Morbidity and Mortality Review

Moderator: Dr Noraslawati Razak

Prepared by: Dr Mohd Azinuddin Abdullah Dr Tengku Abdul Kadir Tengku Zainal Abidin

Mr A, 44 years/M/Male• Previously no known medical illness

Presented with:• Abdominal Pain since x 1/52• Colicky in nature, pain score 7/10• Distended abdomen since x 1/52• Vomiting x 1/7 (more than 10 episodes)• No BO, no flatus 1/7• Minimal bowel output since x 1/12 ago

On Examination• GCS: 15/15, not tachypneic, mild dehydrated, warm periphery, CRT

< 2 second.• BP: 147/84, HR: 82, regular, good pulse volume• RR: 10, Temp: 37 sPO2: 100 % under RA• Lung: clear • CVS: S1S2, no murmur• P/A: distended, bowel sound sluggish• Per Rectum: empty rectum, no mass palpable

• Bed Side Ultrasound: liver homogenous, gallbladder not distended, GB wall not

thickened

• Impression: Intestinal Obstruction

• Plan: Insert ryle’s tube to refer surgical team IV drip 1 pint NS VS monitoring every 15 minutes

Differential Diagnosis of IO

• Mechanical:– Adhesion– Gallstones– Hernias– Impacted stool– Intussusception– Tumours– Volvulus

• Ileus:– Gastroenteritis– Electrolyte imbalance– Mesenteric Ischemia– Intraabdominal

infection– Use of narcotics– Kidney or lung disease

Reviewed by general surgical team documented at 2.35 am at EDImpression: Intestinal Obstruction 2nd VolvolusPlan :•for Exploratory Laparatomy KIV proceed.•To notify operation early morning tomorrow•KNBM•Strict I/O charting•IV Cefobid and IV Flagyl•IV Tramadol 50 mg TDS•To pull out CVP 7 cm•For CVP reading

Patient review at surgical ward

• At 2:42 am• O/E: Patient’s condition stable• Explained to patient regarding current

condition and plan for exp laparotomy kiv proceed.

• Anaesth MO was informed reg plan for op cm , asked for pttk inr and to inform back cm.

• Surgical plan: For Blood ix and notify ot cm.

• How much fluid given and how much patient’s intake and output was not documented.

7/5/2014

• @ 7:30 am case was notified to anaesth MO, noted pttk: 91, plan for repeat coag profile stat and to inform back.

• Surgical plan: to repeat pttk and request 4 units FFP.

• S/T MO blood bank, to rule out cause of isolated prolonged aptt 1st. Not for FFP yet.

7/5/2014

• @ 7:40 am, patient became tachypnoeic, restless and impending collapsed.

• Bp: 80/50 HR:110 spo2:99% under RA.• Referred anaesth for elective intubation

Anaesth Referral attending

• Upon attending: Patient was very tachypnoeic, in severe pain.

• Unable to speak, arousable, obey simple commands.

• Abdominal grossly distended.• Intubated w ETT sized 7.5 anchored @ 20cm.• Given : iv fentanyl 100mcg, iv mida 2mg, iv STP

50mg, iv suxa 100mg, • Post intubation: BP normal, HR: 100-110.

Posted for Exploratory Laparotomy.

• Upon receiving patient at air lock around 10am, no BP monitoring, Spo2: 100% on manual bagging.

• Patient : intubated,sedated, dehydrated ++• Connected to ventilator and other standard

monitoring: BP: 127/96 HR: 96• Ventilator setting: VT: 450, R:24, PEEP:10

fio2:1

Intraoperatively:• Hemodynamically unstable: started on tripple inotropes

– Ivi norad: 20mls/h (single strength)– Ivi dobu 10mls/h – Ivi adrenaline 10mls/h

• Medications given:– Iv morphine 5mg, iv ca gluconate 1g, iv nahco3 150mmol, 1

cycle lyctic cocktail.

• IV fluid given:– 11 pints gelafundin, 6 pints sterofundin, 4 pints NS, 2 pints WB,

4 units FFP.

• Blood loss minimal, Urine output: minimal.

ABG intra-operative

• @10:59 am: ph 6.809 pco2:52.1 po2:517 hb:9.5 K:6.5 Lac:10.7 be:-23.4 hco3:6.6

• @11:40 am: 7.012 pco2:39.8 po2:460 hb:5.8 lact:10.4 be:-19.3 hco3:9.5

Operative findings:

• Dilated, gangrenous from descending colon to sigmoid.

• Dilated and dusky small bowel and caecum, ascending & transverse colon twisted at the sigmoid x 1.

• Dilated sigmoid perforate upon manipulation.

Post OP

• Patient was transferred to ICU for further care.

• On tripple inotropic support. BP still on the lowish side.– Ivi norad 25mls/h– Ivi adrenaline 15mls/h– Ivi dobu 15mls/h

In ICU,

• Patient deteriorating,refractory shock on four inotropic supports. BP: 58/28 HR:85

• ABG: Severe met acidosis, Lac: 12, K:3.5• Informed DIL to family members• Pronounced death on 7/5/2014 at 5:55pm• COD: Septicaemic shock 2ry to intestinal

infection w sigmoid vulvulus

Blood ix: FBC

Blood ix: BUSEC

Blood Ix: PTTK Inr

Points of discussion:

• Timing for surgery – management of colonic volvulus.

• Dynamic of sepsis and deterioration.• Renal failure and abdominal compartment

syndrome.

Management of Colonic Vulvulus

http://emedicine.medscape.com