| Abstract|| |
Disseminated intravascular coagulation (DIC) is a contraindication for major surgical operations. However, if surgery is required to correct the underlying cause of DIC, a clinical conflict is created. In such complex scenario, standard resources such as textbooks and journals offer very little guidance. In this communication, we report a 22-month-old boy who developed sepsis-induced DIC following intestinal obstruction. Pre-operative attempts to normalize coagulation parameters failed. Damage control laparotomy was undertaken as it was considered essential to control the underlying cause of DIC. His abnormal coagulation status reverted quickly after surgical relief of intestinal obstruction. Paradoxically intraoperative blood loss was less than anticipated amount. There are a few case reports of adult patients who have successfully undergone major surgery despite the presence of abnormal coagulation. However, this appears to be the first paediatric report of successful surgery in DIC status. Lessons learnt from this case and hypothetical speculations of clinical paradoxes are discussed.
Keywords: Anaesthesia in coagulopathy, bleeding disorder, coagulopathy, damage control surgery, disseminated intravascular coagulation, intra-operative bleeding, paediatric age, sepsis
|How to cite this article:|
Raveenthiran V, Balachandran S. Uncorrectable coagulopathy due to intestinal obstruction: A clinical dilemma of competing priorities in a child. Afr J Paediatr Surg 2013;10:195-8
|How to cite this URL:|
Raveenthiran V, Balachandran S. Uncorrectable coagulopathy due to intestinal obstruction: A clinical dilemma of competing priorities in a child. Afr J Paediatr Surg [serial online] 2013 [cited 2020 Oct 31];10:195-8. Available from: https://www.afrjpaedsurg.org/text.asp?2013/10/2/195/115055
| Introduction|| |
Major surgical operations are usually contraindicated in the presence of uncorrected disseminated intravascular coagulation (DIC). , The conventional recommendation is to defer surgery until coagulopathy is corrected.  In sepsis-induced DIC, control of infection is essential to correct coagulopathy.  If the source of sepsis is localized, in addition to appropriate antibiotics, surgical evacuation of septic material is frequently indicated.  Thus, when surgery is necessary to treat the underlying cause of DIC, a clinical conflict is created. Standard resources such as textbooks and journals offer very little guidance in such complex scenario. In this report, we share the lessons learnt from one such patient whom we successfully managed.
| Case Report|| |
A 22-month-old male child was admitted with clinical features of complete intestinal obstruction (abdominal distension, bilious vomiting, obstipation, and fever) of 6 days' duration. He was born with high-variety of imperforate anus for which he had undergone decompressing sigmoid colostomy at birth. Posterior-sagittal-anorectoplasty had been carried out at the age of 12 months. Eight weeks later he had the colostomy closed. He had been asymptomatic during the 8-months interval between colostomy closure and the present admission.
He had transient diarrhoea 14 days prior to present admission. A week later, when he developed features of intestinal obstruction, a community paediatrician diagnosed post-diarrhoeal ileus and treated him with nil-per-oral, antibiotics and intravenous fluids. He developed fever on the 4 th day of illness and oliguria on the 5 th day. On the 6 th day he was transferred to our hospital.
On admission, he was grossly dehydrated and malnourished and his weight was 6.5 kg. He was conscious but lethargic. His pulse was 100/min; blood pressure was 100/60 mmHg and the capillary refill time was 5 s. The abdomen was distended but not tender. Bowel sounds were absent and his rectum was empty. Abdominal imaging showed dilated bowel loops and multiple fluid-levels. It was suggestive of post-operative adhesive intestinal obstruction. Serum sodium was 125 mmol/l, potassium was 2.3 mmol/l, calcium was 7.4 mmol/l and bicarbonate was 17 mmol/l. In arterial blood sample PaO 2 was 80 mm Hg and PaCO 2 was 32 mm Hg. Serum protein was 3.9 g/dl and there was reversal of albumin-globulin ratio (1.6 g/dl vs. 2.3 g/dl respectively). However, serum bilirubin (Total 0.8 mg/dl; Direct 0.3 mg/dl) and serum levels of liver enzymes such as aspartate aminotransferase (12 U/l), alanine aminotransferase (41 U/l) and alkaline phosphatase (128 U/l) were within physiological range. Although, serum urea (79 mg/dl) and creatinine (1.6 mg/dl) were elevated on admission, they reverted to normalcy after fluid correction. Blood cultures were negative; but C-reactive protein was elevated (47 mg/dl). Negative bacterial culture was considered to be an artifact due to pre-hospital administration of antibiotics.
In the first 24 h, he was resuscitated with appropriate intravenous fluids and empirically chosen broad spectrum antibiotics (Cefotaxime 125 mg/kg/day + Gentamicin 5 mg/kg/day + Metronidazole 21 mg/kg/day). Electrolyte imbalance was corrected. Although, a laparotomy to relieve intestinal obstruction was intended after 24 h of resuscitation, it had to be postponed due to coagulation abnormality noted on the second day [Table 1]. DIC due to sepsis was diagnosed on the third day based on the scoring system of International Society on Thrombosis and Haemostasis. , In the ensuing 72 h platelet count progressively dropped and prothrombin time (PT) remain prolonged despite multiple transfusions of platelet-concentrates, whole fresh blood and fresh frozen plasma (FFP) [Table 1]. The platelet depletion was consistent with consumption thrombocytopenia of DIC. Although, the surgical and anaesthetic teams carefully considered the prospects of emergency laparotomy, a consensus clinical decision could not be arrived due to lack of published evidence to support major surgery in children with uncontrolled coagulopathy.
As there was no clinical improvement during the initial 48 h, empirical antibiotics were changed to Cefaperazone (200 mg/kg/day), Amikacin (15 mg/kg/day)and Metronidazole (21 mg/kg/day). On the 4 th day of hospitalization, he developed toxic epidermolysis and clinical signs of overt DIC such as nasal bleeds, subcutaneous bruising and petechial haemorrhage of skin. As aggressive replacement therapy evidently failed, it was then realized that the sepsis-induced DIC could not be reverted unless the underlying intestinal obstruction is corrected. However, any surgery with a platelets count of 4000 per μl and a PT of 3.07 International Normalized Ratio would also be dangerous. After explaining these concerns and dilemmas, an informed consent was obtained from parent to proceed with surgery under American Society of Anaesthesiologist risk category 5E.
On the 5 th day of hospitalization, a mini midline-laparotomy was carried out under endotracheal inhalation anaesthesia. The patient did not receive pre-medication. Anaesthesia was induced with propofol (2 mg/kg) and Fentanyl (2 μg/kg). Suxamethonium chloride (1 mg/kg) was given to facilitate orotracheal intubation with a 4.5 mm cuffed endotracheal tube. Anaesthesia was maintained with 2% sevoflurane in 100% oxygen, with positive pressure ventilation in a circle system. Bolus doses of Atracurium (1 mg) and Fentanyl (3 μg) were injected intermittently to maintain muscle relaxation and analgesia respectively. Laparotomy revealed dense adhesion of colonic loops at the site of colostomy closure. As adhesiolysis may leave behind a large raw area with heavy oozing of blood, it was considered imprudent in the presence of coagulopathy. Hence, a proximal decompressing loop colostomy was performed. Intraoperative blood loss was estimated to be around 100 ml, which was adequately replaced. Throughout the peri-operative period, he remained hemodynamically stable and at the end of the operation neuromuscular blockage was reversed with neostigmine (50 mg/kg) and glycopyrolate (7 μg/kg).
Within 24 h of surgery, platelets count and PT started improving. On the post-operative day 7, coagulation profile returned to normalcy [Table 1]. Oral feeds were resumed and intravenous antibiotics discontinued on 5 th and 7 th post-operative day respectively. Multiple blood cultures in the intervening days were negative. Skin lesions resolved gradually. On the 16 th post-operative day he was discharged and had gained 750 g since admission and weighed 7.25 kg on discharge. At the time of this reporting (1 year after DIC), his temporary colostomy has been reversed.
| Discussion|| |
A major surgical operation in the presence of uncontrolled DIC is only rarely reported in the literature. Oba et al.  reported 2 adult patients with chronic DIC due to aortic aneurysm. As pre-operative attempts failed to correct DIC, aneurysmal surgery was performed despite uncorrected coagulopathy. Yoshioka et al.  reported a 52-year-old male who presented with DIC complicating infected left atrial myxoma. Septic embolization from the tumour necessitated an emergency open cardiac surgery to remove the tumour. Garg et al.  successfully performed emergency caesarean section in a 29-year-old pregnant female who presented with DIC complicating hemolysis, elevated liver enzymes and low platelet (HELLP) syndrome. Arai et al.  did emergency subtotal colectomy in a 69-year-old man with toxic megacolon and DIC. Tsukahara et al.  reported successful evacuation of intra-abdominal hematoma in acute DIC patient. In all these patients, surgery was essential to remove the underlying cause of DIC and predictably coagulation status reverted to normalcy soon after surgery. Adding to these anecdotes, our case appears to be the first report of successful surgery in a child with uncontrolled DIC.
We adopted several surgical techniques to minimize intraoperative bleeding. All incisions were made in anatomically avascular planes such as mid-line laparotomy and colostomy through anti-mesenteric tenia coli. Lengths of incisions were kept to the essential minimum. Electro-cautery was used liberally to make all incisions including the colonic one. Prior to electro-cautery incision, combustible gases in colon were decompressed using needle aspiration. Human hand rather than instruments were used gently to hold and retract tissues. Peri-operatively, multiple transfusions of FFP, platelet concentrates and whole blood were given. Although, these manoeuvres were helpful, they do not appear to fully explain the paradoxical lack of the much anticipated huge amount of intraoperative or post-operative bleeding. Hypothetically this phenomenon may be attributed to micro vascular occlusion due to fibrin deposition and thrombosis in DIC patients. Interestingly, similar phenomenon has also been noted in other types of bleeding disorders. Bishop et al.  noted excessive intra-operative bleeding in only 7% of acute leukaemia patients who had platelet counts below 50,000 per μl. Recent publications suggest that invasive procedures can be undertaken at a platelet count as low as 20,000 per μl.  However, our case illustrates the feasibility of a major surgery even at a very low-platelet count of 4000 per μl. As Schiffer  remarked, there seems to be an "imbalance between how much we worry about bleeding and how infrequently it actually occurs."
In conclusion, our experience with a single patient suggests that life-saving surgery need not be withheld in a DIC patient especially, when the operation is indispensable to control the underlying cause of coagulopathy. Contrarily, aggressive surgery in such patients appears to facilitate early recovery. However, we would like to emphasise that further evidence needs to be accrued as to the safety of surgery in DIC. Until then, clinical decisions should be made on case-to-case basis without any generalisation.
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