M&M Data Collection FormDepartment of SurgeryPrince of Wales Hospital

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Complicationsnecessitate ICUadmission? ,

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Date of M&M meeting:

Date of Admisslon:

Date of Death / Discharge:

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Team 1 M&Team 1 M&MM

Dr. Dennis C. C. Chan

Team 1 Surgery

Prince of Wales Hospital

HistoryHistory

87/M87/MAllergic to Allergic to augmentinaugmentin (certain; rash)(certain; rash)ADLADL--IIWalks with stickWalks with stickNSNDNSND

PMHxPMHxHTHTAFAFCVA with good recoveryCVA with good recoveryPartial Partial gastrectomygastrectomy for peptic ulcer 20 years agofor peptic ulcer 20 years agoCA prostate on conservative CA prostate on conservative treamenttreamentFracture left hip with operation doneFracture left hip with operation done

History of History of cholangitischolangitis due to CBD stone due to CBD stone requiring PTBD insertion on 16/2/2011requiring PTBD insertion on 16/2/2011Repeated admissions in 2011 for blocked Repeated admissions in 2011 for blocked PTBD/ dislodged PTBD, requiring PTBD PTBD/ dislodged PTBD, requiring PTBD revisionrevisionERCP attempted in 29/6/2011, but failed ERCP attempted in 29/6/2011, but failed duodenal intubationduodenal intubationPut on list for open Put on list for open cholecystectomycholecystectomy + ECBD + ECBD on 15/8/201on 15/8/20111

Emergency admitted for acute Emergency admitted for acute cholecystitischolecystitis and and acute acute cholangitischolangitis on 5/2/2012 with open on 5/2/2012 with open cholecystectomycholecystectomy + ECBD done 7/2/2012+ ECBD done 7/2/2012IntraIntra--op found dilated CBD and 3 CBD stones op found dilated CBD and 3 CBD stones 1.5cm diameter; T1.5cm diameter; T--tube insertedtube inserted

CholedochoscopyCholedochoscopy confirmed clear CBDconfirmed clear CBDPathology: acute on chronic Pathology: acute on chronic cholecystitischolecystitis

TT--tube tube cholangiogramcholangiogram 12/3/2012:12/3/2012:No filling defect in CBDNo filling defect in CBDStump of cystic duct clearStump of cystic duct clearEccentric luminal narrowing is persistently seen in Eccentric luminal narrowing is persistently seen in distal CBD causing 40% narrowingdistal CBD causing 40% narrowingDrainage of contrast into duodenum is satisfactoryDrainage of contrast into duodenum is satisfactory

TT--tube spigottube spigot

CholangiogramCholangiogram repeated on 2/4/2012repeated on 2/4/2012No No ductalductal stone or significant obstruction evidentstone or significant obstruction evidentSmooth tapering at distal common duct with no Smooth tapering at distal common duct with no significant change compared to previous significant change compared to previous cholangiogramcholangiogram

TT--tube removedtube removed

Admitted again on 24/4/2012 for Admitted again on 24/4/2012 for biliarybiliary sepsissepsisBiliBili 112/ ALP 141112/ ALP 141

CT done 25/4/2012:CT done 25/4/2012:NonNon--obstructive small obstructive small sludgeballsludgeball or blood clot in or blood clot in distal CBDdistal CBD

Bile culture from 3/2012: E. Coli sensitive to Bile culture from 3/2012: E. Coli sensitive to augmentinaugmentin/ / ampicillinampicillin/ / cefuroximecefuroxime// gentamicingentamicinGentamicinGentamicin started in view of history of started in view of history of augmentinaugmentin allergyallergySubsequent blood culture: ESBL E. Coli sensitive to Subsequent blood culture: ESBL E. Coli sensitive to gentamicingentamicinFever down, LFT improving trend on conservative treatmentFever down, LFT improving trend on conservative treatmentMRCP booked for further assessment (6/8/2012, advanced to MRCP booked for further assessment (6/8/2012, advanced to 28/6/2012)28/6/2012)BilirubinBilirubin level upon discharge: 48 staticlevel upon discharge: 48 static

Admitted again on 20/5/2012 for RUQ pain with low grade Admitted again on 20/5/2012 for RUQ pain with low grade feverfeverBilirubinBilirubin 4646USG 21/5/2012:USG 21/5/2012:

No liver abscessNo liver abscessNo dilated IHDNo dilated IHDProximal CBD prominentProximal CBD prominent

GentamicinGentamicin startedstartedZinacefZinacef and and flagylflagyl started according to microbiologists started according to microbiologists suggestionsuggestionFever settled LFT further improved; Fever settled LFT further improved; bilibili down to 21; ALP/ ALT down to 21; ALP/ ALT normalnormalPatient discharged on 26/5/2012Patient discharged on 26/5/2012

Summary of HBP historySummary of HBP history

History of History of cholangitischolangitis due to CBD stone due to CBD stone requiring requiring PTBD 16/2/2011PTBD 16/2/2011Acute Acute cholecystitischolecystitis and and cholangitischolangitis with open with open cholecystectomycholecystectomy + ECBD on + ECBD on 7/2/20127/2/2012TT--tube tube cholangiogramcholangiogram shows distal CBD narrowing, shows distal CBD narrowing, but satisfactory contrast flow into duodenum but satisfactory contrast flow into duodenum

TT--tube spigot and removedtube spigot and removedRepeated episodes of Repeated episodes of biliarybiliary sepsis with ESBL E. Coli sepsis with ESBL E. Coli settled on conservative treatmentsettled on conservative treatmentPending MRCP for further assessmentPending MRCP for further assessment

Last admissionLast admission

Admitted again on 11/6/2012 presenting with feverAdmitted again on 11/6/2012 presenting with feverAssociated with Associated with epigastricepigastric pain, cough, sputumpain, cough, sputumWBC 13; WBC 13; BilirubinBilirubin 19; ALP 108; ALT 7519; ALP 108; ALT 75USG done 11/6/2012:USG done 11/6/2012:

No focal hepatic lesion and intrahepatic No focal hepatic lesion and intrahepatic ductalductal dilatationdilatationProximal CBD 1.4cm Proximal CBD 1.4cm (previously 7.5mm on 21/5/2012)(previously 7.5mm on 21/5/2012)

Septic workup doneSeptic workup donePrevious bile C/ST upon admission showed: Previous bile C/ST upon admission showed: ESBL E. Coli sensitive to ESBL E. Coli sensitive to ertapenemertapenem; ; enterococcusenterococcus sensitive to sensitive to ampicillinampicillinZinacefZinacef and and flagylflagyl was given (antibiotic of was given (antibiotic of choice according to microbiologists during choice according to microbiologists during previous admission)previous admission)

Patient developed high fever to 38.5 with raised Patient developed high fever to 38.5 with raised WCC to 20.2 on 12/6/2012 complicated with WCC to 20.2 on 12/6/2012 complicated with fast AFfast AFMedical Medical colleagues colleagues consulted, started consulted, started amiodaroneamiodarone infusioninfusionMicrobiologists reviewed: Microbiologists reviewed: gentamicingentamicin addedadded

PatientPatient’’s condition deteriorateds condition deterioratedDeveloped SOB with basal Developed SOB with basal crepitationcrepitation and and raised JVPraised JVPRequired 4L O2 to maintain SaO2 98%Required 4L O2 to maintain SaO2 98%WBC 21.2; WBC 21.2; bilibili 23; ALP/ALT normal23; ALP/ALT normalCrepitationCrepitation+ over bilateral lungs+ over bilateral lungsCXR: congestedCXR: congested

Medical consulted: Medical consulted: DigoxinDigoxin added for persistent fast AFadded for persistent fast AFAntibiotics continuedAntibiotics continuedAdded Added lasixlasix in view of congestive heart failure/ fluid in view of congestive heart failure/ fluid overloadoverload

PatientPatient’’s condition continue to deteriorate with s condition continue to deteriorate with renal impairment and fluid overload on renal impairment and fluid overload on 13/6/201213/6/2012CreatinineCreatinine raised to 168 (from 108)raised to 168 (from 108)Urine output was low at 8ml/ hourUrine output was low at 8ml/ hourWBC remains highWBC remains highSaO2 maintained at 96% but required 8L O2SaO2 maintained at 96% but required 8L O2

Fluid challenge not done in view of fluid Fluid challenge not done in view of fluid overload with CHF/ SOBoverload with CHF/ SOBLasixLasix givengivenGentamicinGentamicin was stopped in view of renal failurewas stopped in view of renal failureZinacefZinacef and and flagylflagyl were continuedwere continued

ICU consultedICU consultedNot for ICU admission due to triageNot for ICU admission due to triage

CVP was inserted and showed CVP to be 7cm CVP was inserted and showed CVP to be 7cm H2OH2OMicrobiologists reviewed: Microbiologists reviewed:

Tried a test dose of Tried a test dose of ertapenemertapenem given, but developed given, but developed generalized generalized pruritispruritis

On 14/6/2012, noted blood and sputum culture On 14/6/2012, noted blood and sputum culture to have ESBL to have ESBL E.ColiE.Coli sensitive to sensitive to ertapenemertapenem and and gentamicingentamicinMicrobiologists reviewed: to start Microbiologists reviewed: to start tigecyclinetigecycline, , and stopped and stopped zinacefzinacef (14/6/2012)(14/6/2012)

TigecyclineTigecycline was added according to blood culture was added according to blood culture showing ESBL E. Coli on 24/4/2012showing ESBL E. Coli on 24/4/2012

PatientPatient’’s fever was down, and required less s fever was down, and required less oxygen (4L)oxygen (4L)WBC 20.6; INR 2.07; Platelet decreasing to 74 < WBC 20.6; INR 2.07; Platelet decreasing to 74 < 117; 117; CreatinineCreatinine raised to 365raised to 365BiliBili 37; ALP/ ALT normal37; ALP/ ALT normalStill in fluid overload with SOB and basal Still in fluid overload with SOB and basal crepitationcrepitation

Witnessed arrest by nursing staff on 15/6/2012 13:52Witnessed arrest by nursing staff on 15/6/2012 13:52AsystoleAsystoleCPR CPR commenedcommened but failed to respond; subsequently but failed to respond; subsequently CPR stoppedCPR stoppedPatient certified dead on 14:14 15/6/2012Patient certified dead on 14:14 15/6/2012Cause of death pneumonia/ resistant Cause of death pneumonia/ resistant bacteremiabacteremia/ / multiorganmultiorgan failurefailurePatientPatient’’s relatives seen and accepteds relatives seen and acceptedReferedRefered coroner, but waived autopsy after discussion coroner, but waived autopsy after discussion with family and cause of death being pneumoniawith family and cause of death being pneumonia

Brief summaryBrief summary

Elderly patient with multiple medical coElderly patient with multiple medical co--morbiditesmorbiditesHistoryHistory of of cholangitischolangitis requiring PTBD insertion, with requiring PTBD insertion, with subsequent open subsequent open cholecystectomycholecystectomy and EBCD doneand EBCD donePostPost--op still presents with repeated op still presents with repeated biliarybiliary sepsis settled on sepsis settled on antibioticsantibioticsPending MRCPPending MRCP

Presented with sepsis with respiratory symptomsPresented with sepsis with respiratory symptomsDeveloped CHF/ pneumonia/ progressive renal failure/ sepsis Developed CHF/ pneumonia/ progressive renal failure/ sepsis (sepsis with (sepsis with multiorganmultiorgan failure)failure)Failed to respond to antibioticsFailed to respond to antibioticsSudden arrest which failed CPRSudden arrest which failed CPR

Regarding his distal CBD lesion, MRCP was planned Regarding his distal CBD lesion, MRCP was planned for further investigationfor further investigation

Unfortunately patient succumbed before his MRCPUnfortunately patient succumbed before his MRCP

Cause of death likely to be respiratory in origin, despite Cause of death likely to be respiratory in origin, despite the long history of recurrent the long history of recurrent biliarybiliary sepsissepsis

This patient has a history of drug allergy, and developed This patient has a history of drug allergy, and developed allergic reaction to allergic reaction to ertapenemertapenem, which was the antibiotic , which was the antibiotic the ESBL was sensitive tothe ESBL was sensitive to

Choice of antibiotic was difficult in this caseChoice of antibiotic was difficult in this caseFrequent liaison with miFrequent liaison with micrcrobiologists regarding antibiotic obiologists regarding antibiotic regimenregimen

Date

Team

Presenter

Patient Name

Sex

M & M Meetinq

Thursday 27 September 2012

T1

Dr. CHAN CHI CHIU, DENNIS

First Name (initial): KH Last Name: lP

MAge=87

Gomments from Ghairperson

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Professor Paul B. S. LaiChairmanDepartment of Surgery

Follow-up Action: El No

n Yes (please list the details)

M&M Data Collection FormDepartment of SurgeryPrince of Wales Hospital

Team

(dd/mm/yyyy)

Particulars Discharge Summary (please include dates and name of procedures, clinicalcourses and causes of death

,/*,r^,,r,

i'- tr/orbidity

Name: 0l*-Sex/Age: a f t3HKID:

Ward / Bed No.:

For mortality cases;

Referred to Coroner?,í'^ Yes i/No

Expected death?

f'"' Yes i7* tlo

For morbidity cases:

Complicationsnecessitatelnterventional Radiologyprocedures?

l-'Yes i'' No

Complicationsnecessitate ICUadmission?

i- Yes I-* wo

Complicationsnecessitatere-operation?

{ ' Yes {"" No

ls this case a medicalincident?

J"""' Yes í"' No

Date of M&M meeting:

DateofDeath/Discharge. + I L I >"rL (ddimm/yyyy)

['tu¡1 ' HT c¡rtD

Date of Admission:

Report Date Reported by

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13/9/2012Team 2

73/MWalked unaided, ET > 2 FOSPMH:

HTCOAD

Diagnosed SCC esophagus (T3N1) and small cell cancer over gastric fundus in May 2012Pre-op workup:

ASA 2Lung function: FVC 3.13, FEV1 2.31ECG: sinus rhythm, no ischemic change

Elective VAT assisted 3 stage esophagectomy + total gastrectomy + colonic pull up 30/5/2012

9 hr operationIntra-op blood loss 200mlRequired low dose phenylephrine infusion intra-op

ICU care, extubated

Discharged to general ward in the morningDeveloped sinus tachycardia (110 bpm) and oligouria (~10ml/hr) in the eveningCVP only 4, given fluid challenge (total 1.5L)Not responsive, CVP raised to 14

ECG: sinus tachycardia, no ischemic changeGiven lasix 10mg ivBlood taken for CBC, RFT, TnT

Persistent tachycardia and oligouria, also developed low grade fever and desaturation (95% on 6L O2)CVP 17TnT 423, also ARF (Cr 284)

Re-admitted to ICUFever, lowish BP required noradrenalineAlso found metabolic acidosis (pH7.19, BE -12)Started CVVHOriginally planned for urgent CT to rule out colonic conduit necrosis, but developed cardiac arrestRegained BP after CPR, down time 6mins

Bedside Echo found LVEF 20%Urgent CC found LMS and TVS, not amenable for PCICTS consulted, likely ongoing massive AMI, not for surgical revascularisationIABP was insertedCT was withheld as patient was not fit

Condition deteriorated despite maximal supportive care, developed MOF (liver failure, renal failure, DIC, bilateral LL ischemia)Family decided for withdrawal of support

Finally succumbed

73/MASA 2, PMH with HT and COAD with good exercise toleranceDied of massive AMI on post-op day 4 after elective surgery for esophageal and gastric cancers

Is pre-op cardiac assessment indicated?

Clinical historyRisk of surgeryFunctional capacityRisk stratification

Assess the need for non invasive and invasive cardiac testing

Any serious cardiac conditionsAny clinical risk factors

No serious cardiac condition, no clinical risk factorHigh risk surgeryMET >4

According to European and American guidelines, pre-op cardiac testing is not indicatedLimitation of guidelines!

M & M Meetins

Date : Thursday 27 September 2012

Team = T2

Presenter : Dr. CHONG HOI MAN, DEON

Patient Name : First Name (initial): MC Last Name: CHAN

Sex:MAge=73

Gomments from Chairperson

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Professor Paul B. S. LaiChairmanDepartment of Surgery

Follow-up Action: El No

tr Yes (please list the details)

M&M Data Collection Form ;

Department of SurgeryPrince of Wales Hospital

ft"î OTeam \ I J*,-l

D- 1-.:^ tnJ^.

(dd/mm/yyyy)

ward /.Date of M&M meeting:

Discharge Summary (please include dates and name of procedures, clinicalcourses and causes of deDate of Admission /5t > I u-- (dd/mm/yyy¡)

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[* Yes / ruo

Complicationsnecessitatere-operation?

f- Yes f/*o

ls this case a medicalincident? /

f- yes flNo

Ntlortality

IVorbidity

M&MMeeting

Cardiothoracic Surgery

NHT M/63

• Known chronic alcoholism with psychiatric follow‐up.

• Poorly controlled DM and ischemic stroke with left hemiparesis.

• Scrotal abscess with drainage done 6 mthsago.

• Poor premorbid and ADL partially dependent.• Slept on the street at night instead of staying at home.

NHT M/63

• Presented with fever and shock on 8 Feb 2012.• Attended AED NDH and was intubated and sent to ICU.

• Echo showed severe AR and MR with big vegetations.• Blood culture showed Strep Bovis. Patient was put on Ceftriazone and Gentamicin.

• Patient was on high dose of noradrenaline/dobutamine and developed multi‐organ failure.

NHT M/63

• Patient has been put on appropriate antibiotics for 4 days.

• In view of the worsening clinical condition and failed medical therapy, patient was transferred to PWH for surgery.

• AVR and MVR was performed on 15/2/12 and the intra‐operative progress was uneventful.

• Patient stayed in ICU for 5 days and was transferred back to HDU afterwards. 

NHT M/63

• Patient developed alcohol withdrawal and confusion on the ward.

• The rest of the post‐op period was uneventful. • Patient was sent back to NDH for continuation of antibiotics.

• Patient was then discharged from NDH in March on completion of antibiotics.

NHT M/63

• Patient was put on warfarin for 2 months.• Colonoscopy was performed in view of Strep Bovis infective endocarditis and tubulovillousadenoma was resected.

• Patient was well and all wounds healed up on review.

NHT M/63

• Patient then developed PR bleeding and anaemia and was admitted to medical ward  PWH for assessment.

• Colonoscopy showed no obvious source of bleeding. 

• Blood test showed haemolytic anaemia.• Echo in May showed normal funtioningvalvular bioprosthesis with no paravalvularleak. Warfarin was stopped.

NHT M/63

• Further investigation showed autoimmnuehaemolytic anaemia and was started on steriod.

• Patient was discharged again.• He developed anaemic symptom again in late May and was admitted to medical ward again for investigation and transfusion.

NHT M/63

• He developed drip site infection on the ward and then developed high fever a few days later.

• He then developed high swinging temperature and SOB.

• Urgent echo showed large vegetation over the mitral prosthesis and destruction of the mitral annulus.

• Our team was consulted and we took the patient over on 1/6/2012.

NHT M/63

• We planned to prepare him for urgent  redo‐surgery.

• However, after being transferred to our ward, his condition further deteriorated with acute renal failure and metabolic acidosis.

• ICU colleagues were consulted.• Renal team was also consulted.• Blood culture showed MRSA 

NHT M/63

• The prognosis of MRSA prosthetic valve endocarditis was poor and patient did not have good premorbid status.

• Patient’s family has been interviewed by us and ICU colleagues.

• The risk of surgery is very high > 50% mortality and the prognosis is poor with MRSA prosthetic valve infection. 

NHT M/63

• Final decision is for conservative management and patient died on the same day.

Strep Bovis Endocarditis

• Klein et al. has described the relationship of Strep Bovis infection and colonic carcinoma in 1977.

• Strep bovis is a normal inhabitant of GI tract. The ulceration of the GI tract or altered liver function leading to translocation of bacteria. The exact mechanism is unknown.

• All pateints with Strep Bovis endocarditis warrant endoscopic examination of the GI tract for occult malignancy.

MRSA Prosthetic valve endocarditis

• Prognosis is poor with in hospital moratlity > 50%.

• Early surgery is recommended.• Hospital acquired infection and can be prevented by proper hand hygiene.

• Early recognition especially if the patient has valvular prosthesis in‐situ. 

M & M Meetinq

Date

Team

Presenter

Patient Name

Sex Age : 63

Comments from Chairperson

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Thursday 27 September 2012

CTS

Dr. WAN YUK PUl, INNES

First Name (initial): HT Last Name: NG

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Professor Paul B. S. LaiChairmanDepartment of Surgery

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