Morbidity and Mortality Conference

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Morbidity and Mortality Conference

• 11/7/2006

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MM Conference

• CC RUQ to Periumbilical abdominal pain
• HPI RS- 87 y/o Male presented
• Two day history of RUQgtPerimbilical pain
• No previous episode
• Began as intermittent RUQ pain, progresses to
  include periumbilical region as well as become
  more constant
• Sharp pain with no radiation
• Pain graded as 7-8/10
• No true alleviating or aggravating factors

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MM Conference

• PMHx
• Gastric Ulcers
• HTN
• NIDDM
• Hypercholesterolemia
• PSHx
• Hemigastrectomy (25 yrs ago)

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MM Conference

• Meds
• Atenolol
• Lipitor
• Glipizide
• Lansoprazole
• Allergies
• NKDA

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MM Conference

• Vitals
• T max- 36.2 P-64 BP-126/54 O2 sat-98 RA
• Physical Exam
• HEENT- No Lymphadenopathy
• CVS- RRR
• LUNGS- Dull percussion b/l base
• ABD- Soft, ND, RUQgt Periumbilical tenderness, no
  rebound tenderness, scar, no masses

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MM Conference

• Labs
• WBC-6.0 -H/H-8.5/23.1 -Plts-162
• Na/K-138/3.9 -Cl/CO2-108/21 -Bun/Crea-12/1.1
• D.Bili-1.7 ALP-196 AST-107 ALT-143
• Amylase- 932 Lipase-1244 T. Bili-2.1

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MM Conference

• Radiology
• CT AP- Distended Gallbladder with calculus
  suggesting cholecystitis. Specific changes in
  regards to pancreatitis was not seen
• Ultrasound- Abdomen- Distended Gallbladder with
  sludge and gallstones. Possible cholecystitis.
  Common bile duct dilatation

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MM Conference
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MM Conference

• A/P
• 87 y/o Male with dx of probable Gallstone
  pancreatitis
• Plan
• Prophylactic abx started
• MRCP for evaluation of Common Bile Duct to
  decipher role for exploration
• OR for Cholecystectomy

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MM Conference

• HD2
• Pt felt better. Denied any RUQ or periumbilical
  pain
• Labs- normalizing
• D. Bili- 0.6 ALP-299 AST-31 ALT-75
  Amylase-101
• Lipase- 65 T.Bili- 1.1
• No desire for surgery or workup
• Discussed with patient and family about
  repercussion of discharge at this point
• Pt. discharged home

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MM Conference

• 14 hrs later
• Pt returns to the hospital with similar to
  previous RUQ pain
• Labs are again remarkable
• T. Bili 2.3 ALP-441 AST-40 ALT-79
  Amylase-501 Lipase-1,472 D.Bili-1.7
• Now agrees to surgical plan
• OR plan
• Open Cholecystectomy with possible intraoperative
  cholangiogram

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BON

• Postop Dx- Gallstone Pancreatitis
• Procedure- Open Cholecystectomy without
  introperative cholangiogram
• EBL- 400 cc
• Complicaton- hepatic bleeding- controlled
• Drain- 1 JP subhepatic
• Pt extubated and stable upon leaving OR to ICU

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Post Operative Course

• POD 1
• Hemodynamically stable
• H/H -8.4/24.3
• 1 unit PRBC given
• Responds appropriately with H/H- 9.3/28.5
• JP drainage- 100 cc/24 hrs
• POD 2
• Transferred to floor
• H/H trending down- 8.1/23.6
• 2 units of PRBc given
• Inappropriate response- H/H- 9.5/27.3
• Wound becomes saturated with blood
• H/H continues to trend down 8.5/25.7
• JP drain- 350 cc/12 hrs
• Contacted IR for Hepatic Artery embolization

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Post Operative Course

• POD3
• Pt given 2 Units PRBC
• Taken to OR emergently
• Intraoperatively
• 2 small vessels actively bleeding
• Ligated
• No other overt sites of bleeding
• Hemovac placed
• Pt sent to ICU postoperatively
• H/H 10.1/30.7
• Hemodynamically stable
• Minimal Drainage from Hemovac

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Post Operative Course

• POD4-6
• Maintaining H/H- 9-10/28-30
• OOB
• Tolerating Regular diet
• LFTs normal
• ABx continued

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Complication

• PostOp Bleeding
• What could be done differently?
• Earlier Reoperation