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General Surgery

General Surgery. Date of Event: January 27, 2009 Resident-in-Charge: Ma. Vanessa A. Cristi Team Captain: Jan Marc DC. Ponce Consultant-in-Charge: Dr. Ma Fe P. Pacheco Level of Supervision: phone referral to consultant, assisted by team captain ASA-PS Classification: 3E

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General Surgery

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  1. General Surgery Date of Event: January 27, 2009 Resident-in-Charge: Ma. Vanessa A. Cristi Team Captain: Jan Marc DC. Ponce Consultant-in-Charge: Dr. Ma Fe P. Pacheco Level of Supervision: phone referral to consultant, assisted by team captain ASA-PS Classification: 3E Critical Event: Delayed Emergence

  2. General Surgery • 71-year old male, ~50kg • ASA-PS 3E • Hypertension Stage 1 with Hypertensive Heart Disease • Azotemia, acute on top of chronic for Hypertensive Nephrosclerosis in CKD Stage 4 • Mallampati I

  3. General Surgery • DIAGNOSIS: Acute abdomen probably secondary to ruptured diverticulitis • SURGICAL PLAN: Exploratory Laparotomy • ANESTHETIC PLAN: General endotracheal anesthesia • MONITORS AVAILABLE: 3-lead ECG, NIBP, pulse oximeter

  4. General Surgery REVIEW OF SYSTEMS • (–) fever, (+) anorexia, (+) undocumented weight loss, (+) general malaise • (–) cough, (–) colds • (–) chest pain, (–) palpitations, (+) exertional dyspnea, (–) orthopnea, (–) paroxysmal nocturnal dyspnea • (–) vomiting, (–) diarrhea, (–) hematochezia, (+) melena • (–) edema • (–) pallor, (–) abnormal bleeding, (–) easy bruisability • (–) anuria, (+) decreased UO, (–) dysuria, (–) tea colored urine

  5. General Surgery Physical Examination • Conscious, coherent, not in respiratory distress • BP 130/90 HR 102 RR 18 Temp 37.1 • Pale conjunctivae, anictericsclerae, dry oral mucosa, no distended neck veins, (+) NGT with bilous output • Equal chest expansion, clear breath sounds, no rales or wheezes • Adynamicprecodrium, distinct heart sounds, tachycardic, no murmurs • Slightly globular, tense abdomen, (+) generalized direct tenderness (most prominent over left lower quadrant, (+) rebound tenderness • Pale nailbeds, full pulses, no edema, no cyanosis, poor skin turgor

  6. General Surgery Laboratory Examinations • CBC: Hgb 66, Hct 0.208, WBC 13.8 (N 0.914 L 0.048), Plt 370 • Serum Chemistry: RBS 4.75, Crea 259 ↑, Na 136 ↓, K 6.2 ↑, Cl 105 • 12L ECG: Regular sinus rhythm, normal axis, nonspecific ST-T wave changes

  7. General Surgery Laboratory Examinations • CXR: cardiomegaly LV form, (-) pneumoperitoneum • KUB Utz • Bilateral parenchymal disease with signs of chronicity R>L • Heterogenous focus R post peri-renal space, probably renal mass, cannot r/o psoas abscess • Diffuse urinary bladder thickening, t/c cystitis • Normal prostate gland

  8. General Surgery Course at the ER • Seen by SAPOD with the following notes: • Cleared for surgery with high clinical risk, intermediate surgical risk • Ordered to start Calcium Gluconate 1amp IV bolus, GI solution q6 x 4 doses • Ordered transfusion at least 3 packs RBC • Ordered to start Metoprolol 50mg/tab, 1 tab TID

  9. General Surgery Intraoperative Events • Baseline VS: BP 130/70, HR 110, RR 18 O2Sats 100%, Temp 37.0 • Transfused 1 unit whole blood prior to induction • Preoxygenated • Intubated using Mac 3, ETT 8.0 cuffed and secured at level 20 using Rapid Sequence Induction • Fentanyl 100μg (2μg/kg), Propofol titrated to effect 100mg (2mg/kg), Rocuronium 50mg (1mg/kg)

  10. General Surgery Intraoperative Events • Maintained on Isoflurane 2vol% and Oxygen at 1.5lpm • Respiration by controlled ventilation • Tachycardicintraoperatively (101-120bpm) • No episodes of hypertension/hypotension, bradycardia, or desaturationintraoperatively • No ECG changes in Lead II

  11. General Surgery • Intraoperative findings: 100 cc purulent peritoneal fluid, (+) fibrin, (+) interloop abscess, ruptured appendix, (-) masses, smooth liver, normal stomach, pancreas, spleen, small bowels, colon • Operation performed: exploratory laparotomy, appendectomy, JP drain • Postoperative diagnosis: Ruptured appendicitis

  12. General Surgery • Total OR time: 55 minutes • Estimated blood loss: < 50 cc • Urine output: 50 cc • Fluid summary: 1.5L pNSS + 1 unit whole blood • Pain meds: tramadol drip (Tramadol 300mg in 1L pLR x 24o

  13. General Surgery Fluid Balance • Preoperative • I: 3000 ml crystalloids • O: 300 ml UO 50 ml NGT • (+) 2650 ml • Intraoperative • I: 1500 ml crystalloids 450 ml Whole Blood • O: 50 ml blood loss 190 ml UO 500 ml insensible 90 ml maintenance • (+) 1120 ml

  14. General Surgery • Post-Operative Course

  15. General Surgery • Post-Operative Course

  16. General Surgery • Post-Operative Course

  17. General Surgery • Post-Operative Course

  18. General Surgery Assessment Acute Respiratory Failure 1. Acute Pulmonary Congestion from CKD 2. r/o ACE Encephalopathy 1. Delayed Anesthetic Effect 2. Hypoxic 3. Uremic CKD with acute component Acute Atrial Fibrillations 1. Metabolic 2. ACE 3. Hypoxic

  19. General Surgery • At the SICU

  20. General Surgery • At the SICU

  21. General Surgery • At the SICU

  22. GENERAL SURGERY ANALYSIS OF THE CASE • Immediate cause of death: Shock 1. Cardiogenic 2. Septic • Antecedent cause of death: NSTEMI Killip III-IV Intraabdominal Infection • Underlying cause of death: Acute Renal Failure on top of Chronic Kidney Disease

  23. GENERAL SURGERY OUTCOME GRADING • 6 – Death / Mortality

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