General SurgeryM&M meeting07/11/200726/10/1428
Sultan Al Sheikh
DOA 13/04/28 (30/4/2007)
844895 62 y, SA, M known to have BA C/O
Diarrhea 1/1212/dayBlack, watery, fresh bloodAss Anorexia, Wt loss 15 kg in 2/52
Sought Medical advice in a private clinic CT Abdomen report
Mass at hepatic flexure Liver metastasis
O/EV/S stableChest Ex good AE no added soundsCVS Ex S1 +S2 + 0 no LL edemaABD Ex soft lax abdomen +ve BS
LABSCBC U&E LFT Coagulation NCEA 18.76
14/04/28 (1/5/2007)
ColonoscopySevere Ulcerations suggestive for UCPoor Bowel prep
Repeat colonoscopy
15/04/28 (2/5/2007)
CT reviewedThickened wall of colon at hepatic flexure Inflamed mesenteryFocal Liver lesion most likely a focal fatty liver
MRI recommendedDone 2 days later and confirmed the Liver’s
fatty focal lesion
19/04/28 (6/5/2007)
Colonoscopy repeatedSevere colitisSever deep ulcerationsSevere pseudo polyps necrosis & reddish
pus-like fluidCD
BiopsyActive chronic colitisWith extensive ulcerationsNo granulomaVasculitis and thrombi of small vesselsNo dysplasia or malignant cells
20/04/28 (7/5/2007)
CVL inserted TPN started PPD done Negative IV Methyl prednisolone Cipro & flagyl Daily AXR
21/04/28 (8/5/2007)
9 BMs blood
AXR dilated left colon
22/04/28 (9/5/2007)
8 BMs
T 37C
BP 140/80 mmHg
HR 85/min
RR 20/min
spO2 95% on RA
23/04/28 (10/5/2007)
5 BMs
Imuran started 50mg OD
PPD –ve
27/04/28 (14/5/2007)
No blood in BMs for 3 days Defecation is less
Infleximab was planned for next week
Na 131 K 5.9 Creat 65 Urea 3.8
TPN adjusted
5/05/28 (21/5/2007)
CT done after slow bowel prepDiffused wall Thickening of colonFocal irregular circumferential thickening at
hapatic flexureSmall amount of free airNo free fluids or collectionNo leak or inflammatory changesSuggestive of sealed perforated viscus
7/05/28 (23/5/2007)
CT scan repeated No progression in the disease air under diaphragm Colonic dilatation still the same Diffused wall thickening less than before
2 BMs without blood Clear liquid diet started the next day Ampicllin was started
15/05/28 (1/6/2007)
Diarrhea twice Fresh blood 50 cc last BM
Suffering Pain and distention Tachycardia Tachypnea
Toxic Mega colon
15/05/28 (1/6/2007)
Family and the patient were spoken to Surgery was considered Complications explained
Death quoted at 5%DVT PE MI Stroke Infections Pneumonia UTI Wound
Pt consented for surgery the next day
16/05/28 (2/6/2007)
Laprotomy Sub total colectomy + Ileostomy
Colon distended with adhesions Colon was perforated during surgery
3 PRBCs given
16/05/28 (2/6/2007) D1 post op in ICU Extubated Awake talking oreinted Sips of water In 1621 Out 830 Na 136 K 4.7
Creat 54 Urea 3.6 WBC8.4 Hb 112 Plt 182 PT22.2 INR2.00 APTT 49
CXR 16/05/28 (2/6/2007)
17/05/28 (3/6/2007) D2 post op 4PM
Pt transferred to the floor 6PM
started having SOB sweating LOC and became disoriente
HR 110-130 BP 120/66 RR 23 spO2 99% on NC 5l O2
17/05/28 (3/6/2007)
Chest Ex AE Bilateral crackles and Wheezes
CVS Ex NAD Abd Ex
Soft lax Ileostomy bag2 drainsRectal drain
17/05/28 (3/6/2007) 8PM Transferred to HDU RBS 2.4 50cc D50 RBS 7 CXR
L consulidationsBilat infeltration
ECGSinus tachy
ImpressionBA Volume overload hypoglycemia
CXR 17/05/28 (3/6/2007)
18/05/28 (4/6/2007)
D3 post op 3AM Confused A fib MOC
Tachycardiaobservation
18/05/28 (4/6/2007)
7:30AM Pt confused V/S HR 140-150 BP 100/60
T 38.0 RR 25
WBC 15.2 Hb 114 plt 102 PT 24.7 INR 2.3 APTT 41.7
18/05/28 (4/6/2007)
CT brain and neurology cons
ID consultation
ECG and Cardiology Consultation
Blood C/S Pseudomonas 3 days later
18/05/28 (4/6/2007)
CTNo ischemiaNo bleedingBrain atrophy Normal to age
NeurologyDisoriented to TP Ischemic encephalopathyEEG slow activity
CT Brain
18/05/28 (4/6/2007)
CardiologyNo A fibSinus tachy d/t ventolin No signs of heart failureLasix and space ventolin
IDTazocin 3.375 cont FlagylDC cipro
18/05/28 (4/6/2007)
3PM Transferred to SICU HR 150-175 BP 100/65 80s CVP 8 T 38.7 RR 25 NE and suction started Cardiology asked to taper NE CXR pneumonia Vs overload
CXR 18/05/28 (4/6/2007)
18/05/28 (4/6/2007)
11:30 PMDrowsyResponding to painful stimuli onlyHR 65 BP 70/50 Intubated
LaterA FibElectro Cardioversion
19/05/28 (5/6/2007)
D4 post op NE 20 mcg Tazocin Flagyl hydrocortisone albumin Amiodarone started Sedated intubated Drains: R Nil L 10 cc Rectal Nil In 2700 out 1150
19/05/28 (5/6/2007)
BP 110/63 HR 125 RR18 PEEP 7 CVP 5 T 36.8 post paracetamol
Chest: AE bilat crips and wheezes
WBC 15.3 Hb 10.1 Plt 160
ECHO was Normal
19/05/28 (5/6/2007)
4PM
pH 7.17 pCO2 60.8 pO2 107 O2 sat 98% HCO 21.7
FiO2 .80 PEEP 15 RR 24
19/05/28 (5/6/2007)
8:50 PM
Na 138 K 4.8
Creat 198 Urea 11.9
Dopamin 15mcg
CXR 19/05/28 (5/6/2007)
20/05/28 (6/6/2007)
D5 post op Nephrology
ARF Septic shock Dialysis Input 6244 UOP 298
ID CS G-ve bacilli sensitive to Tazo Mero Imip DC Tazo start Meropenim
20/05/28 (6/6/2007)
A fib Cardioversion HR 135/min BP 105/60 NE 20 mcg Dopamine 15 mcg
CXR 20/05/28 (6/6/2007)
21/05/28 (7/6/2007)
D6 post op
BP 100/45 T 35.2 RR 30/min HR 130 spO2 94%
Epinephrine added
21/05/28 (7/6/2007)
WBC 8.9 Hb 7.8 plt 38
Na 133 K 3.6 Creat 152 Urea 10.3
pH 7.23 pO2 72 pCO 54 HCO 20
IV IGg considered ID agreed but pharmacy refused
22/05/28 (8/6/2007)
D7 post op IGg started
Epi NE Dopa and Fenylephrine at max
Dialysis ultra filtration prisma
22/05/28 (8/6/2007)
BP 52/41 HR 125 T 37.1 CVP 21 RR 34 PEEP 20
pH 7.059 pO 64pCO 56 HCO 15.8After bicarb boluses
PT 24.3 INR 2.25 APTT 45
23/05/28 (9/6/2007)
D8 post op 2AM
Coded Resuscitation 25 mins
Direct Cause of Death Cardiac arrest
Final Diagnosis Septic shock, ARDS, ARF, Coagulopathy
THANK YOU
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