Bleeding the Line: Anesthetic Management of Hemorrhagic Shock After Type A Aortic Dissection Repair without CPB Return 

Authors

Kamayel Jaludi, DO, MS; Kevin Zhang, MS-4; Michael H. Entrup, MD, FASA; Raymond J. Malapero, MD, MPH, FASA 

Brief Description:

We present a medically challenging case of hemorrhagic shock following Type A aortic dissection repair with hemiarch replacement that was successfully managed without returning to cardiopulmonary bypass (CPB). A 58-year-old male with a history of hypertension and nephrolithiasis presented with severe chest and leg pain. Imaging confirmed Type A aortic dissection extending into the right femoral artery. Following emergent surgery under deep hypothermic circulatory arrest, patient developed profound hypotension shortly after separation from CPB. Management included anesthetic-led hemodynamic stabilization, high-dose vasopressors, and massive transfusion of 5 PRBCs, 4 FFP, cryoprecipitate, and platelets, successfully avoiding reinitiation of CPB. The repair remained intact without graft compromise, and limb perfusion was preserved. The patient recovered uneventfully and was discharged to rehabilitation on postoperative day 13.

This case highlights the anesthesiologist's critical role in recognizing and managing hemorrhagic shock, optimizing perfusion, and coordinating rapid transfusion without reliance on CPB. Early intervention, multidisciplinary coordination, and targeted hemodynamic management can prevent additional bypass-related risks and improve outcomes in complex aortic surgery.