A mortality due to obstructed inguinal hernia with background aids

A MORTALITY FOR GENERAL SURGERY – YELLOW TEAM

DR BASSEY AE

BIODATA

• P.O.• 50 YO• MALE• DRIVER• IDOMA

P.C.

• ABDOMINAL PAIN x 4/7

• ABDOMINAL SWELLING x 2/7

HxPC

• 4/7 PRIOR TO PRESENTATION DEVELOPED ABDOMINAL PAIN, UMBILICAL, ACHING, NON-RADIATING, NO KNOWN AGGRAVATING FACTOR, RELIEVED BY VOMITING

• VOMIT – NON-PROJECTILE, NON-BILOUS, NON-BLOODY, OCCURRED AFTER INGESTING FOOD OR FLUID

HxPC (CONT’D)

• ASSOCIATED FREQUENT LOOSE STOOL, WATERY, NON-MUCOID, NON-BLOODY

HxPC (CONT’D)

• 2/7 AFTER ONSET OF THESE PROBLEMS, STARTED HAVING PROGRESSIVE ABDOMINAL SWELLING ASSOCIATED WITH THIRST AND ↓URINE AND STOOL OUTPUT

HxPC (CONT’D)

• NO PRIOR HX OF ABD TRAUMA• NO HX OF ILLNESS XTISED BY HI GRADE FEVER,

HEADACHES, DIARRHOEA• NO HX OF ABD SURGERY• PRIOR TO ONSET, NO HX OF CHANGE IN BOWEL

HABITS, WT LOSS OR HAEMATOCHEZIA • NO HX OSF SWELLINGS IN GROIN OR ANY OTHER

PART OF ABDOMEN THAT APPEAR ON STRAINING OR COUGHING

HxPC (CONT’D)

• PT TOOK HERBAL MEDICATION FOR HIS PROBLEM BUT HAD NO RESPITE

SYS REVIEW

• N A D

PMHX

• KNOWN RVD ON HAART, OFF MEDICATION FOR 2 MONTHS PRIOR TO PRESENTATION

• DGXED 2YRS AGO

FSHX

• DOESN’T SMOKE OR TAKE ALCOHOL

EXAMINATION - GENERAL

• MIDDLE AGED MALE• RESTLESS• PALE• DEHYDRATED• ANICTERIC• ACYANOTIC• FEBRILE (T – 38.8C)• NO PEDAL OEDEMA

ABDOMEN• DISTENDED• MWR• TENSE• TENDER• PN – TYMPANITIC• BS – HYPOACTIVE• 6x4 CM SWELLING IN RT INGUINAL REGION, NO

COUGH IMPULSE, FIRM, TENDER, IRREDUCIBLE• HAD REDUCIBLE SWELLING WITH POSITIVE

COUGH IMPULSE ON LT INGUINAL REGION

RECTAL EXAM

• EMPTY RECTUM• SLIGHTLY ENLARGED PROSTATE

CVS

• PR – 124B/M, SMALL VOL• BP – 100/60 MMHG

CHEST

• DYSPNOIEC• RR – 48C/M

CNS

• N A D

PROBLEMS

• SEPSIS• ACUTE INTESTINAL OBSTRUCTION• OBSTRUCTED RIH• REDUCIBLE LIH

MGT PLAN

• RESUSCITATION WITH R/L VIA 2 WIDE BORE CANNULAE. PT BECAME CALM, VITALS IMPROVED TO PR-90B/M, BP-120/70MMHG

• ANTIBIOTICS – ROCEPHIN, FLAGYL• NG TUBE – 2L BILOUS FLUID• URETHRAL CATHETER PASSED – CONC URINE

INITIALLY THEN DILUTE URINE• NPO

MGT PLAN (CONT’D)

• FLUID CHART FOR I/O MONITORING• VITAL SIGNS MONITORING• URGENT PCV, E/U/CR, URINALYSIS, CXR, PLAIN

ABD XRAY• SR INFORMED – GXM 2UNITS, FOR

EMERGENCY EXLAP AS SOON AS STABLE

2ND DAY OF ADMISSION

• PT OBJECTED TO SURGERY AND PREFERRED MEDICATION DESPITE BEING EDUCATED ON THE NATURE OF HIS PROBLEM, THE NEED FOR SURGERY AND THE PERILS OF FURTHER DELAY

• MEANWHILE, INVX RESULTS:• PCV : 17%• E/U/CR : Na – 152, Cl – 127, HCO3 – 12

• NG TUBE EFFLUENCE: 6500ML OVER PAST 17HRS• URINE BAG – DILUTE URINE

2ND DAY

• RECEIVED 1 UNIT OF BLOOD• 5 UNITS OF BLOOD REQUESTED FOR PRE-OP

TRANSFUSION AND SURGERY• PT STILL REFUSED SURGERY

3RD DAY

• NG TUBE EFFLUENCE – 800ML OF FAECULENT FLUID

• RECEIVED 2ND UNIT AND HAD 2 EXTRA• PT ALSO CONSENTED TO SURGERY AND WAS

BOOKED FOR EMERGENCY EX-LAP

INTRA-OP

• RIGHT DIRECT RICHTER HERNIA WITH HERNIATED SMALL BOWEL SEGMENT ISCHAEMIC

• ON APPLICATION OF WARM SALINE PERFUSION IMPROVED AND BOWEL WAS RETURNED

• LEFT SLIDING HERNIA WITH SIGMOID COLON FORMING PART OF HERNIA SAC

• HERNIORRHAPHY WAS PERFORMED ON BOTH SIDES

POST OP ORDER

• NPO• 3L/DAY, ALT R/L AND D/W• ANTIBIOTICS – LEVOFLOXACIN, FLAGYL• ANALGESIA – PENTAZOCINE• FLUID I/O MONITORING• VITALS MONITORING• TRANSFUSE 2 UNITS IN FIRST 24HRS POST OP

12HRS PO

• NG TUBE – BILOUS• URINE BAG – DIL URINE• FEBRILE – 38.3-39.7C• PLAN – CT POST OP CARE

POD 1

• NG TUBE – BILOUS• FEBRILE – 38.3-40C• DEHYDRATED• PR – 82, BP – 110/70• BOWEL SOUNDS – HYPOACTIVE• PLAN: INCREASE FLUID INPUT TO 4L/DAY,

URGENT E/U/CR

POD 2

• BOWEL MOTIONS RESUMED• FEBRILE – 39.4-40.3C• STARTED TALKING IRRATIONALLY• POST OP PCV – 33%• YET TO DO E/U/CR• PR – 84, BP – 110/60• PLAN – TEPID SPONGING, IM PCM, CHANGE

FLAGYL BRAND, TO RECEIVE 50MMOL KCL/DAY

POD 3

• STILL FEBRILE: 39.8-40.8C• NG TUBE – SLIGHTLY BILOUS• URINE BAG – DILUTE URINE• NO E/U/CR YET• PR – 100, BP – 110/60• PLAN – URINE M/C/S, BLOOD M/C/S, CT IV

ANTIBIOTICS FOR ANOTHER 48HRS

POD 3(CONT’D)

• STILL FEBRILE: 40.8C• PLAN – INVITE PHYSICIAN IN CHARGE OF RVD

MGT, FOR POSSIBLE EX-LAP

• PATIENT PASSED AWAY 7HRS AFTER ABOVE REVIEW

THANK YOU