Disseminated Intravascular Coagulation: A Very Rare Complication Of Neck Dissection

摘要

Purpose: To present a case with lower lip squamous cell carcinoma underwent a fatal condition: Disseminated Intravascular Coagulation (DIC) during neck dissection. Method: A case report Result: Disseminated intravascular coagulation (DIC) often progresses in patients with malignant neoplasms, severe inflammation or multiple injuries, which induce bleeding. It is a very rare condition in head and neck surgery. In this case report, the approach to lower lip squamous cell carcinoma, the diagnosis and treatment of DIC were discussed. Conclusion: Lower lip squamous cell carcinoma is not a benign disease. It should be treated appropriately including neck dissection. DIC is an unfortunate and uncommon condition. Although it is rare, all surgical team should be familiar with early symptoms, diagnosis and treatment of the this condition. Introduction Disseminated intravascular coagulation (DIC) often progresses in patients with malignant neoplasms, severe inflammation or multiple injuries, which induce bleeding. However, because the hemorrhagic symptoms of DIC cannot be observed in the early stage of the disease, the diagnosis and treatments are often delayed, and results can be fatal (1). A case with DIC occurred during neck dissection was presented in this article. The approach to cases with lower lip carcinoma and the diagnosis and treatment of this uncommon entity were disscussed in this article. Case Report A 47 year old man applied to our ENT clinic with a history of right neck mass for 6 months. He had a wedge resection of lower lip squamous cell carcinoma almost a year ago. It was performed by a plastic surgeon. At this time, he had had a 3x2 cm lesion in the midline on the lower lip. He denied any other complaints such as weight loss, night sweating and difficulty in breathing. He smoked cigarettes for 30 years. He denied any alcholic bevereges consumption and massive sunlight exposure.On examination, he had a vertical insicion on the lower lip and a 3x2 cm fixed mass on the right submandibular region. He did not have any other disease other than this neck mass. All laboratuary investigations were within normal limits. His neck scan was presented in Figure 1. The biopsy taken from the neck mass was reported as squamous cell carcinoma metastasis. Right radical neck dissection with left supraomohyoid neck dissection were performed to this patient. The operation took 2 and a half hours with no major complication or bleeding. But, during wake up period after the extubation, the patient started to ooze from the neck insicion. An acute neck swelling occurred. At this time his oxygen saturation decreased. He was reentubated again and all sutures were removed and both neck regions were evaluated for a major bleeding site. At first glance whole neck was covered by a massive, dark coloured hemaetoma. But there was no active bleeding site. He was hyperventilated for about 15 minutes but there was still no bleeding. His blood count was 13.6 for hemoglobin and 39 for hematocrit at this time. He was not administered any blood or blood products during surgery. This second operation took almost one hour. During wake-up period of the second operation, he could not be able to wake –up. His respiratory efforts was inadequate, his pupils were fixed-midriatic and his whole body was very cold and acral regions were cyanotic. His urine output was almost none. His oxygen saturation could not be able to be measured. His blood tests including aPTT, PT and D- dimer, blood gasses and complete blood count were runned immediately. Meanwhile, he was reentubated and connected to respiratory machine. He had cardiac arrest. He responded to rescussitation. His tests were consistent with disseminated intravascular coagulation (DIC). His PT was 56, aPTT was 198 and D-Dimer was 4695 (0-250). These values were very high. His blood gasses showed both a very deep respiratory and metabolic acidosis. The blood PH was 6.8 which we were told that it was unconsistent with