Liver Biopsy and Microwave Ablation Complicated by Hemorrhagic Shock and Massive Hemoperitoneum: A Root Cause Analysis

Abstract

Case Summary: A 47 year-old man with Child-Pugh class B alcoholic cirrhosis was found to have an indeterminate 2 cm right hepatic lobe lesion concerning for hypovascular hepatocellular carcinoma. The patient underwent CT-guided percutaneous liver biopsy followed by microwave ablation. Post-procedure blood loss was minimal, with no immediate complications; however, the patient presented < 48 hours later with hypotension and abdominal pain. CT angiography demonstrated large volume hemoperitoneum with active contrast extravasation from a branch of the right hepatic artery. Distal right hepatic artery branch embolization was performed. Within 24 hours, the patient developed refractory hypotension requiring repeat embolization of the right hepatic artery with no further contrast extravasation. Later that day, the patient developed elevated intra-abdominal pressure, worsening hypotension, and profound lactic acidosis with persistent coagulopathy. The patient was taken emergently to the operating room for exploratory laparotomy and evacuation of the hematoma. Despite these interventions, the patient developed cardiac arrest in the operating room and expired. Methods: A systematic root-cause analysis (RCA) was performed. Data was gathered and evidence collected from multiple hospital stakeholders (staff, nurses, advance practice providers, physicians, bed management, and hospital administrators). Causal factors, current practice paradigms, and root causes were investigated. Potential corrective actions were explored. Results: Detailed discussions were held with emergency, IR, hepatology, hematology, and medical and surgical ICU staffing. Cause and effect diagram was constructed - Figure. RCA revealed potential areas for institutional improvement including post-procedural follow-up (phone contact and lab monitoring), physician consultation methods (automatic consultations for high-risk patients), massive transfusion protocols (thromboelastrography correction of coagulopathy), and triage of patients to medical versus surgical intensive care units (ICU).Figure: Cause and Effect Fishbone Diagram.Discussion: This case highlights a fatal complication from liver biopsy and microwave ablation. Through this RCA, an institution-wide protocol through discussions with all stakeholders is needed to reduce future adverse events. Furthermore, this case emphasizes the need for early involvement of the hepatobiliary surgical service and appropriate triage of massive transfusion protocol patients to a surgical ICU.