General Surgery

Date of Event: January 27, 2009

Resident-in-Charge: Ma. Vanessa A. Cristi

Team Captain: Jan Marc DC. Ponce

Consultant-in-Charge: Dr. Ma Fe P. Pacheco

Level of Supervision: phone referral to consultant,

assisted by team captain

ASA-PS Classification: 3E

Critical Event: Delayed Emergence

General Surgery

71-year old male, ~50kg ASA-PS 3E

Hypertension Stage 1 with Hypertensive Heart Disease

Azotemia, acute on top of chronic for Hypertensive Nephrosclerosis in CKD Stage 4

Mallampati I

General Surgery DIAGNOSIS: Acute abdomen probably

secondary to ruptured diverticulitis

SURGICAL PLAN: Exploratory Laparotomy

ANESTHETIC PLAN: General endotracheal anesthesia

MONITORS AVAILABLE: 3-lead ECG, NIBP, pulse oximeter

General Surgery

REVIEW OF SYSTEMS (–) fever, (+) anorexia, (+) undocumented weight loss,

(+) general malaise (–) cough, (–) colds (–) chest pain, (–) palpitations, (+) exertional dyspnea,

(–) orthopnea, (–) paroxysmal nocturnal dyspnea (–) vomiting, (–) diarrhea, (–) hematochezia, (+)

melena (–) edema (–) pallor, (–) abnormal bleeding, (–) easy bruisability (–) anuria, (+) decreased UO, (–) dysuria, (–) tea

colored urine

General SurgeryPhysical Examination Conscious, coherent, not in respiratory distress BP 130/90 HR 102 RR 18 Temp 37.1 Pale conjunctivae, anicteric sclerae, dry oral

mucosa, no distended neck veins, (+) NGT with bilous output

Equal chest expansion, clear breath sounds, no rales or wheezes

Adynamic precodrium, distinct heart sounds, tachycardic, no murmurs

Slightly globular, tense abdomen, (+) generalized direct tenderness (most prominent over left lower quadrant, (+) rebound tenderness

Pale nailbeds, full pulses, no edema, no cyanosis, poor skin turgor

General Surgery

Laboratory Examinations CBC: Hgb 66, Hct 0.208, WBC 13.8 (N

0.914 L 0.048), Plt 370 Serum Chemistry: RBS 4.75, Crea 259

↑, Na 136 ↓, K 6.2 ↑, Cl 105 12L ECG: Regular sinus rhythm, normal

axis, nonspecific ST-T wave changes

General Surgery

Laboratory Examinations CXR: cardiomegaly LV form, (-)

pneumoperitoneum KUB Utz

Bilateral parenchymal disease with signs of chronicity R>L

Heterogenous focus R post peri-renal space, probably renal mass, cannot r/o psoas abscess

Diffuse urinary bladder thickening, t/c cystitisNormal prostate gland

General Surgery

Course at the ER Seen by SAPOD with the following

notes:Cleared for surgery with high clinical risk,

intermediate surgical riskOrdered to start Calcium Gluconate 1amp IV

bolus, GI solution q6 x 4 dosesOrdered transfusion at least 3 packs RBCOrdered to start Metoprolol 50mg/tab, 1 tab

TID

General Surgery Intraoperative Events Baseline VS: BP 130/70, HR 110, RR 18

O2Sats 100%, Temp 37.0 Transfused 1 unit whole blood prior to

induction Preoxygenated Intubated using Mac 3, ETT 8.0 cuffed and

secured at level 20 using Rapid Sequence InductionFentanyl 100μg (2μg/kg), Propofol titrated to

effect 100mg (2mg/kg), Rocuronium 50mg (1mg/kg)

General Surgery

Intraoperative Events Maintained on Isoflurane 2vol% and

Oxygen at 1.5lpm Respiration by controlled ventilation Tachycardic intraoperatively (101-120bpm) No episodes of hypertension/hypotension,

bradycardia, or desaturation intraoperatively

No ECG changes in Lead II

General Surgery Intraoperative findings: 100 cc purulent

peritoneal fluid, (+) fibrin, (+) interloop abscess, ruptured appendix, (-) masses, smooth liver, normal stomach, pancreas, spleen, small bowels, colon

Operation performed: exploratory laparotomy, appendectomy, JP drain

Postoperative diagnosis: Ruptured appendicitis

General Surgery Total OR time: 55 minutes

Estimated blood loss: < 50 cc

Urine output: 50 cc

Fluid summary: 1.5L pNSS + 1 unit whole blood

Pain meds: tramadol drip (Tramadol 300mg in 1L pLR x 24o

General Surgery

Fluid Balance Preoperative

I: 3000 ml crystalloidsO: 300 ml UO

50 ml NGT(+) 2650 ml

IntraoperativeI: 1500 ml crystalloids

450 ml Whole BloodO: 50 ml blood loss

190 ml UO

500 ml insensible

90 ml maintenance

(+) 1120 ml

General Surgery

Post-Operative Course1o Post-Op Noted bibasal coarse

cracklesOngoing 2nd unit WB

On going 2nd u Whole bloodFurosemide 10mg IV

BP: 130/70HR: 112O2S: 99%UO: 0.5cc/kg/hr

1.5o Post-Op Still with crackles up to mid lung fields, copious secretions per ETTCVP inserted

Combivent nebulization

BP: 120/65HR: 111O2S: 97%CVP: 15mmHg

General Surgery

Post-Operative Course2o Post-Op Pupils 2mm

EBRTL, withdraws to pain equally, (-) facial assymetry(+) crackles, (+) frothy fluid per ETT, (+) copious secretions per ETT

Furosemide 10mg IV

BP: 130/70HR: 120O2S: 91%CVP: 20mmHgUO: 0.5cc/kg/hr

2.5o Post-Op

Furosemide 20mg IV

BP: 160/90HR: 130O2S: 91 -> 84%CBG: 151

General Surgery

Post-Operative Course

3o Post-Op Eye opening to painful stimuli, non-purposeful movements

Reversed with Neostigmine weak respiratory effort

BP: 140/90HR: 130O2S: 84-75%CVP: 20mmHgUO: -

4o Post-Op ABG: metabolic acidosis (pH 6.9 pCO2 40.7, HCO3 9.8) (pH 7.36 pCO2 22.1, HCO3 12.9)

Hyrdocortisone 250NaHCO3 50 meqsSevoflurane 4vol%

BP: 100/60HR: 125O2S: 75%

General Surgery

Post-Operative Course5o Post-Op Furo 10+10+20

Phenylephrine 100+100+100Calcium Gluconate

BP: 100/60HR: 130O2S: 75%UO: -CVP: 20mmHg

60 Post-Op Referral to SAPOD

GI solutionFurosemide - deferred

BP: 80-90/50-60HR: 132O2S: 75-78%UO: -CVP: 20mmHgAF on Cardiac Monitor

7o Post-Op Pt transferred to SICU

BP: 80-90/40-50HR: 132O2S: 77-88%

General SurgeryAssessment

Acute Respiratory Failure1. Acute Pulmonary Congestion from CKD2. r/o ACE

Encephalopathy1. Delayed Anesthetic Effect2. Hypoxic3. Uremic

CKD with acute componentAcute Atrial Fibrillations

1. Metabolic2. ACE3. Hypoxic

General Surgery

At the SICU8o Post-Op Spontaneous eye

opening, spontaneous non-purposeful movements(+) occl bibasal crackles, wheezing

Labs facilitatedStarted on:Calcium Gluconate 10% 1 g SIVPNaHCO3 50 meqs IV bolusGI SolutionCefuroxime + metronidazoleFamotidineMoSO4Furosemide

BP: 118/40HR: 140O2S: 87-94%UO: -CVP: 20mmHg

General Surgery

At the SICU12o Post-Op ABG: compensated metabolic

acidosisCXR: fluffy infiltrates bilateral LFTrop I: 1.42mcg/L ↑CKT: 360u/L ↑CKMB: 34.3u/L ↑FBS: 12.92↑BUN: 29.27↑Crea: 255↑Uric acid: 0.8↑Alb: 17↓Ca: 1.77↓Mg: 0.92P: 3.05↑Na: 145K: 6.1↑

Scheduled for Hemodialysis

Spontaneous eye opening, spontaneous non-purposeful movementsBP: 124/72HR: 124O2S: 94-97%UO: 0.04cc/kg/hrCVP: 20mmhgCM: (+) PVC

General Surgery

At the SICU20o Post-Op s/p Hemodialysis Dopamine drip 2x

dose at 23cc/hr (10ug/kg/min)

BP: 100/70HR: 126O2S: 87%CVP: 20mmhg

26o Post-Op Sinus tachycardia on CM(-) hypotensive episodes on Dopamine drip

Progressive bradycardia -> code called -> ACLS done, revived in 3 mins, 1 epinephrine vial

Vtach on CM -> code called -> cardioversion done -> PEA -> flat line after 15 mins

A> Shock probably 1. Cardiogenic from possible NSTEMI, Killip’s III-IV 2. Septic from intraabdominal infection, severe Acute Renal Failure on top of Chronic Kidney Disease Acute Pulmonary Congestion 2 to Acute Renal Failure

GENERAL SURGERYANALYSIS OF THE CASE Immediate cause of death:

Shock 1. Cardiogenic 2. Septic

Antecedent cause of death: NSTEMI Killip III-IVIntraabdominal Infection

Underlying cause of death: Acute Renal Failure on top of Chronic Kidney Disease

GENERAL SURGERY

OUTCOME GRADING 6 – Death / Mortality