General SurgeryM&M meeting07/11/200726/10/1428

Sultan Al Sheikh

DOA 13/04/28 (30/4/2007)

844895 62 y, SA, M known to have BA C/O

Diarrhea 1/1212/dayBlack, watery, fresh bloodAss Anorexia, Wt loss 15 kg in 2/52

Sought Medical advice in a private clinic CT Abdomen report

Mass at hepatic flexure Liver metastasis

O/EV/S stableChest Ex good AE no added soundsCVS Ex S1 +S2 + 0 no LL edemaABD Ex soft lax abdomen +ve BS

LABSCBC U&E LFT Coagulation NCEA 18.76

14/04/28 (1/5/2007)

ColonoscopySevere Ulcerations suggestive for UCPoor Bowel prep

Repeat colonoscopy

15/04/28 (2/5/2007)

CT reviewedThickened wall of colon at hepatic flexure Inflamed mesenteryFocal Liver lesion most likely a focal fatty liver

MRI recommendedDone 2 days later and confirmed the Liver’s

fatty focal lesion

19/04/28 (6/5/2007)

Colonoscopy repeatedSevere colitisSever deep ulcerationsSevere pseudo polyps necrosis & reddish

pus-like fluidCD

BiopsyActive chronic colitisWith extensive ulcerationsNo granulomaVasculitis and thrombi of small vesselsNo dysplasia or malignant cells

20/04/28 (7/5/2007)

CVL inserted TPN started PPD done Negative IV Methyl prednisolone Cipro & flagyl Daily AXR

21/04/28 (8/5/2007)

9 BMs blood

AXR dilated left colon

22/04/28 (9/5/2007)

8 BMs

T 37C

BP 140/80 mmHg

HR 85/min

RR 20/min

spO2 95% on RA

23/04/28 (10/5/2007)

5 BMs

Imuran started 50mg OD

PPD –ve

27/04/28 (14/5/2007)

No blood in BMs for 3 days Defecation is less

Infleximab was planned for next week

Na 131 K 5.9 Creat 65 Urea 3.8

TPN adjusted

5/05/28 (21/5/2007)

CT done after slow bowel prepDiffused wall Thickening of colonFocal irregular circumferential thickening at

hapatic flexureSmall amount of free airNo free fluids or collectionNo leak or inflammatory changesSuggestive of sealed perforated viscus

7/05/28 (23/5/2007)

CT scan repeated No progression in the disease air under diaphragm Colonic dilatation still the same Diffused wall thickening less than before

2 BMs without blood Clear liquid diet started the next day Ampicllin was started

15/05/28 (1/6/2007)

Diarrhea twice Fresh blood 50 cc last BM

Suffering Pain and distention Tachycardia Tachypnea

Toxic Mega colon

15/05/28 (1/6/2007)

Family and the patient were spoken to Surgery was considered Complications explained

Death quoted at 5%DVT PE MI Stroke Infections Pneumonia UTI Wound

Pt consented for surgery the next day

16/05/28 (2/6/2007)

Laprotomy Sub total colectomy + Ileostomy

Colon distended with adhesions Colon was perforated during surgery

3 PRBCs given

16/05/28 (2/6/2007) D1 post op in ICU Extubated Awake talking oreinted Sips of water In 1621 Out 830 Na 136 K 4.7

Creat 54 Urea 3.6 WBC8.4 Hb 112 Plt 182 PT22.2 INR2.00 APTT 49

CXR 16/05/28 (2/6/2007)

17/05/28 (3/6/2007) D2 post op 4PM

Pt transferred to the floor 6PM

started having SOB sweating LOC and became disoriente

HR 110-130 BP 120/66 RR 23 spO2 99% on NC 5l O2

17/05/28 (3/6/2007)

Chest Ex AE Bilateral crackles and Wheezes

CVS Ex NAD Abd Ex

Soft lax Ileostomy bag2 drainsRectal drain

17/05/28 (3/6/2007) 8PM Transferred to HDU RBS 2.4 50cc D50 RBS 7 CXR

L consulidationsBilat infeltration

ECGSinus tachy

ImpressionBA Volume overload hypoglycemia

CXR 17/05/28 (3/6/2007)

18/05/28 (4/6/2007)

D3 post op 3AM Confused A fib MOC

Tachycardiaobservation

18/05/28 (4/6/2007)

7:30AM Pt confused V/S HR 140-150 BP 100/60

T 38.0 RR 25

WBC 15.2 Hb 114 plt 102 PT 24.7 INR 2.3 APTT 41.7

18/05/28 (4/6/2007)

CT brain and neurology cons

ID consultation

ECG and Cardiology Consultation

Blood C/S Pseudomonas 3 days later

18/05/28 (4/6/2007)

CTNo ischemiaNo bleedingBrain atrophy Normal to age

NeurologyDisoriented to TP Ischemic encephalopathyEEG slow activity

CT Brain

18/05/28 (4/6/2007)

CardiologyNo A fibSinus tachy d/t ventolin No signs of heart failureLasix and space ventolin

IDTazocin 3.375 cont FlagylDC cipro

18/05/28 (4/6/2007)

3PM Transferred to SICU HR 150-175 BP 100/65 80s CVP 8 T 38.7 RR 25 NE and suction started Cardiology asked to taper NE CXR pneumonia Vs overload

CXR 18/05/28 (4/6/2007)

18/05/28 (4/6/2007)

11:30 PMDrowsyResponding to painful stimuli onlyHR 65 BP 70/50 Intubated

LaterA FibElectro Cardioversion

19/05/28 (5/6/2007)

D4 post op NE 20 mcg Tazocin Flagyl hydrocortisone albumin Amiodarone started Sedated intubated Drains: R Nil L 10 cc Rectal Nil In 2700 out 1150

19/05/28 (5/6/2007)

BP 110/63 HR 125 RR18 PEEP 7 CVP 5 T 36.8 post paracetamol

Chest: AE bilat crips and wheezes

WBC 15.3 Hb 10.1 Plt 160

ECHO was Normal

19/05/28 (5/6/2007)

4PM

pH 7.17 pCO2 60.8 pO2 107 O2 sat 98% HCO 21.7

FiO2 .80 PEEP 15 RR 24

19/05/28 (5/6/2007)

8:50 PM

Na 138 K 4.8

Creat 198 Urea 11.9

Dopamin 15mcg

CXR 19/05/28 (5/6/2007)

20/05/28 (6/6/2007)

D5 post op Nephrology

ARF Septic shock Dialysis Input 6244 UOP 298

ID CS G-ve bacilli sensitive to Tazo Mero Imip DC Tazo start Meropenim

20/05/28 (6/6/2007)

A fib Cardioversion HR 135/min BP 105/60 NE 20 mcg Dopamine 15 mcg

CXR 20/05/28 (6/6/2007)

21/05/28 (7/6/2007)

D6 post op

BP 100/45 T 35.2 RR 30/min HR 130 spO2 94%

Epinephrine added

21/05/28 (7/6/2007)

WBC 8.9 Hb 7.8 plt 38

Na 133 K 3.6 Creat 152 Urea 10.3

pH 7.23 pO2 72 pCO 54 HCO 20

IV IGg considered ID agreed but pharmacy refused

22/05/28 (8/6/2007)

D7 post op IGg started

Epi NE Dopa and Fenylephrine at max

Dialysis ultra filtration prisma

22/05/28 (8/6/2007)

BP 52/41 HR 125 T 37.1 CVP 21 RR 34 PEEP 20

pH 7.059 pO 64pCO 56 HCO 15.8After bicarb boluses

PT 24.3 INR 2.25 APTT 45

23/05/28 (9/6/2007)

D8 post op 2AM

Coded Resuscitation 25 mins

Direct Cause of Death Cardiac arrest

Final Diagnosis Septic shock, ARDS, ARF, Coagulopathy

THANK YOU