MORBIDITY & MORTALITY RAHIL “The Man Who Doesn’t Need To Shave To Look Good” SHAIKH, MD Northeast Iowa Family Medicine July 23 rd , 2014
Jan 14, 2016
MORBIDITY & MORTALITY
RAHIL “The Man Who Doesn’t Need To Shave To Look Good” SHAIKH, MD
Northeast Iowa Family Medicine
July 23rd, 2014
Sponsors
Chief Complaint
1 day old M with unwanted foreskin.
HPI
Born to a 30 year old G3, now P3 mother via induced vaginal delivery (for post dates) at 40 1/7 weeks of gestation
Mother’s prenatal Hx complicated by mild tobacco abuse but otherwise nothing else pertinent
Baby was born on Tuesday April 29th, 2014 at 20:48 via NSVD with Apgars of 8 and 9, 3860 g (AGA)
PMH, PSH, FH, SH
• Nothing significant
Review Of Systems
Goal in life was to urinate on Dr. Shaikh multiple times
Medications/Allergies
None NKA
Physical Examination
Completely normal, healthy baby boy
Assessment & Plan
1) Routine newborn cares
2) Bottle feed
3) Circumcision
Timeline Of EventsDATE CLINICAL STATUS
04/29 Birth at 20:48Fed well, urinated, passed stool, VSS
04/30 Circumcision performed at lunch hour, preparations began ~ 12:30Circumcision note signed at 14:15Called in ~ 15:00 for bleeding circumcision site to the L of the ventral frenulum that was refractory to SurgicelTried multiple variations of Surgicel and Surgifoam but bleeding wouldn’t stopAttending evaluated and used silver nitrate and then aluminum nitrate with temporary relief ~ 16:00After family was with baby again, bleeding resumedResident used Surgicel and Surgifoam technique assisted by Neonatologist to stop bleeding; baby was monitored by resident for 1 hour and hemostasis was once again temporarily achievedCalled in ~ 19:00 for bleeding from same site refractory to multiple SurgicelsDecision was made to re-do Surgicel/Surgifoam application and leave baby in warmer without diaper to have hemostasis achieved and maintained
Timeline Of EventsDATE CLINICAL STATUS
05/01 Checked in on baby ~ 05:30 and hemostasis had been achieved, same application of Surgicel that had been applied since the previous night was not soaked through with bloodDischarged baby ~ 13:00 in great condition (no problems with urinating, feeding or vital signs)
05/02 Followed up in office, doing well, remnants of aluminum nitrate (black) still present but otherwise baby was in solid shape
Did I do this?
Was there something wrong with the way I
performed the circumcision?
Was it too early as well?
Review Of Pertinent Literature
World Health Organization: Manual For Early Infant Male Circumcision Under Local Anaesthesia, 2011
Review Of Pertinent Literature
In healthy, term, stable male newborns, circumcisions can be performed anywhere between 12-24 hours after birth, as long as the baby has voided
WHO and AAFP have the same stance I waited 16 hours after birth to perform
the circumcision 12-24 hours does not apply to SGA
babies, babies whose penile shaft length is < 1 cm, preterm babies, or those with a medical contraindication
Review Of Pertinent Literature
Removal of glandular adhesions should be done carefully, with frenulum on the ventral surface to be avoided
Up and down motion with straight hemostat prevents frenulum damage
I performed more side to side motions
Review Of Pertinent Literature
Gomco size 1.3 was accurate, no mismatch between bell and baseplate
Risk of bleeding? 1.0% (similar to Plastibell and Mogen techniques)
Most risk related to mismatching device parts
Review Of Pertinent Literature
After stem of the bell and foreskin are maneuvered through the hole in the baseplate, but before the device is clamped and tightened, the amount of penile shaft that remains below the clamp must be symmetrical and not stretched too tightly
This crucial step was likely misjudged because there was too much foreskin taken off from the ventral surface
Conclusions
When performing a circumcision, be careful around the frenulum and always check below the clamp!
If bleeding complication occurs, use Surgicel/Surgifoam, aluminum/silver nitrate, and worst case scenario, a suture (but obviously get help from Pediatrics/Neonatology unless you’ve done it before!); consider bleeding disorders for resistant cases
Adverse Events & Outcomes
CASE YES NO
Unexpected death X
Medical or surgical complication X
Delay in care X
Delay in diagnosis X
Prolonged medical care in setting of poor prognosis X
Other X
Factors Contributing To Adverse Outcome
FACTOR YES NO
Communication: ex. inadequate handoffs, incomplete clinical information
X
Coordination of care: ex. involving multiple servies and/or care sites
X
Volume of activity/workload: ex. increased clinical volume and/or perception of workload
X
Escalation of care: ex. delay or failure to involve more senior physician or nurse
X
Recognition of change in clinical status: ex. delay or failure to recognize changing clinical signs +/- symptoms
X
Other: surgical technique X
Root Cause Analysis: Fishbone Diagram
Resident Gomco vs. PlastibellCircumcision
Root Cause Analysis: Fishbone Diagram
Improved technique Either method can createcomplications
No death
Practice makes better
Comments & Discussion