Here, we present the case of a 42-year-old female patient, American Society of Anaesthesiologists 1 and donor for renal transplant surgery of her husband. The preanesthesia visit did not reveal any co-morbidity on history and the physical examination was also within normal limits.
The weight recorded was 50 kg and the height corresponded to 1.50 m, and the body mass index was calculated as 20.8 kg/m2. Blood investigations revealed hemoglobin of 11.5 g/dL, total leukocyte count of 8600 mm3, and platelet count of 156,000 mm3.
Random blood sugar was 86 mg dL. Renal function tests and serum electrolytes were within normal limits. Electrocardiogram and chest X-ray done preoperatively were normal.
The patient was taken to the operating room, and routine monitoring in the form of noninvasive blood pressure, SpO2 probe, and five-lead electrocardiogram were applied. The vital parameters had noted before induction were within normal limits.
Intravenous access was secured with one 16-gauge (G) and one 18-G cannula.
Anesthesia was induced with intravenous midazolam 1 mg intravenous (i.v.), fentanyl 100 mug i.v., propofol 100 mg i.v., and vecuronium bromide 5 mg i.v. The patient was mask ventilated by a mechanical ventilator to achieve normocarbia with O2, N2O, and isoflurane (0.9-1 minimum alveolar concentration [MAC]) for 3 min approximately. The trachea was intubated using endotracheal tube no 7.0 mm internal diameter. After confirming the position of endotracheal tube, the patient was mechanically ventilated with a tidal volume of 400 ml, respiratory rate of 12/min, and maintaining an ETCO2 between 32 and 35 mmHg, and an esophageal temperature probe was inserted. The patient was maintained on O2, N2O (50:50%), and isoflurane (MAC 1).
Donor nephrectomy for the left side was completed in 3 h. At the end of the surgery, anesthesia was reversed, and breathing attempts were observed. Suddenly, the monitor displayed a drop in the ETCO2 to 5-6 mmHg. Immediately, the ventilator circuit was checked which was found to be in place and on chest auscultation, bilateral equal air entry was heard. Sudden bradycardia with heartbeat dropping to 32 beats/min (bpm) and a blood pressure reading of 90/50 mmHg was displayed on the monitor.
Injection atropine 0.6 mg i.v. was given and a second dose repeated after 2 min following that arise in the heart rate to 120 bpm was observed, and a blood pressure of 90/60 mmHg was noted. On examination, patient's conjunctiva was pale. Surgeons were informed about the possibility of an intra-abdominal bleed.
An emergency laparotomy was planned while resuscitation with crystalloids, colloids, and packed red blood cells was instituted. On surgical exploration, the renal artery pedicle (at the hilum of the kidney) ligature was found to have slipped away resulting in torrential amount of bleeding. The bleeder having been identified was secured, and a complete inspection of other possible bleeding sites was done. Meanwhile, hemodynamic status stability was ensured with inotropic support. A total of 5 liters (L) of crystalloids, 1 L of colloids, 4 units of packed red blood cells, and 2 units of fresh frozen plasma were transfused during the entire re-open laparotomy. The estimated blood loss was 2500 ml approximately, and urine output of 2800 ml was noted.
Postoperatively, the patient was shifted to the Intensive Care Unit with inotropic support. It was decided to keep the patient mechanically ventilated on volume control mode of ventilation. All blood investigations including complete blood count, liver function tests, kidney function tests, arterial blood gas, coagulation profile, and chest X-ray were sent postoperatively. Extubation was planned to take place only when hemodynamic stability would be achieved without inotropic support.
Next day, the patient's condition improved significantly. Inotropic support was switched off, and vitals were stable. The hemoglobin was 7 g/dL and other parameters were within normal limits. Two units of packed red blood cells were transfused on the 1st postoperative day. Weaning from mechanical ventilation was commenced and subsequently, postoperative day 3, extubation was planned with patients general condition have improved and a hemoglobin of 9 g/dL. The patient remained stable on postoperative day 5; the patient was shifted to the ward.