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Morbidity and Mortality Review

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

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Morbidity and Mortality Review

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  1. Morbidity and Mortality Review Moderator: DrNoraslawatiRazak Prepared by: DrMohdAzinuddin Abdullah DrTengku Abdul KadirTengkuZainalAbidin

  2. 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

  3. 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

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

  5. 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

  6. Reviewed by general surgical team documented at 2.35 am at ED Impression: Intestinal Obstruction 2ndVolvolus Plan : • 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

  7. 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.

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

  9. 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.

  10. 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

  11. 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.

  12. 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

  13. Intraoperatively: • Hemodynamically unstable: started on trippleinotropes • Ivinorad: 20mls/h (single strength) • Ividobu 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.

  14. 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

  15. 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.

  16. 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

  17. 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

  18. Blood ix: FBC

  19. Blood ix: BUSEC

  20. Blood Ix: PTTK Inr

  21. Points of discussion: • Timing for surgery – management of colonic volvulus. • Dynamic of sepsis and deterioration. • Renal failure and abdominal compartment syndrome.

  22. Management of Colonic Vulvulus http://emedicine.medscape.com

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