Severe metabolic shock after open abdominal aortic aneurysm repair

PIG Meeting: 11th February 2021

Case details

  • Sestamibi preop (organized by vascular surgeons) – normal EF and nil ischaemia
  • Uneventful procedure, short clamp time
  • EDB functioning well, extubated, transported to ICU, doing well
  • ~3am developed shock + respiratory failure
  • Reintubated, NAd and vasopressin commenced
  • Cause of shock difficult to establish
    • CT showed no bleeding, all vessels perfused, some small areas of gut ischaemia but not thought significant enough to cause the degree of shock
    • Bedside TTE – difficult views but nil obvious cause of severe shock
    • Fluid responsive with lactate dropping from 9 to 5 with fluid resus
  • Surgical team reluctant to take patient to OT for a re-do laparotomy which they believed was likely to be non-diagnostic.
  • Patient eventually taken to OT – ischaemic colon and 2m of small bowel – resected, abdo left open
  • Patient survived with AKI


  • Discussion involved consideration of immediate postoperative complications needing surgical complication to be excluded. This case shows the important of looking to the obvious, common causes of shock in a patient after major surgery.
  • Discussion about whether or not a TOE should have been used in this patient while the cause of shock was still unclear. The clinician felt that the limited TTE views obtained were adequate to exclude a cardiac event as a cause of shock, at least while the most likely source (an intra-abdominal complication) was still being investigated.
  • Acknowledged that re-look laparotomies have an accepted false negative rate, in order to avoid missing the opportunity for life-saving intervention.