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Case presentation

Case presentation. 2002/10/28 By Liu Chih-Min. Patient ’ s Information. Name: Lin G.G Chart no: 4133516 Sex: Female Age: 48 y/o Admission date: 2002-10-17. Chief complaint & Present illness: Colon cancer with liver metastasis which was diagnosed at other hospital

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Case presentation

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  1. Case presentation 2002/10/28 By Liu Chih-Min

  2. Patient’s Information • Name: Lin G.G • Chart no: 4133516 • Sex: Female • Age: 48 y/o • Admission date: 2002-10-17

  3. Chief complaint & Present illness: • Colon cancer with liver metastasis which was diagnosed at other hospital • Bowel habit change since 4 months ago • Colonscopy showed tumor mass at sigmoid colon and the pathology revealed adenocarcinoma • Abdomonal sonogram was done and showed colon cancer with liver metastasis, cancer peritonitis, and large amount of ascites

  4. 2002-10-21PM 3:401st time operation

  5. Clinical diagnosis: • Colon cancer • Operation proposed: • Explorative laparotomy • Operator: • Dr. Liang • Date of operation: • 2002-10-21

  6. Pre-operative evaluation • Pre-operative data: • BP: 130-90 mmHg • HR: 82/min • BW: 45.6 kg • Past history: • Allergy to unknown drug

  7. Laboratory data: Blood type: O+ WBC: 8610/mm3 RBC: 43100/mm3 Hb: 14.2 gm/dl PLT: 375000/mm3 PT: 12.2/11.6 PTT: 30.5/35.9 Blood chemistry: A/G: 3.5/3.4 mg/dl Bilirubin T: 0.6 mg/dl GOT/GPT: 43/18 kU BUN: 5.5 mg/dl Creatinine: 0.5 mg/dl Na:132 mmol/l K: 2.8 mmol/l Ca: 2.16 mmol/l Sugar AC: 119 mg/dl

  8. ASA Class: 2 • Terminal stage of colon cancer

  9. OP note • Post op diagnosis: • Colon ca with liver and omentum metastasis • Op method: • Hartmann’s procedure • Ileostomy + ometectomy + peritonectomy + bilateral salpingo oothectomy • Op findings: • Colon mass: 8*5*6cm; LN (+) • Multiple metastasis to colon, small intestine, liver, omentum and peritoneal • Ascites, clear, 3800 c.c.

  10. Anesthesia recordand POR record

  11. Hb: 12.2 to 5.8 in 2 hours Input: PRBC: 2U FFP: 2U HAES: 500 ml IVF: 3200 ml Output: Blood loss: 1700 ml Ascites: 3800 ml U/O: 1000 mll During op

  12. Input: PRBC: 10U WB: 2U FFP: 4U IVF: 1300 ml Hb: 7.0 - 7.6 - 7.3 CVP: 5 mmHg SpO2: 100 > 97 Output: Drain: 200 ml+ 25 ml U/O: 600 ml BP: downhill HR: 90 > 130 /min During POR

  13. 10/22 AM 1:00 Patient was transferred to 4C1

  14. 10/22 1:00~7:00AM Input: WB: 4U, PRBC: 4U, PLT: 12U Output: Chest tube: 1900 ml, Abdominal drainage: 340 ml Urine output: 200 ml 10/22 8:00~15:00 Input: PRBC: 2U, PLT & FFP: 12U IVF: 1300 ml Output: Chest tube: 2400 ml Abdominal drainage: 170 ml Urine output: 400 ml I/O

  15. Input: PRBC: 18U WB: 6U FFP:18U PLT: 24U IVF: 6300 ml Output: Blood loss: 2435 ml Chest tube: 4300 ml U/O: 2200 ml Summary during OP, POR & 4C1(within 24 hours)

  16. Hemodynamic: • tachycardia, low BP • Respiratory: • Tachypnea: 40/min • Chest X-ray: • Left hemotheoax was noticed on 3AM • Chest tube: • initial drain1600 ml, bloody • Average chest tube drainage: • 300 ml/hour in 4C1 • F/U chest X-ray on 6AM: • clear, no hemomediastinum was noted

  17. Drain function: • Milking: minimal fresh blood • Abdonimal sonogram: 2AM • No specific finding, few blood clot • Chest sonogram: 7-10AM • No fluid accumulation in plural space • Abdominal sonogram: 10AM • Seems large blood clots and small amount of fluid accumulation, source?

  18. Intra-abdominal pressure: 10AM • 32 cmH2O • CVS and chest consult: 12AM • Check bleeding source

  19. 2002/10/22PM 3:45Emergent operation

  20. Input: PRBC: 28U WB: 8U FFP: 21U PLT: 24U Cry: 12U Output: Blood loss: 11000 ml U/O: 900 ml I/O

  21. OP findings • Profuse fresh blood and blood clot was noted in abdominal cavity • Diffuse oozing over rough surface of pelvic cavity, left side retroperitoneum, and right diaphragm • Diffuse tumor seeding over diaphragm • A diaphragmatic tear over right posterior aspect, about 10 cm in length • Blood loss: more then 13000ml

  22. Post 2nd operation in 4C1 • 10/22 19:00~ 10/23 7:00 • Input: • IVF: 1000ml • PRBC: 3U • Output: • Chest tube: minimal • Drainge: right upper: 690ml, right lower: 350ml, left side: 880ml (total: 1920ml)

  23. Discussion

  24. Unstable hemodynamic • Hb down? BP down? Shock? • Hypovolemic, septic, or cardiogenic? • Not comparable input with output during POR? • Where is the fluid? • Internal bleeding? • But there was not massive blood drained • PE findings during POR & 4C1? • Breathing sound, abdomen

  25. Hemothorax?Hemopneumothorax?Or other source? • Source? • Major vessel puncture in chest? • Due to CVP? • Other source? • What happened during operation? • VATS; Angiography or any other internal bleeding?

  26. Diagnosis of blunt rupture of the right hemidiaphragm by technetium scan. May AK - Am Surg - 01-Aug-1999; 65(8): 761-5 University of Virginia Health Sciences Center, Charlottesville, USA. • Rupture of the diaphragm, particularly of the right hemidiaphragm, may be occult and can be difficult to diagnose • The majority of right-sided injuries are diagnosed during laparotomy performed for other injuries. • Intraperitoneal injection of technetium sulfur colloid was used to establish the diagnosis of right diaphragm rupture, and an uncomplicated repair was undertaken.

  27. Diagnosis and treatment of diaphragm rupturesAbakumov MM - Khirurgiia (Mosk) - 01-Jan-2000; (7): 28-33 Russian • Basic methods of diagnosis in this condition including X-ray, ultrasonic methods, computed tomography and thoracoscopy • The differential diagnosis between right-sided coagulated hemothorax and diaphragm's right cupula ruptures was the most difficult

  28. Should this operation be done?Should we stop it?Or take any other actions?

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