Question about post-op patient scenario

  1. 0
    I am a new nurse working in a SICU and am trying to find some information on a patient situation, but am not finding anything on the internet! It is bugging me and just want thoughts from some of you guys.

    Background:
    Post-op liver transplant, intubated, propofol/fentanyl and IVF at 125/hr.
    2 JP's on right side of abdomen draining serosanguinous immediate post-op; emptied about 200cc for first 5 hours.
    BP stable; NSR. H&H 10.8 and 32. Stable patient.

    Problem:
    About 5 hours in, urine output dropped to about 20 for two consecutive hours.
    Paged resident; went to empty JPs and noticed that the gown and chux were completed saturated (pt was turned an hour before, so this was all within an hour); emptied the JP and immediately refilled with blood; emptied for a total of 740cc within 10 minutes.
    Gave 500cc NS bolus for low urine output.
    SBP was 120s (norm) and HR was 80s (also what it had been running). Again, stable.
    Sent all the labs; H&H was still 10.5/32 based on ABG but the VBG (source was from JP drainage) H&H was 3.2 and can't remember- but it was low.

    What I don't understand:
    Docs said it was bleeding ascites? I have never heard of this and can not find anything on the internet about this, except that bloody ascites fluid = not good; yet they aren't too concerned.

    Also- where did this blood come from since the pt came back from surgery with the JPs draining normal amounts of serosang drainage and then 5 hours later a random 700cc dark bloody drainage.

    Why didn't this affect BP, HR and H&H?

    I am wondering if it had to do with positional change from the turn? But, I am pretty sure the pt was turned on that side before, but i am not 100% sure now.

    What am I missing?
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  3. 6 Comments so far...

  4. 1
    Perhaps someone can put out a definitive response, and I'm more cardiac surgery than liver transplants, but I'm guessing that all that blood is coming from general ooziness from portal hypertension and ascites. Guess the docs didn't feel there would be a focal point of bleeding worth taking him back to O.R. While this patient did get his new liver, he was far from healthy going in. I found this: Current management of the complications of portal hyper... [CMAJ. 2006] - PubMed - NCBI
    Esme12 likes this.
  5. 0
    With the HgB in the ascities being 3.2....it shows that it is oozing mixed with the "usual" ascities fluid indicating that it isn't an active bleed but generalized oozing from trauma and a normal part of the operative process. The patient probably had a pocket buried somewhere that when turned it "released itself".

    Since this is not an active bleed....it would not affect the patient's vital signs as this is really strictly "abdominal fluid" and not involved in the circulation fluid stability of the patient. I do know that the abdomen of "flushed" with an antibiotic fluid after surgery to look for potential issues and for infection reasons.

    I am not a Liver transplant expert but that is my take on the information provided.
  6. 1
    Thanks for the responses guys! So I found out today that H&H dropped during night shift, requiring 3 units of PRBCs and platelets. Patient ended up going to OR today and found out it was a hematoma. Makes sense to me... atleast more than a "bleeding ascites." Now if only I could understand why the weekend staff didn't want to deal with it on Sunday... gotta love it.
    Esme12 likes this.
  7. 1
    Quote from ChipNurse
    I am a new nurse working in a SICU and am trying to find some information on a patient situation, but am not finding anything on the internet! It is bugging me and just want thoughts from some of you guys.

    Background:
    Post-op liver transplant, intubated, propofol/fentanyl and IVF at 125/hr.
    2 JP's on right side of abdomen draining serosanguinous immediate post-op; emptied about 200cc for first 5 hours.
    BP stable; NSR. H&H 10.8 and 32. Stable patient.

    Problem:
    About 5 hours in, urine output dropped to about 20 for two consecutive hours.
    Paged resident; went to empty JPs and noticed that the gown and chux were completed saturated (pt was turned an hour before, so this was all within an hour); emptied the JP and immediately refilled with blood; emptied for a total of 740cc within 10 minutes.
    Gave 500cc NS bolus for low urine output.
    SBP was 120s (norm) and HR was 80s (also what it had been running). Again, stable.
    Sent all the labs; H&H was still 10.5/32 based on ABG but the VBG (source was from JP drainage) H&H was 3.2 and can't remember- but it was low.

    What I don't understand:
    Docs said it was bleeding ascites? I have never heard of this and can not find anything on the internet about this, except that bloody ascites fluid = not good; yet they aren't too concerned.

    Also- where did this blood come from since the pt came back from surgery with the JPs draining normal amounts of serosang drainage and then 5 hours later a random 700cc dark bloody drainage.

    Why didn't this affect BP, HR and H&H?

    I am wondering if it had to do with positional change from the turn? But, I am pretty sure the pt was turned on that side before, but i am not 100% sure now.

    What am I missing?
    We see this all the time. Post transplant patients will continue to accumulate ascites for a period of time after transplant. The ascites can accumulate in pockets and be mixed with blood from the surgery. Its not uncommon to get a bunch of drainage at once when mobilizing turning the patient as you mobilize the pockets. What matters more is the quality. We don't do hgb on these. You just look and shake the bulb. After a while its pretty easy to determine if its more blood or ascites.

    As for the BP and HR, remember that there are three compartments for fluids. Intravascular, intracellular, and extracellular. What you were losing was fluid not blood from the intravascular compartment to the extracellular compartment. HR and BP are relatively late indicators of fluid loss. The urine output will drop first. Also remember that many of the liver transplant patients still may be beta blocked from preop so you may not see HR rise. As for H&H again the loss was in fluid not blood.

    In your second post you noted they received blood and went back for hematoma evacuation. This is relatively common (around 2-5%) in our program. Usually what happens is that the patient oozes from the cut edge of the liver and forms a hematoma. These bring backs rarely find anything bleeding since you have usually corrected the coagulopathy by that time. However, if the clot gets infected the patient does poorly. One program I worked with had an automatic bring back if the patient received 6 PRBCs. Our program is more surgeon dependent.
    Esme12 likes this.
  8. 1
    Thanks Core0, that was very helpful!!
    Esme12 likes this.
  9. 0
    Quote from ChipNurse
    Thanks for the responses guys! So I found out today that H&H dropped during night shift, requiring 3 units of PRBCs and platelets. Patient ended up going to OR today and found out it was a hematoma. Makes sense to me... atleast more than a "bleeding ascites." Now if only I could understand why the weekend staff didn't want to deal with it on Sunday... gotta love it.
    Ha!


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