverse colonic injury  Cirrhosis

4. Clinical History  BRIEF Clinical History  44 y/o  PMH: DM, cirrhosis (?NASH)  2/25 – MVC into tree at high speed  Cardiac arrest, OR – splenectomy, transverse colectomy, packing, VAC, ortho injuries  Cirrhosis, intraabd varices  Admission – hgb 10.6, plts 65, INR 1.8-2.3, Cr 0.67  ARF, Cr 1.77 – CVVH  Hypotension on pressors  Resp failure  Increased LFTs, TB  Neuro?

5. Clinical History  BRIEF Clinical History  3/1 variceal bleeding (hgb 6.8), Blakemore tube placed, EGD banding, TIPS (portosystemic gradient 15-4mmHg)  3/2 fixed dilated pupils, ARF, increased vent requirements, pressors  Withdraw care, death

6. Analysis of Complication Was the complication potentially avoidable? – No – traumatic injuries, cirrhosis What factors contributed the complication? – Underlying disease

7. Evidence Based Literature  Cirrhosis and trauma: a deadly duo.  Am Surg 2005  Review: 61 cirrhosis/156 controls  Increased LOS, increased transfusion requirements/24h, mortality (33%/1%)  55% deaths due to depsis  Mortality  Childs A = 15%, B = 37%, C = 63%

8. Evidence Based Literature  Liver cirrhosis in patients undergoing laparotomy for trauma: Effect on outcomes  JACS 2004  46 pts with cirrhosis, matched with 2 controls (based on age, gender, MOI, ISS  Mortality = 45/24%  ISS<15 = 29/5%  ISS 16-25 = 56/11%  ICU stay = 11.5/6.6d

9. Evidence Based Literature  Cirrhosis and trauma are a lethal combination.  World J Surg 2009, USC/LAC  Review 10 yrs - 36,038 trauma registry patients, 468 (1.3%) had a diagnosis of cirrhosis  Mortality = 12/6%  ARDS, trauma-associated coagulopathy, and septic complications were significantly more common in the cirrhotic group  For the subgroup of patients who underwent emergent abdominal exploration, the mortality rate increased to 40% compared with that of noncirrhotics at 15%

10. Sengstaken-Blakemore tube  Passed into esophagus and gastric balloon is inflated inside the stomach. A traction of 1 kg is applied to the tube so that the gastric balloon will compress on the GE junction to reduce the blood flow to esophageal varices. If the use of traction alone cannot stop the bleeding, the esophageal balloon is also inflated to help stop the bleeding. The esophageal balloon should not remain inflated for more than six hours, to avoid necrosis. 