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Morbidity and Mortality review `Team A June.pptx

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Morbidity and Mortality review `Team A

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Discharge Summary General Surgery Team A June, 2024.
SUMMARY Mrs N.M, A 34 year old female who had exploratory laparotomy and modified Grahams repair for a perforated gastric ulcer. She passed on post-op day 2. Admission Date 15th June 2024 Died 20th June 2024 DOA 5 Days on Admission.
Case 1. Mrs. N.M a 34yr old petty trader who resides at Low cost, Keffi. Umbilical pain x 3days Abdominal pain x 1 day HPC She was in her usual state of a health until about 3 days prior to presentation she noted an initially painless umbilical budge which failed to resolve spontaneously. Noted to have become painful, with associated tenderness, but no redness of overlying skin, no colicky abdominal pain, vomiting or constipation.
Case 1. HPC About 12 hours prior to presentation She developed sudden onset burning epigastric pain, radiating to the right upper quadrant with associated hx of non bilious vomiting and passage of loose stool, but no Fever. No prior hx of colicky abdominal pain, no fever, no abdominal distension. Nil hx of trauma to the abdomen, nil hx of falls. Not a known PUD pxt, there was no prior hx of recurrent epigastric pain, nil hx of indiscriminate use of NSAIDs Had been on NSAIDs for the Jaw fracture and is being managed by the MFU of NHA. Nil prior hx of abdominal surgeries, No chronic cough, contact with patient with chronic cough, ingestion of unpasteurized milk, weight loss or drenching night sweats, For the above she self medicated with some over the counter medications, but with no improvement in symptoms she presented at the AnE of this facility for care.
Case 1 She is not a known Hypertensive, Diabetic, asthmatic or epileptic. No previous surgeries or blood transfusion. She is married in a monogamous family setting with 2 children. She does not smoke or take alcohol. No recreational drug of abuse. No history of drug or food allergy. Not on any long term medications.
Examination Young lady, not in mild painful distress, afebrile, anicteric, not pale, not dehydrated, nil pedal edema, nil palpable peripheral lymph nodes. Abdomen Full, Moved with respiration, 3 by 2 cm, tender umbilical swelling, Umbilical defect measuring about 1cm Mild to moderate tenderness in the epigastrium, R. hypochondrium and lumber region Nil rebound tenderness. Rest of abdomen was soft and non tenderness. Nil palpable organomegaly. DRE was unremarkable Respiratory System. RR 20cpm Chest Vesicular breath sounds all over. CVS PR 84bpm BP 130/80mmHg HS S1, S2 only
Diagnosis Reduced Incarcerated Umbilical hernia with ? Bowel ischemia. Differentials. 1. Uncomplicated umbilical hernia with NSAID induced Gastritis.
INVESTIGATION EUCr Na 142.8, Cl 100.9, K 4.7 ,HCO3 24.7 ,Urea 5.3 ,Cr 84.6 FBC PCV 30% WBC differential - Mild neutrophilic leucocytosis. TC 19,000. [N- 78%, L-19%, BEM 3%] Plt 283,000 Abdominal X-Ray and Abdominal USS Not done
Initial Intervention NPO IV Fluids. IV Antibiotics IV Omeprazole IV PCM Patient admitted for close monitoring and to be properly investigated. Patient encouraged to do the abdominopelvic scan.
2nd Day on Admission Hx Worsening of abdominal pain. 3 episodes of bilious vomiting. Exam Febrile, Vitals PR 96bpm, BP 110/70mmHg, RR 22cpm Abdominal Exam. Moved minimally with respiration, Marked tenderness with rigidity in the R. hypochondrium and lumber region with guarding. Rest of abdomen was soft. ASS: Localized peritonitis 2 reduced gangrenous bowel. Plan Abandon conservative management and explore.
INTRA-OPERATIVE 3rd DOA FINDING 1. Solitary anterior gastric perforation measuring about 5 by 5mm on the distal third of the body. 2. About 250mls of Clear Bilious effluent in the right subhepatic space and extending to the upper right paracolic gutter, walled off by omentum, stomach, and proximal jejunum 3. Rest of the abdomen was clean and grossly normal. PROCEDURE 1. Bilious effluent suctioned, Gastric perforation identified, and a thorough exploration done. 2. Biopsy of the ulcer edge was taken after stay sutures were applied. 3. A modified grahams repair was done. 4. Copious lavage was done, and the wound closed over an drain in the subhepatic space. Transfused with one unit of blood intra-op
Post-Op Intervention 1. NG tube maintained Drained bilious effluent. 2. IV Fluids 3L in 24 hrs. 3. Analgesics Pentazocine and PCM 4. Antibiotics Ceftriaxone, Metronidazole 5. Antacids Omeprazole and Ranitidine. 6. Vitals monitored closely
2hrs Post-Op Hx Not Fully recovered from anaesthesia. Exam Febrile, T 38.1C, Sleeping but responded to calls Vitals PR 90bpm, BP 130/90mmHg, RR 22cpm Abdominal Exam. Drian in situ, draining minimal haemorrhagic effluent. Wound dressing clean and dry. Nil area of undue tenderness, Abdomen was soft. Urine output 0.5 0.8mls/kg/hr. ASS: Stable post-op Plan Ensured post-op order Ensured 500mls of fluid every 4hrs
1st Day Post-Op Hx Fully recovered from anaesthesia. Complained of pain at op site and hunger. Exam Febrile, T 38.6C Vitals: PR 102bpm, BP 130/90mmHg, RR 24cpm Abdominal Exam. Drian in situ, draining minimal haemorrhagic effluent. Wound dressing clean and dry. Nil area of undue tenderness, Abdomen was soft. Urine output 1.3 -1.5mls/kg/hr. ASS: Severe sepsis on treatment KIV Sepsis induced post-op diabetes insipidus Plan FBC & EUCr [Unable to get results that day] Increased Fluid to 4L in 24 hrs Ensures antibiotics and analgesia. Respiratory System. RR 24cpm Kussmals breathing Chest CLear CVS PR 102bpm BP 130/90mmHg HS S1, S2 only
2nd Day Post-Op Hx Noted to be restless necessitating restraint. Made incoherent speech. Exam Febrile, T 39C, warm extremities Vitals PR 132bpm, BP 110/90mmHg, RR 30cpm, RBS 20.8mmol/L, repeat 12.9mmol/L Abdominal Exam. Drian in situ, draining minimal haemorrhagic effluent. Wound inspected and seen to be well apposed and clean. Nil area of undue tenderness, Abdomen was soft. Not distended. Urine output 2 -2.5mls/kg/hr. ASS: Sepsis Associated Encephalopathy with Diabetes insipidus. Investigations FBC PCV 30%, Plt 620,000. WBC T 40,200 [N 86%, L-13%, BEM-1% E/U/Cr Na 153, K 6.1, Cl 117.2, HCO3- 19, Cr 133.4 Ur 6.6 Hypernatremia, Hyperkalemia, mildly elevated creatinine, and the High anion gap metabolic acidosis. Respiratory System. RR 30cpm Kussmals breathing Chest Clear CVS PR 132bpm BP 110/90mmHg HS S1, S2 only CNS GCS 12 [M-5, V-3, E-4] Pupils about 3mm, equal reactive to light bilaterally qSOFA 2/3 RR 30cpm BP 110/90mmHg Altered sensorium
Intervention Samples for blood culture Changed antibiotics Levoflox, Rocephin and Metro. Commenced on INO2 by nasal prongs Continuous vitals monitoring. Internal Medicine review Severe sepsis in a ? Prediabetic in poly uric phase of AKI. Monitor RBS. Maintain other care. Anaesthesiologist Review Patient passed on during their review.
2nd Day Post-Op Hx Decrease in consciousness level Exam GCS 5 [M-1,V-2,E-2] Vitals PR 162bpm, BP 100/60mmHg, RR 36cpm Chest RR 36cpm, SPO2 96 on 2L INO2 Wide spread coarse crepitations in the right Upper and Middle lung zones Still pouring urine. ASS: SAE with Aspiration Plan Expedite Anesthesiologist review and counselled for ICU care. Suction PRN Nursed in Left lateral position.
2nd Day Post-Op Findings Noted to have stopped making respiratory effort Nil heart sounds noted. Commenced CPR Stat dose of IV Adrenaline given, repeated after 5mins x 3 doses. Nil ROSC after 30mins Pupils fixed and dilated Patient was declared clinically dead at 11:15am Primary Cause of Death 1. Perforated Peptic Ulcer Secondary Cause of Death 1. Brain stem failure 2 Sepsis associated Encephalopathy.
Discussion Disease factor Disease burden 20% Mortality Atypical presentation Perforated Gastric ulcer. 2% as first presentation. Uncommon in females A concomitant umbilical hernia. Atypical course Worsening sepsis after source control ? Antibiotics [tyonnex brand]. Sepsis Associated Encephalopathy Why? [First organ in the Sequential organ failure assessment ] 損 Rapid deceleration of the CNS with sparing of other organs. 2-3 times greater mortality than Sepsis. Devastating out come in a short course. Sepsis associated post-op diabetes insipidus. Made fluid resuscitation more challenging. Masked early diagnosis of organ disfunction. Patient and Relative factor Domestic violence Initial source if the problem. Prolonged NSAID use. Financial constraint Malnourished Worsened in the last 2 weeks due to jaw fracture. Subtle delays with investigations and procurement of medications. Hospital factor. 12hrs from decision to operate to knife on skin Usual delay Ongoing Neurosurgery case. Team Factor Missed diagnosis 1. Atypical presentation and course.
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Morbidity and Mortality review `Team A June.pptx

  • 2. SUMMARY Mrs N.M, A 34 year old female who had exploratory laparotomy and modified Grahams repair for a perforated gastric ulcer. She passed on post-op day 2. Admission Date 15th June 2024 Died 20th June 2024 DOA 5 Days on Admission.
  • 3. Case 1. Mrs. N.M a 34yr old petty trader who resides at Low cost, Keffi. Umbilical pain x 3days Abdominal pain x 1 day HPC She was in her usual state of a health until about 3 days prior to presentation she noted an initially painless umbilical budge which failed to resolve spontaneously. Noted to have become painful, with associated tenderness, but no redness of overlying skin, no colicky abdominal pain, vomiting or constipation.
  • 4. Case 1. HPC About 12 hours prior to presentation She developed sudden onset burning epigastric pain, radiating to the right upper quadrant with associated hx of non bilious vomiting and passage of loose stool, but no Fever. No prior hx of colicky abdominal pain, no fever, no abdominal distension. Nil hx of trauma to the abdomen, nil hx of falls. Not a known PUD pxt, there was no prior hx of recurrent epigastric pain, nil hx of indiscriminate use of NSAIDs Had been on NSAIDs for the Jaw fracture and is being managed by the MFU of NHA. Nil prior hx of abdominal surgeries, No chronic cough, contact with patient with chronic cough, ingestion of unpasteurized milk, weight loss or drenching night sweats, For the above she self medicated with some over the counter medications, but with no improvement in symptoms she presented at the AnE of this facility for care.
  • 5. Case 1 She is not a known Hypertensive, Diabetic, asthmatic or epileptic. No previous surgeries or blood transfusion. She is married in a monogamous family setting with 2 children. She does not smoke or take alcohol. No recreational drug of abuse. No history of drug or food allergy. Not on any long term medications.
  • 6. Examination Young lady, not in mild painful distress, afebrile, anicteric, not pale, not dehydrated, nil pedal edema, nil palpable peripheral lymph nodes. Abdomen Full, Moved with respiration, 3 by 2 cm, tender umbilical swelling, Umbilical defect measuring about 1cm Mild to moderate tenderness in the epigastrium, R. hypochondrium and lumber region Nil rebound tenderness. Rest of abdomen was soft and non tenderness. Nil palpable organomegaly. DRE was unremarkable Respiratory System. RR 20cpm Chest Vesicular breath sounds all over. CVS PR 84bpm BP 130/80mmHg HS S1, S2 only
  • 7. Diagnosis Reduced Incarcerated Umbilical hernia with ? Bowel ischemia. Differentials. 1. Uncomplicated umbilical hernia with NSAID induced Gastritis.
  • 8. INVESTIGATION EUCr Na 142.8, Cl 100.9, K 4.7 ,HCO3 24.7 ,Urea 5.3 ,Cr 84.6 FBC PCV 30% WBC differential - Mild neutrophilic leucocytosis. TC 19,000. [N- 78%, L-19%, BEM 3%] Plt 283,000 Abdominal X-Ray and Abdominal USS Not done
  • 9. Initial Intervention NPO IV Fluids. IV Antibiotics IV Omeprazole IV PCM Patient admitted for close monitoring and to be properly investigated. Patient encouraged to do the abdominopelvic scan.
  • 10. 2nd Day on Admission Hx Worsening of abdominal pain. 3 episodes of bilious vomiting. Exam Febrile, Vitals PR 96bpm, BP 110/70mmHg, RR 22cpm Abdominal Exam. Moved minimally with respiration, Marked tenderness with rigidity in the R. hypochondrium and lumber region with guarding. Rest of abdomen was soft. ASS: Localized peritonitis 2 reduced gangrenous bowel. Plan Abandon conservative management and explore.
  • 11. INTRA-OPERATIVE 3rd DOA FINDING 1. Solitary anterior gastric perforation measuring about 5 by 5mm on the distal third of the body. 2. About 250mls of Clear Bilious effluent in the right subhepatic space and extending to the upper right paracolic gutter, walled off by omentum, stomach, and proximal jejunum 3. Rest of the abdomen was clean and grossly normal. PROCEDURE 1. Bilious effluent suctioned, Gastric perforation identified, and a thorough exploration done. 2. Biopsy of the ulcer edge was taken after stay sutures were applied. 3. A modified grahams repair was done. 4. Copious lavage was done, and the wound closed over an drain in the subhepatic space. Transfused with one unit of blood intra-op
  • 12. Post-Op Intervention 1. NG tube maintained Drained bilious effluent. 2. IV Fluids 3L in 24 hrs. 3. Analgesics Pentazocine and PCM 4. Antibiotics Ceftriaxone, Metronidazole 5. Antacids Omeprazole and Ranitidine. 6. Vitals monitored closely
  • 13. 2hrs Post-Op Hx Not Fully recovered from anaesthesia. Exam Febrile, T 38.1C, Sleeping but responded to calls Vitals PR 90bpm, BP 130/90mmHg, RR 22cpm Abdominal Exam. Drian in situ, draining minimal haemorrhagic effluent. Wound dressing clean and dry. Nil area of undue tenderness, Abdomen was soft. Urine output 0.5 0.8mls/kg/hr. ASS: Stable post-op Plan Ensured post-op order Ensured 500mls of fluid every 4hrs
  • 14. 1st Day Post-Op Hx Fully recovered from anaesthesia. Complained of pain at op site and hunger. Exam Febrile, T 38.6C Vitals: PR 102bpm, BP 130/90mmHg, RR 24cpm Abdominal Exam. Drian in situ, draining minimal haemorrhagic effluent. Wound dressing clean and dry. Nil area of undue tenderness, Abdomen was soft. Urine output 1.3 -1.5mls/kg/hr. ASS: Severe sepsis on treatment KIV Sepsis induced post-op diabetes insipidus Plan FBC & EUCr [Unable to get results that day] Increased Fluid to 4L in 24 hrs Ensures antibiotics and analgesia. Respiratory System. RR 24cpm Kussmals breathing Chest CLear CVS PR 102bpm BP 130/90mmHg HS S1, S2 only
  • 15. 2nd Day Post-Op Hx Noted to be restless necessitating restraint. Made incoherent speech. Exam Febrile, T 39C, warm extremities Vitals PR 132bpm, BP 110/90mmHg, RR 30cpm, RBS 20.8mmol/L, repeat 12.9mmol/L Abdominal Exam. Drian in situ, draining minimal haemorrhagic effluent. Wound inspected and seen to be well apposed and clean. Nil area of undue tenderness, Abdomen was soft. Not distended. Urine output 2 -2.5mls/kg/hr. ASS: Sepsis Associated Encephalopathy with Diabetes insipidus. Investigations FBC PCV 30%, Plt 620,000. WBC T 40,200 [N 86%, L-13%, BEM-1% E/U/Cr Na 153, K 6.1, Cl 117.2, HCO3- 19, Cr 133.4 Ur 6.6 Hypernatremia, Hyperkalemia, mildly elevated creatinine, and the High anion gap metabolic acidosis. Respiratory System. RR 30cpm Kussmals breathing Chest Clear CVS PR 132bpm BP 110/90mmHg HS S1, S2 only CNS GCS 12 [M-5, V-3, E-4] Pupils about 3mm, equal reactive to light bilaterally qSOFA 2/3 RR 30cpm BP 110/90mmHg Altered sensorium
  • 16. Intervention Samples for blood culture Changed antibiotics Levoflox, Rocephin and Metro. Commenced on INO2 by nasal prongs Continuous vitals monitoring. Internal Medicine review Severe sepsis in a ? Prediabetic in poly uric phase of AKI. Monitor RBS. Maintain other care. Anaesthesiologist Review Patient passed on during their review.
  • 17. 2nd Day Post-Op Hx Decrease in consciousness level Exam GCS 5 [M-1,V-2,E-2] Vitals PR 162bpm, BP 100/60mmHg, RR 36cpm Chest RR 36cpm, SPO2 96 on 2L INO2 Wide spread coarse crepitations in the right Upper and Middle lung zones Still pouring urine. ASS: SAE with Aspiration Plan Expedite Anesthesiologist review and counselled for ICU care. Suction PRN Nursed in Left lateral position.
  • 18. 2nd Day Post-Op Findings Noted to have stopped making respiratory effort Nil heart sounds noted. Commenced CPR Stat dose of IV Adrenaline given, repeated after 5mins x 3 doses. Nil ROSC after 30mins Pupils fixed and dilated Patient was declared clinically dead at 11:15am Primary Cause of Death 1. Perforated Peptic Ulcer Secondary Cause of Death 1. Brain stem failure 2 Sepsis associated Encephalopathy.
  • 19. Discussion Disease factor Disease burden 20% Mortality Atypical presentation Perforated Gastric ulcer. 2% as first presentation. Uncommon in females A concomitant umbilical hernia. Atypical course Worsening sepsis after source control ? Antibiotics [tyonnex brand]. Sepsis Associated Encephalopathy Why? [First organ in the Sequential organ failure assessment ] 損 Rapid deceleration of the CNS with sparing of other organs. 2-3 times greater mortality than Sepsis. Devastating out come in a short course. Sepsis associated post-op diabetes insipidus. Made fluid resuscitation more challenging. Masked early diagnosis of organ disfunction. Patient and Relative factor Domestic violence Initial source if the problem. Prolonged NSAID use. Financial constraint Malnourished Worsened in the last 2 weeks due to jaw fracture. Subtle delays with investigations and procurement of medications. Hospital factor. 12hrs from decision to operate to knife on skin Usual delay Ongoing Neurosurgery case. Team Factor Missed diagnosis 1. Atypical presentation and course.

Editor's Notes

  • #2: .
  • #11: She was explored 3rd day on Admissions with findings of a solitary anterior gastric perforation measuring about 5 by 5mm