1. Morbidity and Mortality Review Moderator: Dr Noraslawati Razak Prepared by: Dr Mohd Azinuddin Abdullah Dr Tengku Abdul Kadir Tengku Zainal Abidin

2. Mr A, 44 years/M/Male Previously no known medical illness Presented with: Abdominal Pain since x 1/52 Colicky in nature, pain score 7/10 Distended abdomen since x 1/52 Vomiting x 1/7 (more than 10 episodes) No BO, no flatus 1/7 Minimal bowel output since x 1/12 ago

3. On Examination GCS: 15/15, not tachypneic, mild dehydrated, warm periphery, CRT < 2 second. BP: 147/84, HR: 82, regular, good pulse volume RR: 10, Temp: 37 sPO2: 100 % under RA Lung: clear CVS: S1S2, no murmur P/A: distended, bowel sound sluggish Per Rectum: empty rectum, no mass palpable Bed Side Ultrasound: liver homogenous, gallbladder not distended, GB wall not thickened

6. Impression: Intestinal Obstruction Plan: Insert ryle’s tube to refer surgical team IV drip 1 pint NS VS monitoring every 15 minutes

7. Differential Diagnosis of IO Mechanical: – Adhesion – Gallstones – Hernias – Impacted stool – Intussusception – Tumours – Volvulus Ileus: – Gastroenteritis – Electrolyte imbalance – Mesenteric Ischemia – Intraabdominal infection – Use of narcotics – Kidney or lung disease

8. Reviewed by general surgical team documented at 2.35 am at ED Impression: Intestinal Obstruction 2 nd Volvolus Plan : for Exploratory Laparatomy KIV proceed. To notify operation early morning tomorrow KNBM Strict I/O charting IV Cefobid and IV Flagyl IV Tramadol 50 mg TDS To pull out CVP 7 cm For CVP reading

9. Patient review at surgical ward At 2:42 am O/E: Patient’s condition stable Explained to patient regarding current condition and plan for exp laparotomy kiv proceed. Anaesth MO was informed reg plan for op cm, asked for pttk inr and to inform back cm. Surgical plan: For Blood ix and notify ot cm.

10. How much fluid given and how much patient’s intake and output was not documented.

11. 7/5/2014 @ 7:30 am case was notified to anaesth MO, noted pttk: 91, plan for repeat coag profile stat and to inform back. Surgical plan: to repeat pttk and request 4 units FFP. S/T MO blood bank, to rule out cause of isolated prolonged aptt 1 st. Not for FFP yet.

12. 7/5/2014 @ 7:40 am, patient became tachypnoeic, restless and impending collapsed. Bp: 80/50 HR:110 spo2:99% under RA. Referred anaesth for elective intubation

13. Anaesth Referral attending Upon attending: Patient was very tachypnoeic, in severe pain. Unable to speak, arousable, obey simple commands. Abdominal grossly distended. Intubated w ETT sized 7.5 anchored @ 20cm. Given : iv fentanyl 100mcg, iv mida 2mg, iv STP 50mg, iv suxa 100mg, Post intubation: BP normal, HR: 100-110.

14. Posted for Exploratory Laparotomy. Upon receiving patient at air lock around 10am, no BP monitoring, Spo2: 100% on manual bagging. Patient : intubated,sedated, dehydrated ++ Connected to ventilator and other standard monitoring: BP: 127/96 HR: 96 Ventilator setting: VT: 450, R:24, PEEP:10 fio2:1

15. Intraoperatively: Hemodynamically unstable: started on tripple inotropes – Ivi norad: 20mls/h (single strength) – Ivi dobu 10mls/h – Ivi adrenaline 10mls/h Medications given: – Iv morphine 5mg, iv ca gluconate 1g, iv nahco3 150mmol, 1 cycle lyctic cocktail. IV fluid given: – 11 pints gelafundin, 6 pints sterofundin, 4 pints NS, 2 pints WB, 4 units FFP. Blood loss minimal, Urine output: minimal.

16. ABG intra-operative @10:59 am: ph 6.809 pco2:52.1 po2:517 hb:9.5 K:6.5 Lac:10.7 be:-23.4 hco3:6.6 @11:40 am: 7.012 pco2:39.8 po2:460 hb:5.8 lact:10.4 be:-19.3 hco3:9.5

17. Operative findings: Dilated, gangrenous from descending colon to sigmoid. Dilated and dusky small bowel and caecum, ascending & transverse colon twisted at the sigmoid x 1. Dilated sigmoid perforate upon manipulation.

19. Post OP Patient was transferred to ICU for further care. On tripple inotropic support. BP still on the lowish side. – Ivi norad 25mls/h – Ivi adrenaline 15mls/h – Ivi dobu 15mls/h

20. In ICU, Patient deteriorating,refractory shock on four inotropic supports. BP: 58/28 HR:85 ABG: Severe met acidosis, Lac: 12, K:3.5 Informed DIL to family members Pronounced death on 7/5/2014 at 5:55pm COD: Septicaemic shock 2ry to intestinal infection w sigmoid vulvulus

22. Blood ix: FBC

23. Blood ix: BUSEC

24. Blood Ix: PTTK Inr

25. Points of discussion: Timing for surgery – management of colonic volvulus. Dynamic of sepsis and deterioration. Renal failure and abdominal compartment syndrome.

26. Management of Colonic Vulvulus http://emedicine.medscape.com