55F with post op hypotension following ovarian tumor removal (WhatsApp conversations)

WhatsApp conversations around this case:

Ramesh: Post-OP Case reports

Prof: Rakesh: Acute tubular damage. But please read up similar case reports of post operative hypotension following large tumor removal and discuss. Vivek? "The severe hypotension seen in our patient could be attributed to the splanchnic shock which had occurred when the tamponade effect of the mass on the abdominal wall was removed."

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4003629/#__ffn_sectitle

Let's find out more about splanchnic shock?

"Intraoperative drainage of cystic fluid prevents the phenomenon of splanchnic shock which occurs when the compressed splanchnic vascular bed adjacent to inferior vena cava is released with removal of mass (Einenkel et al., 2006)." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3862319/

Did our current 55F with post op hypotension following ovarian tumor removal have intraoperative cyst drainage? Dr Siphora please share all these above information with our surgical colleagues.

Revisiting abdominal hypertension while problem solving for a patient of abdominal hypotension:

 https://drive.google.com/file/d/0By-bbPaEHz2pNVBtU0FYMWs1M2M/view?usp=sharing 

https://drive.google.com/open?id=0By-bbPaEHz2pc25LSGIxUWVxQmM 

Above is another patient similar to our current patient now.

Vivek: "Based on a critical evaluation of the medical courses and the discussed miscellaneous advantages and complications, we conclude that a pre- and intraoperative drainage should be avoided"!! "Removal of large intra-ab-dominal masses may produce sudden and severe hypotension(Fig.i).This may be due to splanchnic vasodilatation and venous pool-ing10. Eames "1 termed this 'splanchnic shock' and suggested that, inaddition to venous pool-ing, removal of partial compression of the ab-dominal aorta might produce a sudden fall in peripheral resistance. Chronic postural hypo-tension has also been described 2."

https://www.ncbi.nlm.nih.gov/pubmed/17177843
https://drive.google.com/file/d/0By-bbPaEHz2pMFlqU3ZnWHN2Ykk/view?usp=sharing

If Intraoperative drainage of cystic fluid prevent splanchnic shock then why it is advised to avoid?

Prof. rakesh: Perhaps as tumor seeding into the peritoneal cavity as a result of drainage is deemed more harmful than the post op hypotension? This paper is about the open abdomen in intraabdonimal hypertension though.

"Postoperative intra-abdominal hypertension (IAH) is a frequent occurrence in critically ill patients operated on for severe abdominal trauma, secondary peritonitis or ruptured abdominal aortic aneurysm. IAH may progress to abdominal compartment syndrome (ACS) with new-onset organ dysfunction. Early recognition of IAH and interventions that prevent the development of ACS may preserve vital organ functions and increase the probability of survival. The best method to prevent postoperative ACS is to leave the abdomen open during the operation. The decision to leave the abdomen open is usually based on the surgeon's judgment without intra-abdominal pressure (IAP) measurements during the operation"

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2875490/

Wow! Never realized there was so much medicine to learn in surgery! Thanks Vivek.

WhatsApp Conversations around this case linked (next admission) https://saratuppaluri.blogspot.in/2017/10/case-of-ovarian-mass-with-chronic.html?m=1:

Sarat: Hello! This is the case in Surgical ICU who was referred to medicine I/v/o hypotension.
Patient is still in the ICU and we could use as much input as possible from everybody :) 

Ashwini: There's persistent hypotension. So start with body volume issues, endocrine- aldosterone, renal dysfunction and then go to secondary causes like pituitary and then hypothalamus etc. Right ? Was the tumor vascular ? Could that have caused excessive blood loss leading to hypotension. Her reticulocyte count has increased which would mean the marrow is also trying to pump cells into circulation to increase hct back to normal ? 

Ashwini: I have a doubt here - is colloid helpful in such patients ??  Did she have any other complaints ? Was there anything to suggest a paraneoplastic syndrome due to CA ovary ? Do we do the corrected reticulocyte count here ? To see if the marrow is actually responding ?Corrected count is 0.5 %.

Ramesh: reticulocyte count is 1.2 here

Ashwini: Here there is decrease in Hb and PCT so we'll have to correct it na ? Reticulocyte count x PT's hct/ normal hct. So I did 1.2 x 19/45. 

Ramesh: CBC and Iron profile reports are attached in the main link. Same pt here  she has bilateral pitting edema also surgery pt. 

Ashwini: Can the bilateral pitting edema be due to hypotension causing aldosterone release causing the kidney to retain salt and water. Actually can all of this be attributed to massive blood loss ? There some formula na to calculate from grams of tumor mass ? I'll try to find out. So will colloids or blood transfusion help in this patient rather than pressor ? Also what about third space losses ? I am actually fuzzy with the concept so if anyone can explain it that'll be super awesome. 

Sarat: Thanks Dr Ashwini! Yes paraneoplastic syndrome was suspected. Hypercalcemia and hyperaldosteronism are few that I remember. There are some neurological PNS s also with ovarian cancer. But why would hyperaldosteronism, salt and water retention cause hypotension? Shouldn't they cause hypertension? I should find out if the tumor is vascular which may have caused blood loss. But why would the hypotension persist even after 2 months of excising the tumor.

Ashwini: It's two months ?? I didn't see that

Sarat: You have got me thinking as well. Actually I did not see the case myself so I don't know the exact course of treatment. But I'll try to find out the intraoperative findings :)

Ashwini: Could the episode of acute blood loss due to surgery cause hypotension cause infarction to say maybe anything on the hypothalamo-pituitary-adrenal axis ?? I remember seeing an empty sella syndrome the ward in the same vein.

Sarat: Also, could you please throw some light on "corrected reticulocyte count"? Could this be a secondary cause for empty sella syndrome? I think I need to search for it. Post operative empty sella syndrome causing hypotension?

Ashwini:  Yeah I think. It was last year. Even I don't remember the entire histor. But I don't know about that either in this patient. Should have had electrolyte disturbances if cortisol and aldo was affected. That's normal. We don't know whether she lactated cause she didn't have babies only

Ashwini: Normal reticulocyte count can't be trusted in anemic patients. Normally reticulocytes lose the RNA in a day. But in an anemic patient even more premature forms of reticulocytes are released. They thus stay in the circulation longer. And are thus counted double. So in any anemic patient to see the actual marrow response you have to correct for it. So if it's greater than 3% it means marrow is responding. Less than that means it's a marrow problem.

Sarat: Thank you Dr.Ashwini :)

Ashwini:: Happy to help ! Please let us know about the patient !

Sarat: Electrolytes were reduced. There's hyponatremia and  hypokalemia.

Ashwini: They were ? Oh I didn't see. So must be cortisol then ? I think our patient too had persistent hyponatremia.

Sarat: My bad! I forgot to upload the ECG of the patient. There are changes consistent with hypokalemia. Give me a few minutes.

Ashwini: Could she be Addison's then ? Does she have hyperpigmentation ?

Sarat: Updated the blog the ECG graphs. No she doesn't have hyperpigmentation.

Ashwini: Then it could point more to a pituitary cause rather than adrenal. No acth.

Sarat: Can we consider metastasis?

Ashwini: Ooh yes ! Of course ! That's actually the first thing that should have been checked !Then would you repeat ca 125 ? To see if levels have increased ?

Sarat: I think yes. That can be done! CECT for abdomen and pelvis was done today and we will get the report tomorrow.

Ashwini: This is a very interesting case ! Thank you for sharing.

Professor Rakesh: Excellent find Ashwini. Please do also share the link to it. Dr Ramesh please let us know what the CT images are showing.

Ramesh: CT report is normal sir.

Ashwini: The reticulocyte count is used to estimate the degree of effective erythropoiesis, [1] which can be reported as absolute reticulocyte count or as a reticulocyte percentage. In the latter case, if anemia is present, the reticulocyte percentage is spuriously high and may not reflect true bone marrow responses to anemia; therefore, the value has to be adjusted to a corrected reticulocyte percentage based on the patient’s hematocrit. [4, 5, 1, 2] Using an automated hematology analyzer, the automated absolute reticulocyte count is reported. https://emedicine.medscape.com/article/2086146-overview#a1

Professor Rakesh: Thanks Ashwini needed a reference for this, "Normally reticulocytes lose the RNA in a day. But in an anemic patient even more premature forms of reticulocytes are released. They thus stay in the circulation longer. And are thus counted double." Excellent discussion Ashwini and Sarat. Please also join the discussion in Tabula rasa around this patient.

Ashwini: I'll try searching for a similar referenc. I think I read that on a wiki article.Either medscape or wiki.

Professor Rakesh: Sarat if only you could motivate more students to work to create discussable online records for such complex patients we could actually help these patients and they wouldn't need to get pushed from here to Hyderabad and from there to their homes in a terminal state without any hope or help and what's worse is none of us realize that most of our Hyderabad referrals are eventually just going home and dying helplessly as we don't have the follow up of any of them. 😟

Sarat: I do realize how unfortunate it is sir. I promise that will do my best to motivate more students. I'll teach them how to create online records.

Professor Rakesh: This article looks promising in solving the mystery of our patient of ovarian carcinoma with persistent hypotension. Vivek, Avinash any way to read the full text?
http://www.sciencedirect.com/science/article/pii/S0012369215383781

Vivek: Full text of the article is uploaded here sir. https://drive.google.com/open?id=0By-bbPaEHz2pc25LSGIxUWVxQmM

Professor Rakesh: Thanks Vivek for sharing. This may be a good lead. Please share this amazing full text in Tabula rasa for the benefit of our team thereRamesh please let us know the echocardiography findings in this patient and plan a HRCT chest urgent today.

Sarat: Updated with new reports. Also, I came to know that the patient is a known case of paranoid schizophrenia and a psychiatry referral was done today. I think the psychiatrist put her on risperidone.

Abhishek Choudhary: I would be interested in the patients psychometry, if evaluated.

Professor Rakesh: Siphore, Could this iron deficiency be due to occult blood loss? I guess no Ryle's tube was put Siphora?

Professor Rakesh: I had talked to her brothers who are school teachers. She was divorced 30 years back and used to lie with her mother and brothers. They didn't go into further details but it appeared to me that she may have been getting some psychopharmacology. Siphora can you share the detailed Note of the psychiatrist here?

Ashwini:Sir now for her what will be the plan of treatment ? CT for pulmonary embolism ? Sir why is her ferritin so high ? Shouldn't iron stores should be less ?

Professor Rakesh: Ferritin is an inflammatory marker. Yes CT to detect Pulmonary embolism is the next step
Vivek: Iron profile appears to be due to Anemia of chronic disease!!

Professor Rakesh: Yes possible.

Ashwini: And sir you asked for ryles tube ?

Sarat: To detect GI bleeding. And yes the iron profile seems to be pointing towards anemia of chronic disease.!

Abhishek Choudhary: A naive question Dr Sarath. .. why ryles tube and not endoscopy for checking for GI bleeding? Is it because ryles will offer continuous monitoring?

Sarat: That question doesn't seem to be naive Sir :) I think an endoscopy is required if there is a strong suspicion of GI bleeding. Also, a gastroenterologist is required to perform endoscopy and it is an expensive procedure. And like you said sir, ryles will give continuous monitoring. We may perhaps take her up for endoscopy if bleeding is detected through ryles tube.

Abhishek Choudhary: Thanks for explaining. 🙂 I understand there are practical considerations here.

Professor Rakesh: Very well explained. Abhishek, Yes it is more for easy access to the data from her stomach regarding if there is any slow oozing of blood from the gastric mucosa and how much of blood if any is she losing from there. Endoscopy would definitely help more. Endoscopy would help in a better qualitative single point assessment.

Professor Rakesh: CVP  zero,  BP 70/0 mmhg, urine output 2600ml /550ml.



 Siphora: 50F with ovarian cancer and post operative hypotension updates. Urinary chloride 150 mmol/L, Spot urine potassium 13.7, spot urine 101 mmol/L.

Ashwini: This value is for 24 hours or random sample ?

Siphora: Spot urine. A random sample.

Ashwini: So I just googled this- normal value for sodium should be 20 and potassium should be 20-40. So here it means her intake is less ? For potassium and her abg ? Shows hyperkalemia ?

Sarat: There's no mention of potassium in her ABG. It showed mild metabolic alkalosis

Ashwini: Oh sorry my mistake. I meant abg and electrolytes.

Harshini: Intake is fine it suggests no (renal cause)urinary loss potassium. ABG doesn’t mention about potassium.

Ashwini: Yeah yeah I was asking about both together and forgot to write it separately. Oh okay so that's ruled out.



Ashwini: How is she alert with such low BP ? Shouldn't  she have some end organ damage or something.

Professor: Yes so perhaps her intra-arterial is what we need to see. If only our medtech people could create better non invasive BP measuring tools for such patients here

Ashwini: So the fluid is just not able to stay in the intravascular  compartment? Where does it go then? Her urine output isn't like DI type where she's losing litres and litres everyday.  Where does it go then?  Interstitial space?  Is this third space loss? Just Googled this- third space losses are due to volume overload,  increase capillary  hydrostatic  pressure,  hyponatremia,  albumin loss,  increased capillary  permeability due to trauma,  anaphylaxis,  DIC and lymph obstruction.

Vivek: All these are altering starling forces with net filtration pressure outward. (I have doubt for direct relationship with hyponatremia).

Ashwini: Yeah if there's hyponatremia outside  the cell that means water is more and water will flow from its higher level to its lower level so water will go inside the cell na? So it won't stay in the intravascular  compartment  I think.

Vivek: Yes it should go inside the cells causing cell swelling but that shouldn't cause loss of third space? Volume overload though can cause dilutional one.

Ashwini: Good catch. Thank you.

Sarat: I guess dexamethasone suppression test was done couple of days back.

Ashwini: Siadh ?