A Case of Two–stage Surgery to Treat Septic Shock Caused by Perforated Rectal Cancer After Resuscitation for Cardiopulmonary Arrest

Abstract

A 50–year–old woman with lower abdominal pain was transferred to our facility and developed cardiopulmonary arrest just after vomiting during computed tomographic (CT) imaging. Spontaneous circulation returned after 8 minutes. Abdominal CT showed ascites, parenteral gas on the dorsal side of the descending colon, and upper rectal wall thickening, with an irregular border. Rectal perforation caused by cancer was suspected. We diagnosed the cardiopulmonary arrest in this case as having been due to suffocation and dehydration, and not due to septic shock. We prioritized the stabilization of hemodynamics and infection control, and treated the patients with intravenous fluids, catecholamines, red cells concentrates (RCC), fresh frozen plasma (FFP), and meropenem (MEPM), along with polymyxin B–immobilized fiber column–direct hemoperfusion (PMX–DHP) and intraperitoneal drainage. The hemodynamics improved after 20h. Hartmann’s operation was performed 60h after hospitalization. After the surgery, the patient was diagnosed as having liver and ovarian metastases from the rectal cancer, and abdominoperineal resection, hepatectomy and bilateral oophorectomy were performed 56 days after the initial surgery. The short–term recovery from CPA and localized peritonitis were both considered as good prognostic factors. When encountering a patient with rectal perforation associated with CPA not due to septic shock, it is effective to provide intensive supportive care while waiting to determine whether or not surgery is required.