Complex Case Study - The MSQC was founded in 2005 under ...



Complex Case StudyFace SheetName: L. M. MRN: 459324 Account Number: 56486Date of Birth: 7/2/1984 Gender: FemaleRace: Black, HispanicDate of Admission: 3/3 Date of Surgery: 3/8,3/10,3/12 Date of Discharge: 4/17 Time of Discharge: 15:36 Insurance Provider: Blue Cross Complete of MichiganED Provider Notes 03/02/2018 21:30 – 07:30Ms. M. is a 34 y.o. with a history of asthma, ETOH abuse and pancreatitis, who presented to the ED with 4-day history of abdominal pain, nausea and vomiting, and PO intolerance. She reports fever of up to 100.1 and chills. She reports drinking a pint of alcohol and some beer about 4 days ago. She has not had any drinks since then. She usually consumes two tall beers/day. Of note patient has also had upper respiratory infection like symptoms with rhinorrhea, congestion. ?States that this has flared her asthma symptoms and she has been using her albuterol inhaler more than normal at around 5-6 times a day. ?Denies any significant cough or wheeze. Signs of dehydration with dry mucous membranes, tachycardia,?lactic acidosis, AKI. Likely etiology of current symptoms is progression of her pancreatic pseudocyst with compression of stomach causing her current nausea, vomiting, deceased PO intake and subsequent electrolyte abnormalities and dehydration. Antibiotics started for intra- abdominal source of infection. Patient is not a candidate for surgery at this time. Patient admitted to the general medicine unit.Past Medical History: albuterol controlled asthma, chronic pancreatitisPast Surgical History: NoneFamily History: diabetes, motherSocial History: history of ETOH abuse, admits to smoking e-cigarettes and marijuana when drinkingRadiologyDateImaging StudyResult3/2 22:30CXRNo acute cardiopulmonary process3/223:30CT Abdomenenlargement of the known pancreatic pseudocyst, causing deformity of the stomach and duodenum. 3/622:38CT Chest, Abdomen, Pelvis?Interval development of small bilateral pleural effusions with accompanying atelectasis. Interval progression of abdominal and pelvic ascites with moderate abdominal and pelvic fluid being present. Pseudocyst has decreased in size.3/715:24CT ChestBilateral multifocal airspace opacities progressed from the chest x-ray of 03/06/2017. Pulmonary edema, multifocal pneumonia and ARDS need to be considered.3/815:46Ultrasound guided paracentesis850 mL cloudy yellow/tan-colored fluid aspirated3/816:48CXR1. Dialysis catheter in the right atrium.2. right IJ terminates in superior vena cava2. Worsening severe bilateral airspace disease with pleural effusions.3/1221:59CXRNew right upper lobe infiltrate.3/2018:38CT helical scan: Chest, Abd, pelvisSevere left upper lobe pneumonia with possible early cavitation/necrosis. There are also multifocal upper lobe opacities that are probably infectious in nature and bilateral lower lobe atelectasis/infiltrate. New pulmonary embolus in the left lower lobe.3/2207:30CXR1. Improved right basilar opacity2. worsening persistent left consolidation consistent with pneumonia. ????3/2407:38CXRBibasilar airspace disease much worse on the left remains suspicious for pneumonia.4/13/2017 Venous Duplex ReportThrombus surrounding the PICC line in upper arm brachial vein consistent with occlusive DVT. Consistent with severe edema throughout arm.LabsDateCreatinineGlucoseAlbuminT-bilLactic HCT WBCPLTINRCulture3/221:301.8972.51.35.835.59.22511.1Blood cx x2 – no growth3/62.4801.81.55.03410.52491.2Urine cx 20,000 CFU lactose fermenter3/72.6791.71.46.225.212.11851.63/808:002.41003.83015.3250Paracentesis: Ascites fluid + E.coli3/1213:001.8752.129.211.8190Surgical path report3/201.91052.135.614.41721.83/221.212129.216.51753/310.61101.51.51.132.711.8211UA negVital SignsDateBPHRTempRespHtWt BMI3/2 21:30100/8214536.8C18, 98% RA63”59kg23.023/695/5910599.8283/785/49139100.237, 82%RA3/808:00100/85118100.429100% vent63”73kg28.513/1213:00115/85909916, vent3/20118/9095100.128, vent3/21120/70899824, trachProgress notes: 3/3 - 3/5 no acute events3/6 Admitted to the SICU for tachycardia/tachypnea/hypoglycemia/hypotension on the medical floor. Concern for an underlying infection and sepsis given her hypoglycemia, tachycardia and hypotension. On admission to the SICU patient was resuscitated with fluids.3/7 Rales in RLL with scattered expiratory wheezing, chronic cough. Start duonebs. Distended abdomen, mildly tender to palpation, liver enlarged to palpation. Parenteral vancomycin therapy is being initiated for suspected intraabdominal infection.??Currently on broad spectrum antibiotics, so no additional antibiotics needed to treat UTI and possible pneumonia. Over the course of the day continued to decline, she had sustained hypotension, and vasopressors started to keep MAP>65 and 2.5L fluid bolus given and decompensated prompting intubation. Septic shock - of unknown infectious etiology. 3/8 Paracentesis was performed in IR which 3L of foul smelling pus was suctioned. Cultures pending. Patient was evaluated by the surgical team and then taken to the OR at 09:30 for worsening clinical picture and hemodynamic instability. She was found to have ruptured pseudocyst with purulent peritonitis. Abdomen left open, abthera vac placed. Ms. M. was also evaluated by nephrology for hemodialysis and patient was placed on sustained low-efficiency dialysis (SLED) for a significant period of time to assist with volume overload control. OP NOTE #1 Procedure Date: 3/8Procedure(s): laparotomy exploratory; cholecystectomyPre-operative Diagnosis:?Pancreatitis, acute Post-operative Diagnosis:??ruptured pseudocyst with purulent peritonitis; necrotic gallbladderAnesthesia Type:?GeneralIndications:?This is a 34 y.o.?female?who is known to have pancreatitis with formation of pseudocysts. She deteriorated clinically over the course of the last 24 hrs with becoming tachycardiac and tachypneaic. CT scan showed that the pseudocyst has ruptured. She continued to have deterioration of her clinical status manifesting with multiorgan failure. The abdominal fluid collection was tapped and showed murky fluid.?We discussed with the family our concerns for abdominal compartment syndrome and infected pseudocyst. We decided to take the patient to the OR for exploratory laparotomy. ?An extensive discussion of the procedure, the risks of surgery, and the postoperative lifestyle changes to be successful were had. Consent was obtained. Procedure: The patient was placed supine on the operating table. Lower extremity compression boots were placed. ?The abdomen was prepped and draped in a sterile fashion. A midline laparotomy was performed with careful entrance into the peritoneal cavity. Upon entry into the abdomen, we encountered close to 3L of foul smelling pus that was suctioned. Thorough exploration was performed. The liver had no palpable abnormalities, had couple of capsular?tears over the inferior border of the left lobe that were controlled with Everest and packing. The pseudocyst anterior to the stomach had a perforation that drained pus, that was suctioned. The pseudocyst wall was unroofed to ensure adequate drainage and a piece was sent to pathology. The pseudocyst tract from anterior to the stomach posteriorly and was in continuity and was rained completely. Gallbladder was necrotic so decision was made to do cholecystectomy. We set up the self-retaining Bookwalter retractor and obtained visualization of the gallbladder and liver. The gallbladder fundus was grasped and retracted. The gallbladder was dissected from the liver fossa utilizing the fundus down technique. We carefully dissected the cystic artery and duct using blunt dissection and tied the cystic artery proximally and distally using 0 silk. We used Metzenbaum scissors to divide the structure. We then noted the cystic duct going directly into the gallbladder and placed two 0 silk ties and cut above the ties. The gallbladder was removed and passed off as a specimen for pathology. The small intestine was inspected and palpated from the ligament of Treitz to the ileocecal valve and noted to be normal, there was a small 0.5cm X0.5cm serosal tear noted in the terminal ileum upon manual blunt dissection of the adhesions that was lamberted with 3-0 silk sutures. The appendix and entire colon were normal. The uterus and ovaries were inspected and found to be within normal limits. ?Abdominal irrigation was carried with 9L of warm saline.??Packs around the liver were kept in place and an Abthera Vac was placed.?The patient was returned to the ICU in critical plications: ?None.Disposition: SICU- intubated and on pressors Condition:?critical on pressors 3/10 To OR today at 10am for exploration, washout, and abthera vac changeOP NOTE #2 Procedure Date: 3/10Procedure(s): 1) reopening of laparotomy 2) small bowel resection 3) drain placement 4) abthera wound vac placementPre-operative Diagnosis: Infected pseudocyst of pancreas Post-operative Diagnosis:??Infected pseudocyst of pancreas; Small bowel ischemiaAnesthesia Type:?GeneralEstimated Blood Loss: 200 mLIndications: 34 y.o. female who is known to have pancreatitis with formation of pseudocysts. She deteriorated clinically on 3/8 and was taken to OR for abdominal exploration. At that time, 3L of foul smelling pus that was suctioned.Procedure:?The patient was brought to the Operating Room and placed on the operating table in the supine position. Patient was already intubated, had foley catheter and was on scheduled antibiotics. Bilateral sequential compression devices were in place. Abthera wound vac was taken down and the abdomen was prepped and draped in the usual sterile manner. ?A critical pause was carried out. Sponges that were intentionally packed under liver were removed. No pus was noted. We irrigated left and right gutters with 6L of fluids. ?Small bowel was inspected and there is an area of ileum that was noted to be grossly necrotic with a sharp demarcation at the terminal ileum at the previous suture repair. The entire small bowel was run from the ligament of Treitz to the cecum and the only area of necrosis was approximately 1-2 feet long of ileum including most of the terminal ileum. A GIA stapler blue load was used to staple across the terminal ileum at the demarcated portion leaving approximately 4 cm of terminal ileum that was healthy. Proximally the small bowel was stapled across in a similar fashion just proximal to the area of demarcation along the healthy pink appearing bowel. LigaSure device is used to take the mesentery. The specimen was removed. The decision was made to leave the patient who is in critical condition and on 30 mics of Levophed during the procedure in discontinuity. We irrigated the RUQ with 3L of sterile normal saline and confirmed hemostasis. We then placed 2 19F JP drains in the pancreatic pseudocysts and were then secured to skin to left of wound using 2.0 nylons. An Abthera sponge was then placed. The patient was returned to the ICU in critical condition. 3/12 patient was taken back to the operating room for wound closure at 0730 with out of room time at 1030am. Over the following few days, patient's ventilator was adjusted according to blood gas results, and patient’s respiratory status was stable. OP NOTE #3 Procedure Date: 3/12Procedure: Planned Re-Exploratory Laparotomy with Primary Fascial Closure of the Abdomen; ostomy creationPre-operative Diagnosis:?Pancreatic pseudocystPost-operative Diagnosis:??Pancreatic pseudocyst; Small bowel ischemiaAnesthesia Type:?GeneralEstimated Blood Loss: minimalIndications:?This is a 34 y.o.?female?who previously underwent emergent laparotomy for abdominal compartment syndrome secondary to infected pancreatic pseudocyst required a planned laparotomy after the abdomen was left open with a negative pressure wound vac over the last 48 hours and improved hemodynamic status. ?Attempted fascial closure was recommended to further prevent loss of domain and risk of fistula. ?The indications, risks, and possible complications of the procedure were explained to the patient who voiced understanding and wished to proceed with the surgery. The natural history of the disease process was explained to the family as the patient was intubated.??Risks including, but not limited to, bleeding, infection, anesthesia complication, DVT, PE, MI, CVA, failure of operation, hernia, need for re-operation and even death were all discussed.Procedure Details: ?The patient was taken to the Operating Room and placed on the Operating Table in supine position. After general anesthesia was obtained, the abdomen was prepped and draped in a sterile manner. ?Bilateral sequential compression boots were in place. ?A Foley catheter was already in place. ?A nasogastric tube was already in place. ?The patient had been receiving antibiotics prior to incision. ?A critical pause was carried out. ?The ABThera wound vac was removed. The peritoneum was entered carefully to avoid injury to the intra-abdominal organs. Copious warm irrigation was used to break up lose adhesions and the abdomen was explored looking for any retained instruments or sponges from the prior operation and none other were found. The stomach was adhered with omentum and fused with the pseudocyst capsule. ?The ascending, transverse and descending colon were healthy. ? The patient bled easily from the friable tissues that were tenuous from severe inflammation. ?Two JP drains were seen entering the left flank and into the lesser sac. ?We did not feel comfortable bringing up a feeding tube because we could not identify the entire anatomy of the stomach. ??The area of the proximal small bowel resection had approximately 1 foot of bowel that was questionable therefore the decision was made to resect this. This is done with Endo GIA the mesentery was taken with the LigaSure. Specimen was passed off. A 2 cm circular incision was made in the right lower quadrant carried down to the fascia which was incised 2 fingerbreadths was passed to the fascia and the proximal segment of ileum was brought through this for an ileostomy. The abdominal contents were placed back with in the abdominal cavity in their natural orientation. ?The skin was undermined to release the anterior fascia and better identify healthy edges of the fascia. ?The fascia was then closed using looped Maxon 1 sutures. In a running fashion. ?Hemostasis was achieved with electrocautery and the wound copiously irrigated with normal saline. The skin was left open. ?Then my attention was turned to the ileostomy it was created with brooking stitches using 3-0 Vicryl sutures followed by simple interrupted 3-0 Vicryl sutures. The ostomy appliance was applied. A sterile dressing was then applied and covered with sterile dressings. ?All sponge, instrument, and needle counts were correct. ?Xray was taken as protocol and again confirmed to retained instruments. ?Airway pressures remained stable at the end of the case. ?The patient was taken to the Surgical Intensive Care Unit?on pressors in good condition. ?The family was updated upon completion of the case. SURG PATH FINAL REPORT: OR Case #3, 3/12GROSS: Received in formalin, labeled "small bowel," is a 30 cm in length, 4 cm in circumference small bowel.? A 0.5 cm serosal defect with suture is present in the distal portion of the small bowel, 4-5 cm from distal margin.? The mucosa surrounding the defect is slightly deeper in color and hemorrhagic. The serosa is brown-gray.? Attached mesenteric fat runs the length of the specimen up to 4 cm.? DIAGNOSIS: Small bowel, resection: Severe acute ischemic enteritis with patchy mucosal necrosis.3/20 CT was completed for persistent fever and elevated white cell count despite being on antibiotics. CT Thorax exhibited concern for multifocal pneumonia, LUL cavitation/necrosis, and LLL PE. Due to PE finding patient was placed on heparin gtt. 3/21 Patient underwent a tracheostomy due to prolong ventilator dependence and poor pulmonary hygiene with increased secretions. Bronchoscopy performed after tracheostomy placement that revealed purulent secretions in the airway. 4/7 Tolerating tube feeding, continues to fail daily CPAP trials, JP drains removed. Removed from SLED for the first time since it was placed. 4/13 Severe edema throughout arm. Thrombus surrounding the PICC line in upper arm brachial vein consistent with occlusive DVT. Anticoagulation therapy initiated. 4/14 completed treatment for pneumonia. 4/17 discharge to LTAC. ................
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