Morbidity

1
Morbidity MortalityConference

• 9/5/2006

2
HPI

• 53 year-old AA Female with a PMHx significant for
  Lung Ca x 1 year
• As per family- pt. awakened c/o low back pain and
  abdominal pain which progressed throughout the
  day
• Patients pain continued to intensify which
  prompted the family to call 911
• During transport to SH, patient went into PEA

3
HPI

• Patient given 1 mg Atropine and Epinephrine
• Patients pulse returns in the Emergency Room. Pt
  without pulse for approximately 10 minutes.
• At that time, patient was intubated and sedated
  being sustained with 100 mcg of Neosynephrine
  with a pulse of 68 bpm.
• Patient is undergoes a cat scan of the head,
  chest and abdomen pelvis

4
Cat scan

• Head Ct- 0.6 cm lesion in the right cerebellar
  hemisphere without any edema and mass effect.
  Small bleed could not be ruled out
• Chest- Large neoplasm in Right Lung with
  involvement of the hilum and mediastinum.
  Metastatic nodules noted in left lung
• ABD Pelvis- Large pneumoperitoneum, moderate
  ascites

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(No Transcript)
6
HPI

• General surgery consulted for a perforated viscus
• Physical Exam-
• Neuro- Intubated, sedated
• CV- 80-95/40-50 HR 80 S1 S2 no murmurs
• Lung- Decreased on R side
• Abdomen- firm, mild distention, BS- none, no
  mass, no scars
• Ext- palpable pulses x all 4 ext

7
HPI

• Labs- Na-103 K-3.8 Cl-101 CO2-7 Bun-23
  Crea-1.1 Gluc-271 Alb-0.8 T. Protein-2.1
  ALP-65 AST-556 ALT-205 T. Bili-0.6
• WBC- 20.1 Hgb/Hct-7.8/26.1 Plt-94
• PT/INR/PTT-12.2/1.2/29.2
• ABG-7.27/34.3/563/16/100 on 100 FiO2
• Trop- lt.04
• Pt taken to the operating room for exploration

8
Brief Operative Note

• PreOp Dx- Perforated Viscus
• PostOp Dx- Perforated Gastric Antrum
• Procedure- Exploratory Laparotomy with primary
  repair of perforated gastric antrum with omental
  patch
• Anesthesia- GET
• EBL- 100 cc
• Findings- gastric fluid/contents throughout
  abdomen
• IVL- 5 Liters crystalloid 2 units PRBC
• Urine output- 200cc/2hrs
• Abdomen thoroughly irrigated with 5 Liters of
  fluid

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Post Operative Course

• Vitals- 89/55 on 80 mcg of Neosynephrine switched
  to Lephoved and Vasopressin
• HR-60-80s
• H/H- 15/43
• ABG- 7.19/52/44/17/89 on 60 FiO2
• Lactate- 7.8?8.6
• Peak Airway pressure?35-50
• Bladder Pressure?35
• Urine output- decreasing to 10 cc/hr
• Physical exam
• Abd- Firm, distended, No bowel Sounds

10
Post Operative Course

• Pt. Asystolic ( 4 hrs post operative)
• ACLS protocol instituted
• Atropine and Epiniphrine given- producing no
  change
• Code called after 10 minutes

11
Intra-abdominal Hypertension

• The exact clinical conditions that define
  abdominal compartment syndrome (ACS) are
  controversial however, organ dysfunction caused
  by intra-abdominal hypertension (IAH) is
  considered to be ACS.
• Dysfunction due to
• may be respiratory insufficiency secondary to
  compromised tidal volumes,
• decreased urine output caused by falling renal
  perfusion,
• or any organ dysfunction caused by increased
  abdominal compartment pressure
• Initially recognized clinically in the 19th
  century when Marey and Burt observed its
  association with declines in respiratory function

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ACS

• Pathophysiology-
• ACS follows a destructive pathway similar to
  compartment syndrome of the extremity. Problems
  begin at the organ level with direct compression
  hollow systems such as the intestinal tract and
  portal-caval system collapse under high pressure.
  Immediate effects such as thrombosis or bowel
  wall edema are followed by translocation of
  bacterial products leading to additional fluid
  accumulation, further increasing intra-abdominal
  pressure
• As pressure rises, ACS impairs not only visceral
  organs, but also the cardiovascular and the
  pulmonary systems it may also cause a decrease
  in cerebral perfusion pressure.
• Incidence- According to recent literature,
  frequency in trauma ICU admissions is anywhere
  from 5-15 and is 1 of general trauma
  admissions.

13
ACS

• Causes-
• Primary
• Penetrating trauma
• Intraperitoneal hemorrhage
• Pancreatitis
• External compressing forces, such as debris from
  a motor vehicle collision or after a large
  structure explosion
• Pelvic fracture
• Rupture of abdominal aortic aneurysm
• Perforated peptic ulcer
• Secondary
• Large volume resuscitations
• Postoperative
• Packing and primary fascial closure, which
  increases incidence
• Sepsis

14
ACS

• Diagnosis-
• Physical Exam
• distended, rigid abdomen
• High Peak Airway pressures
• Low urine output with High Bladder pressure
• Treatment-
• Isolate cause
• Exploration