This is like watching a car accident in slow motion. Pain attributed to “anxiety.” Pain out of proportion to exam. Sitting on a lactate of 8.8 for 12 hours. PE used as a scapegoat to the point of starting a heparin drip and NO scan. This is a great case for new ICU attendings to learn from.
I’m curious from surgeons what postop day 0 pain would suggest in this case - perforation you would think would take at least a day to manifest. So I’m not sure what pacu 10/10 pain after RnY would be related to?
That's interesting about the timing of perforation manifestation. Maybe things move faster if there is feculent material pressing through a dehiscence. Maybe her abdomen was already compromised leading into the surgery - we don't know the reason for the revision in the first place.
I hate this idea that an emergent CT scan needs to wait for the pt to be more stable. Sometimes, they aren’t getting any more stable. Maybe a doctor even needs to accompany the pt to the scanner. But the scan needs to get done. In this case, it would have definitely made the diagnosis.
At least in the ER, the whole "dont send an unstable patient to radiology" was useful advice when radiology was on the opposite end of the hospital. But now the scanners are super close and we can send a doctor and nurse along with the patient, so the advice probably doesn't hold.
lol reminds me of oral boards where for some reason the CT scanner is down every other case (but xray never is, even though iv definitely had CTs get done faster than X-rays)
If I waited for every patient head injured patient who was herniating to "become stable" while training as a neurosurgical resident, they all would have died. Doctors need to pack up their egos & take the patient to be scanned. Push the damn stretcher.
Free air is common after laparoscopy and is due to the pneumoperitoneum developed during the case. I find it strange that it was mentioned as a critique of the management. Free air means viscus perforation in the pre-operative setting, e.g. sigmoid perforation as a complication of diverticulitis. The failure to return to the OR or obtaining earlier imaging is more concerning based on the vitals, symptoms, exam, and lab work.
Totally agree with Gregor on this one. Strange for a chart reviewer whose listed qualifications include professor of laparoscopic surgery to fault the poor Chief Resident who’s looking at a plain film of a patient operated with full pneumoperitoneum barely more than 24 hours earlier? If I’d been him/her, I would’ve *expected* to see residual air under the diaphragm. The harder part to overlook is the early high lactate, RUQ guarding, and hypotension not prompting Dr. Z to go back to the OR much sooner.
Tremendous obesity fills the peritoneal cavity with fat, impeding visualization of everything. I wonder if the original surgeon's reliance on a laparoscopic exploration when she first leaked was an additional error of judgement. If he had opened her belly the wider exposure may have revealed the true extent of the problem. I think minimalistic approaches are not always suitable in emergency situations, re-operations, cases in the middle of the night with personnel unfamiliar with the equipment, if your dedicated surgical tech is absent, etc.
This business about getting a CT when the patient is stable enough has come up in other cases. Whatever process instigates shock will simply progress without intervention, and much intervention can be implemented without or before CT. This patient had abnormal VS and abdominal tenderness shortly after her intestines were sliced and replumbed. I'm sure peritonitis was discussed early on, but unfortunately, they didn't explore her abdomen right away (maybe that wasn't feasible for reasons that aren't clear from the info we have). As for the echocardiogram findings, that might have been a distraction - heart failure, perhaps acute (decompensated shock) on chronic (severe obesity) should not have been surprising. Maybe they were doing it to evaluate for PE?
In a patient with severe lactic acidosis and pain after complicated abdominal surgery, do the CT, especially if the patient is unstable.
The only reason to defer CT is if you're going straight to OR, which is what our surgeons would likely do in such a case. This was a perf, but CT can sometimes underestimate things like ischemic bowel.
This is like watching a car accident in slow motion. Pain attributed to “anxiety.” Pain out of proportion to exam. Sitting on a lactate of 8.8 for 12 hours. PE used as a scapegoat to the point of starting a heparin drip and NO scan. This is a great case for new ICU attendings to learn from.
I’m curious from surgeons what postop day 0 pain would suggest in this case - perforation you would think would take at least a day to manifest. So I’m not sure what pacu 10/10 pain after RnY would be related to?
That's interesting about the timing of perforation manifestation. Maybe things move faster if there is feculent material pressing through a dehiscence. Maybe her abdomen was already compromised leading into the surgery - we don't know the reason for the revision in the first place.
I hate this idea that an emergent CT scan needs to wait for the pt to be more stable. Sometimes, they aren’t getting any more stable. Maybe a doctor even needs to accompany the pt to the scanner. But the scan needs to get done. In this case, it would have definitely made the diagnosis.
At least in the ER, the whole "dont send an unstable patient to radiology" was useful advice when radiology was on the opposite end of the hospital. But now the scanners are super close and we can send a doctor and nurse along with the patient, so the advice probably doesn't hold.
lol reminds me of oral boards where for some reason the CT scanner is down every other case (but xray never is, even though iv definitely had CTs get done faster than X-rays)
If I waited for every patient head injured patient who was herniating to "become stable" while training as a neurosurgical resident, they all would have died. Doctors need to pack up their egos & take the patient to be scanned. Push the damn stretcher.
Free air is common after laparoscopy and is due to the pneumoperitoneum developed during the case. I find it strange that it was mentioned as a critique of the management. Free air means viscus perforation in the pre-operative setting, e.g. sigmoid perforation as a complication of diverticulitis. The failure to return to the OR or obtaining earlier imaging is more concerning based on the vitals, symptoms, exam, and lab work.
Totally agree with Gregor on this one. Strange for a chart reviewer whose listed qualifications include professor of laparoscopic surgery to fault the poor Chief Resident who’s looking at a plain film of a patient operated with full pneumoperitoneum barely more than 24 hours earlier? If I’d been him/her, I would’ve *expected* to see residual air under the diaphragm. The harder part to overlook is the early high lactate, RUQ guarding, and hypotension not prompting Dr. Z to go back to the OR much sooner.
Tremendous obesity fills the peritoneal cavity with fat, impeding visualization of everything. I wonder if the original surgeon's reliance on a laparoscopic exploration when she first leaked was an additional error of judgement. If he had opened her belly the wider exposure may have revealed the true extent of the problem. I think minimalistic approaches are not always suitable in emergency situations, re-operations, cases in the middle of the night with personnel unfamiliar with the equipment, if your dedicated surgical tech is absent, etc.
This business about getting a CT when the patient is stable enough has come up in other cases. Whatever process instigates shock will simply progress without intervention, and much intervention can be implemented without or before CT. This patient had abnormal VS and abdominal tenderness shortly after her intestines were sliced and replumbed. I'm sure peritonitis was discussed early on, but unfortunately, they didn't explore her abdomen right away (maybe that wasn't feasible for reasons that aren't clear from the info we have). As for the echocardiogram findings, that might have been a distraction - heart failure, perhaps acute (decompensated shock) on chronic (severe obesity) should not have been surprising. Maybe they were doing it to evaluate for PE?
I found it surprising that PE was being evaluated when the patient's abdomen was screaming "take a look"
In these surgical complication medmal cases it'd be great to have diagrams of the anatomy described.
True, the Roux-en-Y anatomy in particular is a bit challenging to grasp if you don't think about it regularly.
In a patient with severe lactic acidosis and pain after complicated abdominal surgery, do the CT, especially if the patient is unstable.
The only reason to defer CT is if you're going straight to OR, which is what our surgeons would likely do in such a case. This was a perf, but CT can sometimes underestimate things like ischemic bowel.