Background: Point-of-care ultrasound has been gaining importance as a valuable tool for evaluating critical patients in the ICU or emergency department. This skillset can also be applied in the peri-operative setting. We present a case where its use allowed safe management of a potentially fatal surgical complication.

Case Report: An ASA I 37-year-old female underwent an uneventful elective abdominal hysterectomy under general balanced anaesthesia. At the post-operative care unit, she started an IV perfusion of Metamizole, Tramadol and Metoclopramide. Shortly after she complained of nausea, dyspnea, and she was pale, hypotensive and tachycardic. Our main hypothesis consisted of intra-abdominal hemorrhage; despite an initial responde to fluids, this diagnosis was not supported by the arterial blood gas lab findings. Furthermore, the surgeon performed an endovaginal and abdominal ultrasound (US) which did not reveal any free fluid. Differential diagnosis included anaphylaxis and pulmonary embolism; as such, the IV infusion was stopped and 0.5mg of IM Adrenaline and 200mg of IV Hydrocortisone administered, with no improvement. We then performed a focused cardiac US, which revealed an hyperkinetic, "empty" right ventricle and a collapsed inferior vena cava. Although a 2nd abdominal US still revealed no free fluid, our high suspicion for hemorrhage led us to perform emergent surgery, which confirmed our hypothesis (with numerous blood clots limiting the blood pooling in the costophrenic recesses). We were ultimately successful in its management, and the patient was transfered to the ICU for post-operative vigilance.

Discussion: Point-of-care US is a relatively novel instrument which allow diagnosis, monitoring and management of several different stages of the ABCDE approach. In this case, it heightened our suspicion of hemorrhage and helped us timely manage of an otherwise fatal case: intra-operative attitudes demanded the activation of massive hemorrhage protocol due to a clinical picture of consumption coagulopathy, as well as hypothermia and acidosis. 

09 / Seeing further beyond with point-of-care US: a powerful tool in the perioperative setting.