A 35 year old female patient with history of sickle cell presents to emergency department on June 3, 2023 with complaints of pain in her back and extremities. Her initial labs taken that day reflect her WBC as 13.9, hemoglobin as 7.6 and platelet level of 136. CMP showed a BUN of 2.7 and creatinine of .38. Her vitals were normal aside from a heart rate of 118. The emergency room physician’s differential included sickle cell pain crisis, anemia and aplastic crisis. She was admitted to medicine.
The patient was seen by the hospitalist that same morning. The H&P states that the patient was doing relatively okay up until 30 days prior when she started to experience intractable nausea with multiple episodes of vomiting with 10 episodes in the last 24 hours. Patient also claimed to have hematemesis with her last episode. She also began to experience abdominal pain with her back pain after episodes of vomiting. The hospitalist admitted her for IV hydration and pain medication. She did not feel patient required a sepsis workup since she had recently been discharged from the hospital a few days prior during which she was worked up for leukocytosis and her blood and urine cultures were normal. The hospitalist did request a GI consult.
GI sees the patient later on the morning on June 3rd. GI notes that GI symptoms of unknown etiology. He further notes that the labs reveal slight leukocytosis, normocytic anemia, slight thrombocytopenia, and hypocalcemia. His plan included abdominal US. He further recommended a hematology consult.
A hematology consult is completed on June 3rd. The hematologist notes that patient’s nausea was improving as well as her pain. He further noted that the Hgb had decreased to 6.8 for which he ordered 1 unit of blood.
The abdominal ultrasound was completed on June 5th and was interpreted as showing a contracted gallbladder with wall thickening and positive sonographic Murphy’s sign. No cholelithiasis or pericholecystic fluid identified. Surgery was consulted and a HIDA scan was ordered. Please note, the patient had tested positive for RSV on admission.
Patient’s HIDA interpreted as "nonvisualized gallbladder consistent with cystic duct obstructions/acute cholecystitis.' The surgeon planned a robotic-assisted cholecystectomy for the following day.
On June 6th, the surgeon noted that when patient was evaluated by anesthesia in preop, her labs had worsened from the previous day. Her INR was now 2.0, platelets were 98 and her Hgb was 8.0. Given the patient had not received blood products/FFP, a decision was made to delay the patient’s surgery for the following day. The surgeon charted “request further optimization of bleeding vs clotting risk as per hematologist who has given 1uPRBC earlier in admission due to her sickle cell anemia”.
Despite the surgeon’s note, there is no charting that hematology was called or saw the patient that day. Additionally, no additional blood products were provided.
The labs the following morning (June 7th) initially were reported by the lab as showing the INR down to 1.0 and the PT at 10.9 with a platelet level of 103. However, at 10:28am, the lab contacted the OR nurse and reported that the INR had been corrected to 1.9 and the PT to 19.3. The nurse noted that she reported these corrected labs to the physician. The cholecystectomy proceeded forward at 10:35am.
The surgeon’s operative note describes a markedly abnormal appearing liver. The gallbladder was contracted and mostly intrahepatic. There was significant inflammation posterior to the gallbladder which resulted in oozing from the liver bed throughout the dissection. Cautery was used to obtain hemostasis of the liver bed. The patient was returned to the floor following the surgery to be followed by medicine for her RSV and sickle cell pain crisis. EBL was 10 ml.
That same evening the patient developed hypotension, acute blood loss anemia and profound hemorrhagic shock. She was intubated and massive transfusion protocol was initiated. However, patient continued to drop her Hgb. Throughout the course of the night, her abdomen became increasingly distended and she eventually developed abdominal compartment syndrome. Surgery was contacted and the patient was taken to surgery the morning of June 8th for an exploratory laparotomy.
The surgeon noted in her operative note that upon entry into the abdomen blood immediately began to pour from the wound. The liver was noted to have diffuse oozing present on the surface anteriorly, laterally and inferiorly. Diffuse bleeding was also noted on omentum and the abdominal wall at prior port sites but no discrete vessels were visible. Hemostatic agents were applied to the liver surfaces and the area was packed. The upper abdomen was packed and the abdomen left open with a drain. NO visible bleeding vessel was identified. She was transferred to the ICU for ongoing resuscitation and transfusions.
The patient was brought back to the OR the following day (June 9th) due to increased pressor support and development of abdominal compartment syndrome. Clots overlying the Abthera devise were removed. The liver was inspected and demonstrated a small amount of oozing from “the abnormal cirrhotic nodular liver surface.” Patient's abdomen was re-packed.
The patient remained critically ill and passed away after coding on June 10th which was precipitated by profound hypotension and bradycardia.
I am seeking input regarding the standard of care applicable to the surgeon. Specifically, should this surgery have been delayed given the patient's INR, Hgb, PT and platelet level on June 7th? As stated, the surgeon delayed it on June 6th as a result of the abnormalities from the lab draw that day. No corrective measures were made and the labs on June 7th were similar to June 6th. The records do not reflect why the surgeon now felt it appropriate to proceed with the surgery on June 7th with essentially the same labs.
Also, did the surgeon have a responsibility to discuss the patient's coagulopathy with the hematologist given her initial decision to delay the surgery on June 6th?
Additionally, if the surgery should have been delayed, what could have been done regarding the patient's gall bladder to avoid the bleeding that subsequently occurred?
Files:
Q: Was a hepatologist consult it in the case?
A: Not before the surgery. Two days after, the intensivist did reach out to a hepatic specialist at another facility re: liver transplant; told too unstable and not a candidate.
Q: The patient presented with hepatitis, profound anemia from the sickle cell disease, or possibly bone marrow failure and acute renal failure. Did anyone consider transferring her to a tertiary care hospital?
A: No
Q: Outside of pain, what was the indication for surgery? The HIDA scan was probably false positive given that she had hepatitis and her liver cannot excrete the radionucleotide.
A: Pain, hx of vomiting and the HIDA scan. Surgical path shows 4.2x2.1x1.3cm gallbladder with smooth pink-gray serosa. Mucosa was up to .4 cm thickness.
Q: Did the surgeon discuss the case in the notes with the hospitalist and hematologist in regards to the high mortality risks of the patient?
A: There is no note in the chart from the surgeon, hospitalist or heme that such a discussion took place.
Do you believe there might have been medical error?
INR of 1.9 is ok to proceed with surgery. this operation has a low risk of bleeding The surgeon’s operative note describes a markedly abnormal appearing liver. The gallbladder was contracted and mostly intrahepatic. There was significant inflammation posterior to the gallbladder which resulted in oozing from the liver bed throughout the dissection. Cautery was used to obtain homeostasis of the liver bed. The patient was returned to the floor following the surgery to be followed by medicine for her RSV and sickle cell pain crisis. EBL was 10 ml. THIS IS THE KEY DESPITE THE PREOP.....THE OPERATIVE NOTE......SEEMS LIKE EVERYTHING WAS DONE CORRECTLY, NO BLEEDING, AND IF IT WAS DRY AND HOMEOSTATIC WHEN HE LEFT, THEN HE MET THE STANDARD OF CARE. I do not think the hematologist would have added anything further.......especially if there was no bleeding during the surgery....
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
This is common in massive bleeding....no source found....just oozing would be importation to see the hematology note to see what they recommended.
What makes you a good expert for this case?
Familiar with this surgery, sickle cell disease and post op bleeding Have previously testified in a plaintiff case where sickle cell was at the center.
How often do you encounter cases similar to this one in your practice?
monthly with gallbladder disease. Post op bleeding always a concern.
Do you believe there might have been medical error?
patients had worsened Coagulopathy without knowing why even after the delay on June 6th. A liver function test result is necessary to know what her liver function was before surgery. Given the description of th liver intraoperatively I suspect that the LFT pre-op were abnormal.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Anemic patient with Sickle cell disease who is coagulopathic before surgery should not have had surgery without correction of coagulopathy or she should have had a cholecystostomy tube placed.
What makes you a good expert for this case?
Over 18 years experience as an acute care surgeon, and I have done over 600 laparoscopic cholecystectomies
How often do you encounter cases similar to this one in your practice?
two patients /year with sickle cell disease
Do you believe there might have been medical error?
This was a critically ill, complicated patient with hematological problems. The surgeon requested a heme consult but didn't get it. He should have at least spoken with heme. It may have been prudent to get better imaging pre-op (considering the findings) - not sure there was a valid reason to operate so quickly and without the heme consult.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The patient would still be alive had there been no surgery and thus no hemorrage
What makes you a good expert for this case?
I do robotic cholecystectomy routinely
How often do you encounter cases similar to this one in your practice?
Hopefully never We operate on a lot of sickle cell patients. I've never had a death
Do you believe there might have been medical error?
Patient’s with sickle cell disease often develop abdominal pain due to crises. They all have gallstones. There is no necessity to do a gallbladder surgery with an INR of 1.9. It is important to optimize the coagulation and figure out why the patient has this prolonged INR. Maybe the cirrhosis could have been anticipated and better decisions made. If anatomy is not clear during surgery or dissection is difficult switch to laparoscopy or open surgery. If bleeding is a problem from the liver bed it should be addressed before closing the case. If the case is difficult consider bail out options including a drain the gall bladder.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The patient’s problem has not been completely understood and should have been worked up better to have an Optimal outcome. Gall bladder surgery in the setting of sickle cell disease is never to be underestimated as the liver is usually enlarged and fibrotic or even cirrhotic as seen in this case. When numbers returned showing high INR case should have been postponed. Who does robotic surgery in the setting of sickle cell disease? The fact that the patient had a belly full of blood indicates surgical bleeding that was not controlled or incorrect preparation prior to surgery that squarely lay the responsibility on the surgeon’s shoulder.
What makes you a good expert for this case?
I take care of a lot of gall bladder disease in the setting of sickle cell disease. These cases are never easy and patients should not go to the operating room without 100% optimization and they should be on the hematologist service with them having the final say as to when patient is ready.
How often do you encounter cases similar to this one in your practice?
Once a month. These cases should be done in larger centers with sufficient understanding of risks.
Do you believe there might have been medical error?
The entire management of the case is concerning. The patient is extremely complicated and should’ve been transferred to a tertiary care center. I questioned the reason for surgery given her history and the inconclusive test. Also. not reviewing the labs before a procedure and ensuring that the appropriate blood products are available is an error. The patient was not optimize by the Hospitalist nor the Surgeon.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The patient clearly was not optimized prior to her surgery. I’m not sure the surgery was indicated based on the limited work up. I feel the HIDA scan was miss interpreted as being falsely positive..
What makes you a good expert for this case?
I have a 17 year history of doing general surgery at a tertiary care center and in a community setting. In addition to working at critical access hospitals. The patient in question was extremely complicated and clearly the hospital system trying to manage her was not qualified.. My experience has provided me a great deal of knowledge about patient care. Knowing when to transfer a patient and went to not operate on a patient is very critical. The surgeon appeared to not be invested or understand the complexities of this patient. Since Covid and even during Covid, the acuity of patients increased markedly, unfortunately or fortunately I work throughout this entire period of time which exposed me to the most critical patients I’ve seen in my entire career.
How often do you encounter cases similar to this one in your practice?
Quite often since Covid and during Covid.
Do you believe there might have been medical error?
Given the degree of cirrhosis, as well as the hypercoagulable state, I do not think it was in the best judgment to proceed with surgery. These livers can be very brittle and bleed significantly. In addition, there was a recent paper published, showing that complications occur more often, following robotic cholecystectomy Compared to traditional laparoscopy.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Yes, surgical bleeding, and ultimately lead to this patient’s demise. In addition, the timing in the return to the operating room seems to be very delayed in this case.
What makes you a good expert for this case?
I’m a complex general surgical oncologist who performs cholecystectomy‘s, as well as have extensive robotic training. I take care of patients frequently who are anemic, including Jehovah’s Witnesses. I don’t think sound judgment was made in this case, and there are certainly inconsistencies in the logic in the chart.
How often do you encounter cases similar to this one in your practice?
Is a complex general surgical oncologist I perform both open and minimally invasive approaches weekly. This includes patients with cirrhosis.
Want to open a case or submit response?
Comments are accepted only from Surgery (General Surgery) experts.