Veterans Affairs - WBAndrew Young

Introduction

•Complication: Death

•Procedure: Small bowel resection

•Primary Diagnosis: Intra-abdominal abscess

WB

•73yo man with left lower quadrant pain x 3 weeks▫Associated with nausea, no emesis▫Decreased PO intake over last several days

with worsening pain▫Seen by PCP the week prior and CT

ordered and scheduled for next week•No fevers or chills•No recent weight loss

WB

•PMeHx: CAD, DM, HTN, XOL, PVD, Angina, COPD

•PSurgHx: CABG in 1998, L iliac angioplasty

•Meds: Pletal, HCTZ, Isosorbide, NTG, Lisinopril, Norvasc, ASA 81, Plavix

•Soc: 1.5 ppd

Exam

•98.6 80 129/50 18 92% RA•NAD, AAOx3•Heart: RRR•Lung: CTA•Abd: soft. Mild TTP in LLQ. No rebound or

guarding. +BS. •Rectal: no blood, masses.

Laboratory Data:• Na: 132• K: 3.1• Cl: 93• CO2: 31• BUN: 15• Cr: 1.2• Glucose: 120• Ca: 8.3

• ECG: ST dep in lateral leads

• (unchanged)

• WBC: 7.7• Hgb: 11.0• Plt: 196

• Troponin: 0.4 1.04

• Lactate: 1.8

• ECHO 2010: EF 60%

Initial treatment

•Consult cardiology regarding probably ACS▫Load with ASA/Plavix

•Cardiology stated likely demand due to intra-abdominal process.

•Admit to medicine▫Requested CT scan for r/o mesenteric

ischemia

Operating Room

•Exploration:▫Abscess walled off with omentum▫Area of necrosis 1x1 cm in mesentery

which was contiguous with lumen▫Kissing area in nearby loop with 0.5cm

area of necrosis and purulent drainage•Procedure:

▫Small bowel resection – 13cm▫Primary anastomosis

Pathology

•Mucosal ulceration•Transmural perforation•Acute on chronic inflammation•Acute serositis

•Culture – pan-sensitive E. Coli

Post Operative Course

•Extubated post operatively•POD 1

▫Hemodynamically stable▫Out of bed to chair▫Beta-blocker begun per cardiology

• POD 2▫Noted low urine output in AM▫Hypotension to 80-100 SBP. ▫Fluid challenge▫Central line placed – CVP 9▫Respiratory distress – intubated▫Troponin ~ 30; ▫ECHO – LV severely reduced function – EF

20%▫Cardiology paged – declined intervention▫V-tach V-fib

Cardiac arrest – coded and expired

Analysis of Complication

•Avoidable? ▫Possibly – PCI

•Would avoiding the complication change the outcome for the patient?▫Yes

•Contributing factors:▫CAD, Previous CABG, Smoker

Post-operative MI•Troponin is preferred bio-marker

▫AHA, ACC, ESC, WHF ▫ECG and symptoms may not be reliable

•When to check?▫75% of MI occur within 48 hours of surgery▫65% are asymptomatic

•Supportive care:▫Decrease cardiac oxygen demand

Beta blocker & alpha 2 agonists▫Thrombolysis, CABG, PCI

Thygesen et al. Universal definition of Myocardial Infarction. Circulation. 2007 Nov 27;116(22):2634-53. Epub 2007 Oct 19Deveraux et al. Characteristic and Short-Term Prognosis of Perioperative Infarction in Patients Undergoing Noncardiac Surgery. Ann Intern Med. 2011; 154:523-528.Chong et al. Incidence of post-operative troponin I rises and 1-year mortality after emergency orthopaedic surgery in older patients. Age and Ageing 2009; 38: 168-174.

Complication

•Myocardial infarction▫Cardiogenic shock

Arrhythmia Death

•What to do different?

Cardiac Risk – Elective cases•50k patients will have perioperative MI•Identify patients at elevated risk:

▫Unstable coronary syndromes: unstable angina, recent MI

▫Poor functional status, renal insufficiency, CHF, DM, ischemic heart disease

•Versus those that are not at elevated risk▫Asymptomatic patients with one risk factor

(family history of CAD, smoking, high cholesterol, obesity, inactivity) *except DM

Fliesher LA et al. Clinical Practice. Lowering cardiac risk in non cardiac surgery. NEJM. 2001Mangano et al. Effects of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. NEJM. 1996