Call

On call, I get paged for an emergency surgery. A patient is transferred to Stanford from an outside hospital for symptoms of a small bowel obstruction. He has inflammatory bowel disease, cirrhosis, hepatitis C, and a history of a small bowel resection and colostomy. He presented initially with nausea, vomiting, and abdominal pain; imaging was consistent with an SBO. The general surgeons told me that they expected to take down some adhesions near his colostomy, and the surgery duration would be less than an hour.

When on call, there's not much time to prepare, and so I set the room up for a general anesthetic, spoke to and examined the patient in five minutes, and put him to sleep. I noticed initially he was tachycardic with a heart rate in the 110s and slightly hypotensive with a blood pressure around 100/60 but I attributed this to his hypovolemia from dehydration and cirrhosis. The surgery initially seemed to go well but he needed intermittent vasopressors to keep his blood pressure going.

Suddenly, I heard a lot of talking over the drape (across the blood-brain barrier). Unfortunately, the surgeons had opened up the belly only to find frank peritonitis; the patient had perforated his bowel and was spilling gut contents into his abdomen. As if on cue, the patient's blood pressure and heart rate started reflecting widespread infection. He was septic. I immediately sprang into action, ordering colloid fluids and platelets given the cirrhosis, placing an arterial line under the drapes and sending an ABG, and starting broader-spectrum antibiotics. I had to start the patient on a vasopressor drip, obtain additional IV access, and secure an ICU bed. Fortunately, he did okay and although he had a short stay in intensive care, the surgeons were able to get the infection under control.

This call reminded me that anesthesia is a dynamic process and that what we expect going into a surgery may be entirely different than what we get and how things look coming out of surgery. We have to be ready to act quickly and escalate our care given rapidly evolving medical and surgical conditions. A situation that appears relatively stable can change rapidly and unexpectedly.