How to manage a 66-year-old female patient with severe anemia, jaundice, and respiratory instability after a failed Endoscopic Retrograde Cholangiopancreatography (ERCP) procedure and subsequent surgical intervention for a Common Bile Duct (CBD) stricture?

Critical Analysis of Perioperative Complications in High-Risk Biliary Surgery

Primary Clinical Catastrophe

This patient experienced multifactorial perioperative decompensation driven by severe baseline physiologic compromise (profound anemia with Hgb 41 g/L, hypoalbuminemia 18 g/L, leukocytosis 28,000), acute hemorrhage (>600cc intraoperative blood loss), inadequate fluid resuscitation leading to acute kidney injury, and respiratory failure from fluid overload in the context of aggressive transfusion without adequate diuresis. The combination of these factors created a perfect storm of organ dysfunction requiring ICU-level care that was inappropriately managed in a non-ICU setting.

Critical Baseline Assessment Failures

Preoperative Risk Stratification

• This patient should never have proceeded to surgery without ICU admission and optimization. The combination of Hgb 41 g/L (normal 120-160 g/L), albumin 18 g/L (normal 35-50 g/L), creatinine 1.5 mg/dL, and recent oxygen desaturation to 81% represented ASA Class 4-5 status 1
• The failed ERCP one week prior with CBD stricture indicated complex biliary pathology requiring expert management in a tertiary center with full ICU support 1
• Severe acute pancreatitis and biliary obstruction with jaundice mandate HDU/ITU management with full systems support 1

Cardiovascular Optimization Deficit

• Starting surgery with hematocrit 0.14 (14%) represents profound anemia with critically reduced oxygen-carrying capacity
• The 3 units PRBC transfused preoperatively were insufficient—this patient likely required 6-8 units to achieve Hgb >70 g/L before elective surgery
• Hypoalbuminemia (18 g/L) causes reduced oncotic pressure, predisposing to pulmonary edema and tissue edema, complicating fluid management 1

Intraoperative Management Errors

Anesthetic Induction Complications

• Desaturation to 80% during induction in a severely anemic patient (Hgb 41 g/L) represents critical hypoxemia with inadequate oxygen delivery to tissues
• The ketofol (ketamine-propofol 1:1) induction was appropriate for hemodynamic instability, but the dose (40mg total = 20mg each) may have been excessive given severe hypoalbuminemia affecting drug distribution
• Fentanyl 100mcg in a 66kg patient (1.5 mcg/kg) was reasonable, but respiratory depression was predictable given baseline hypoxemia

Fluid Management Catastrophe

• Oliguria (20cc/hour for 3 consecutive hours) with concentrated urine indicated severe hypovolemia and acute kidney injury, yet fluid resuscitation was grossly inadequate
• Total intraoperative fluids: 400cc PNSS + 200cc PLR + 300cc PLR + 480cc PRBC = 1,380cc over approximately 3-4 hours
• For a patient with >600cc blood loss, baseline severe anemia, and hypoalbuminemia, this represents massive under-resuscitation
• Goal-directed fluid therapy should have targeted urine output >0.5 mL/kg/hr (33cc/hr for 66kg patient), which was never achieved 1

Hemorrhage Management Failure

• Estimated blood loss >600cc in a patient starting with Hgb 41 g/L represents loss of approximately 15-20% of already critically low oxygen-carrying capacity
• Only 2 units PRBC (480cc) transfused intraoperatively was insufficient—should have received 4-6 units to maintain Hgb >70 g/L during active bleeding
• Vasopressor (norepinephrine) initiation for hypotension (BP 90/60) without adequate volume resuscitation represents treating the monitor rather than the patient—this is a cardinal error in hemorrhagic shock management 1

Respiratory Failure Pathophysiology

Multifactorial Pulmonary Dysfunction

• Postoperative desaturation (89-94%) with labored breathing represented acute pulmonary edema from aggressive late fluid administration (furosemide 60mg total given) superimposed on baseline respiratory compromise
• The patient received 5 units PRBC total (3 preop + 2 intraop) over approximately 12 hours without adequate diuresis until late in the case
• Hypoalbuminemia (18 g/L) reduced oncotic pressure, allowing fluid extravasation into pulmonary interstitium with even modest fluid administration 1

Delayed Extubation Complications

• Hypoglycemia (CBG 89 mg/dL after prolonged NPO status and stress) contributed to delayed emergence—this was appropriately treated with D50W
• The 90-minute wait before extubation was prudent given respiratory instability, but extubation should have occurred in ICU with continuous monitoring
• Labored breathing post-extubation indicated residual pulmonary edema, respiratory muscle fatigue, and possible diaphragmatic dysfunction from abdominal distension

Acute Kidney Injury Development

Prerenal Azotemia Progression

• Baseline creatinine 1.5 mg/dL with oliguria (20cc/hr × 3 hours = 60cc over 3 hours) indicated acute kidney injury
• Urine output <0.3 mL/kg/hr for >3 hours meets KDIGO Stage 2 AKI criteria
• The combination of hypovolemia, hypotension (MAP 61 mmHg), anemia, and vasopressor use created perfect conditions for acute tubular necrosis
• Furosemide administration in the setting of hypovolemia was contraindicated and likely worsened renal perfusion

Postoperative Management Deficiencies

ICU Admission Denial

• The surgeon's decision to avoid ICU admission due to "financial constraints" represents a catastrophic lapse in medical judgment
• This patient met multiple criteria for ICU admission: respiratory failure requiring high-flow oxygen, acute kidney injury with oliguria, hemodynamic instability requiring vasopressors, severe anemia, and altered mental status 1
• All cases of severe acute pancreatitis and complex biliary surgery with complications should be managed in HDU/ITU setting with full systems support 1

Monitoring Inadequacy

• Post-extubation monitoring on regular ward with episodes of desaturation represents inadequate level of care
• Required continuous pulse oximetry, hourly vital signs, strict intake/output monitoring, and serial arterial blood gases
• The patient needed invasive arterial line for continuous blood pressure monitoring and frequent blood sampling

Recommended Management Algorithm

Preoperative Optimization (Should Have Occurred)

• Mandatory ICU admission for optimization before any surgical intervention 1
• Transfusion target: Hgb >80 g/L (minimum 6-8 units PRBC over 24-48 hours with furosemide between units)
• Albumin replacement: 25% albumin 100mL to achieve albumin >25 g/L
• Respiratory optimization: High-flow nasal cannula, incentive spirometry, chest physiotherapy
• Renal protection: Maintain urine output >0.5 mL/kg/hr with balanced crystalloid resuscitation
• Nutritional support: Enteral feeding if possible, TPN if not
• Delay surgery 48-72 hours for physiologic optimization unless life-threatening cholangitis present 1

Intraoperative Management (Corrected Approach)

• Invasive monitoring: Arterial line (mandatory), central venous catheter (strongly recommended), consider pulmonary artery catheter or esophageal Doppler for goal-directed therapy 1
• Fluid resuscitation: Liberal crystalloid (2-3 L PNSS) + colloid (albumin 5% 500mL) + blood products to maintain MAP >65 mmHg, CVP 8-12 mmHg, urine output >0.5 mL/kg/hr
• Transfusion threshold: Maintain Hgb >80 g/L intraoperatively given active bleeding and cardiovascular disease
• Vasopressor use: Only after adequate volume resuscitation (CVP >8 mmHg, stroke volume variation <13%)
• Ventilation strategy: Lung-protective ventilation (Vt 6-8 mL/kg ideal body weight, PEEP 5-8 cmH2O, plateau pressure <30 cmH2O)

Postoperative ICU Management (Mandatory)

• Delayed extubation in ICU with mechanical ventilation overnight for respiratory optimization
• Diuresis: Furosemide infusion (5-10 mg/hr) to achieve negative fluid balance 500-1000 mL over 24 hours
• Renal support: Consider continuous renal replacement therapy if oliguria persists despite optimization
• Transfusion: Additional PRBC to maintain Hgb >70 g/L
• Antibiotics: Broad-spectrum coverage for biliary sepsis (piperacillin-tazobactam or carbapenem) 1, 2
• Nutritional support: Early enteral feeding via nasogastric tube
• DVT prophylaxis: Sequential compression devices (avoid pharmacologic prophylaxis given recent surgery and bleeding risk)

Specific Complications and Mechanisms

Acute Respiratory Distress Syndrome Risk

• This patient is at high risk for ARDS given multiple risk factors: sepsis (WBC 28,000), massive transfusion (5 units PRBC), aspiration risk, and fluid overload
• Berlin criteria monitoring: PaO2/FiO2 ratio, bilateral infiltrates on chest X-ray, respiratory compliance
• Lung-protective ventilation mandatory if reintubation required

Abdominal Compartment Syndrome Consideration

• "Slightly bloated abdomen" with oliguria and hypotension raises concern for intra-abdominal hypertension
• Bladder pressure measurement should have been performed—intra-abdominal pressure >20 mmHg with organ dysfunction defines abdominal compartment syndrome 1
• Treatment: Nasogastric decompression, rectal tube, avoid excessive fluid resuscitation, consider decompressive laparotomy if pressure >25 mmHg

Biliary Sepsis Management

• Failed ERCP with CBD stricture and jaundice indicates biliary obstruction with high risk of cholangitis 1, 2
• The surgical procedure (partial cholecystectomy with IOC) may not have adequately addressed the CBD stricture
• ERCP with sphincterotomy and stent placement should be performed postoperatively once stabilized 1, 2
• Prophylactic antibiotics mandatory for any biliary instrumentation 1

Key Learning Points and Pitfalls

Critical Pitfall #1: Operating on Unstable Patient

• Never proceed with elective surgery in a patient with Hgb 41 g/L, albumin 18 g/L, and recent oxygen desaturation to 81%
• The urgency of CBD stricture does not justify operating on a physiologically decompensated patient—ERCP with stent placement would have been safer initial approach 1

Critical Pitfall #2: Inadequate Fluid Resuscitation

• Oliguria with hypotension requires aggressive volume resuscitation BEFORE vasopressor initiation
• The "PLR" (passive leg raise) test should guide fluid responsiveness, but actual fluid administration was grossly inadequate
• Goal: Urine output >0.5 mL/kg/hr, MAP >65 mmHg, lactate clearance

Critical Pitfall #3: Furosemide Misuse

• Administering furosemide (60mg total) in a hypovolemic, oliguric patient with AKI is contraindicated and harmful
• Furosemide should only be given AFTER adequate volume resuscitation and in the setting of fluid overload with adequate renal perfusion
• The concentrated urine (100cc residual) indicated hypovolemia, not fluid overload

Critical Pitfall #4: Non-ICU Management

• Financial constraints should NEVER dictate level of care for a critically ill patient
• This represents both a medical and ethical failure
• The hospital/surgeon should have absorbed costs or transferred to appropriate facility

Outcome Prediction and Prognosis

Mortality Risk Assessment

• This patient has >30% mortality risk based on severe acute pancreatitis criteria, AKI, respiratory failure, and hemodynamic instability 1
• APACHE II score likely >15 (age 66, severe physiologic derangements)
• Sequential Organ Failure Assessment (SOFA) score likely 8-10 (respiratory failure, cardiovascular dysfunction, renal failure, coagulation abnormalities from liver disease)

Expected Complications

• High risk for: ARDS, acute tubular necrosis requiring dialysis, biliary sepsis/cholangitis, wound infection, deep vein thrombosis/pulmonary embolism, prolonged mechanical ventilation 1, 2
• Delayed diagnosis or inadequate treatment can lead to sepsis, multiorgan failure, and death 2
• Unresolved CBD stricture may progress to secondary biliary cirrhosis with portal hypertension and liver failure 2

Recovery Timeline

• If survives: Expect 7-14 days ICU stay, possible tracheostomy for prolonged ventilation, dialysis for 2-4 weeks, total hospital stay 3-6 weeks
• Long-term: Will require repeat ERCP with stent placement for CBD stricture once stabilized 1, 2