Complex Case Study

Face Sheet
Name: L. M.
MRN: 459324
Account Number: 56486
Date of Birth: 7/2/1984
Gender: Female
Race: Black, Hispanic
Date of Admission: 3/3
Date of Surgery: 3/8,3/10,3/12
Date of Discharge: 4/17
Time of Discharge: 15:36
Insurance Provider: Blue Cross Complete of Michigan

ED Provider Notes
03/02/2018 21:30 – 07:30
Ms. M. is a 34 y.o. with a history of asthma, ETOH abuse and pancreatitis, who presented to the ED with 4-day history of
abdominal pain, nausea and vomiting, and PO intolerance. She reports fever of up to 100.1 and chills. She reports
drinking a pint of alcohol and some beer about 4 days ago. She has not had any drinks since then. She usually consumes
two tall beers/day. Of note patient has also had upper respiratory infection like symptoms with rhinorrhea, congestion.
States that this has flared her asthma symptoms and she has been using her albuterol inhaler more than normal at
around 5-6 times a day.  Denies any significant cough or wheeze.

Signs of dehydration with dry mucous membranes, tachycardia, lactic acidosis, AKI. Likely etiology of current symptoms
is progression of her pancreatic pseudocyst with compression of stomach causing her current nausea, vomiting,
deceased PO intake and subsequent electrolyte abnormalities and dehydration. Antibiotics started for intra- abdominal
source of infection. Patient is not a candidate for surgery at this time. Patient admitted to the general medicine unit.

Past Medical History: albuterol controlled asthma, chronic pancreatitis

Past Surgical History: None
Family History: diabetes, mother
Social History: history of ETOH abuse, admits to smoking e-cigarettes and marijuana when drinking

Radiology
Date Imaging Study Result
3/2 CXR No acute cardiopulmonary process
22:30
3/2 CT Abdomen enlargement of the known pancreatic pseudocyst, causing deformity of the stomach and
23:30 duodenum.
3/6 CT Chest,  Interval development of small bilateral pleural effusions with accompanying atelectasis.
22:38 Abdomen, Pelvis Interval progression of abdominal and pelvic ascites with moderate abdominal and
pelvic fluid being present. Pseudocyst has decreased in size.
3/7 CT Chest Bilateral multifocal airspace opacities progressed from the chest x-ray of 03/06/2017.
15:24 Pulmonary edema, multifocal pneumonia and ARDS need to be considered.
3/8 Ultrasound 850 mL cloudy yellow/tan-colored fluid aspirated
15:46 guided
paracentesis
3/8 CXR 1. Dialysis catheter in the right atrium.
16:48 2. right IJ terminates in superior vena cava
2. Worsening severe bilateral airspace disease with pleural effusions.
3/12 CXR New right upper lobe infiltrate.
21:59
3/20 CT helical scan: Severe left upper lobe pneumonia with possible early cavitation/necrosis. There are also
18:38 Chest, Abd, multifocal upper lobe opacities that are probably infectious in nature and bilateral lower
pelvis lobe atelectasis/infiltrate. New pulmonary embolus in the left lower lobe.
3/22 CXR 1. Improved right basilar opacity
07:30 2. worsening persistent left consolidation consistent with pneumonia.     
3/24 CXR Bibasilar airspace disease much worse on the left remains suspicious for pneumonia.
07:38
4/13/201 Venous Duplex Thrombus surrounding the PICC line in upper arm brachial vein consistent with occlusive
7 Report DVT. Consistent with severe edema throughout arm.

Labs
Date Creatinine Glucose Albumi T-bil Lactic HCT WBC PLT INR Culture
n
3/2 1.8 97 2.5 1.3 5.8 35.5 9.2 251 1.1 Blood cx x2 – no growth
21:30
3/6 2.4 80 1.8 1.5 5.0 34 10.5 249 1.2 Urine cx 20,000 CFU
lactose fermenter
3/7 2.6 79 1.7 1.4 6.2 25.2 12.1 185 1.6

3/8 2.4 100 3.8 30 15.3 250 Paracentesis: Ascites

08:00 fluid + E.coli
3/12 1.8 75 2.1 29.2 11.8 190 Surgical path report
13:00
3/20 1.9 105 2.1 35.6 14.4 172 1.8

3/22 1.2 121 29.2 16.5 175

3/31 0.6 110 1.5 1.5 1.1 32.7 11.8 211 UA neg

Vital Signs
Date BP HR Temp Resp Ht Wt BMI
3/2 100/82 145 36.8C 18, 98% RA 63” 59kg 23.02
21:30
3/6 95/59 105 99.8 28

3/7 85/49 139 100.2 37, 82%RA

3/8 100/85 118 100.4 29 63” 73kg 28.51

08:00 100% vent
3/12 115/85 90 99 16, vent
13:00
3/20 118/90 95 100.1 28, vent

3/21 120/70 89 98 24, trach

Progress notes:
3/3 - 3/5 no acute events

3/6 Admitted to the SICU for tachycardia/tachypnea/hypoglycemia/hypotension on the medical floor. Concern for an
underlying infection and sepsis given her hypoglycemia, tachycardia and hypotension. On admission to the SICU patient
was resuscitated with fluids.

3/7 Rales in RLL with scattered expiratory wheezing, chronic cough. Start duonebs. Distended abdomen, mildly tender to
palpation, liver enlarged to palpation. Parenteral vancomycin therapy is being initiated for suspected intraabdominal
infection.  Currently on broad spectrum antibiotics, so no additional antibiotics needed to treat UTI and possible
pneumonia. Over the course of the day continued to decline, she had sustained hypotension, and vasopressors started
to keep MAP>65 and 2.5L fluid bolus given and decompensated prompting intubation. Septic shock - of unknown
infectious etiology.

3/8 Paracentesis was performed in IR which 3L of foul smelling pus was suctioned. Cultures pending. Patient was
evaluated by the surgical team and then taken to the OR at 09:30 for worsening clinical picture and hemodynamic
instability. She was found to have ruptured pseudocyst with purulent peritonitis. Abdomen left open, abthera vac
placed. Ms. M. was also evaluated by nephrology for hemodialysis and patient was placed on sustained low-efficiency
dialysis (SLED) for a significant period of time to assist with volume overload control.
OP NOTE #1 Procedure Date: 3/8
Procedure(s): laparotomy exploratory; cholecystectomy
Pre-operative Diagnosis: Pancreatitis, acute
Post-operative Diagnosis:  ruptured pseudocyst with purulent peritonitis; necrotic gallbladder
Anesthesia Type: General
Indications: This is a 34 y.o. female who is known to have pancreatitis with formation of pseudocysts. She
deteriorated clinically over the course of the last 24 hrs with becoming tachycardiac and tachypneaic. CT scan
showed that the pseudocyst has ruptured. She continued to have deterioration of her clinical status manifesting
with multiorgan failure. The abdominal fluid collection was tapped and showed murky fluid. We discussed with
the family our concerns for abdominal compartment syndrome and infected pseudocyst. We decided to take the
patient to the OR for exploratory laparotomy.  An extensive discussion of the procedure, the risks of surgery,
and the postoperative lifestyle changes to be successful were had. Consent was obtained.
Procedure: The patient was placed supine on the operating table. Lower extremity compression boots were
placed.  The abdomen was prepped and draped in a sterile fashion. A midline laparotomy was performed with
careful entrance into the peritoneal cavity.
Upon entry into the abdomen, we encountered close to 3L of foul smelling pus that was suctioned. Thorough
exploration was performed. The liver had no palpable abnormalities, had couple of capsular tears over the
inferior border of the left lobe that were controlled with Everest and packing. The pseudocyst anterior to the
stomach had a perforation that drained pus, that was suctioned. The pseudocyst wall was unroofed to ensure
adequate drainage and a piece was sent to pathology. The pseudocyst tract from anterior to the stomach
posteriorly and was in continuity and was rained completely.
Gallbladder was necrotic so decision was made to do cholecystectomy. We set up the self-retaining Bookwalter
retractor and obtained visualization of the gallbladder and liver. The gallbladder fundus was grasped and
retracted. The gallbladder was dissected from the liver fossa utilizing the fundus down technique. We carefully
dissected the cystic artery and duct using blunt dissection and tied the cystic artery proximally and distally using
0 silk. We used Metzenbaum scissors to divide the structure. We then noted the cystic duct going directly into
the gallbladder and placed two 0 silk ties and cut above the ties. The gallbladder was removed and passed off as
a specimen for pathology. The small intestine was inspected and palpated from the ligament of Treitz to the
ileocecal valve and noted to be normal, there was a small 0.5cm X0.5cm serosal tear noted in the terminal ileum
upon manual blunt dissection of the adhesions that was lamberted with 3-0 silk sutures. The appendix and
entire colon were normal. The uterus and ovaries were inspected and found to be within normal limits.  
Abdominal irrigation was carried with 9L of warm saline.  Packs around the liver were kept in place and an
Abthera Vac was placed. The patient was returned to the ICU in critical condition.
Complications:  None.
 Disposition: SICU- intubated and on pressors
Condition: critical on pressors

3/10 To OR today at 10am for exploration, washout, and abthera vac change
OP NOTE #2 Procedure Date: 3/10
Procedure(s): 1) reopening of laparotomy 2) small bowel resection 3) drain placement 4) abthera wound vac
placement
Pre-operative Diagnosis: Infected pseudocyst of pancreas
Post-operative Diagnosis:  Infected pseudocyst of pancreas; Small bowel ischemia
Anesthesia Type: General
Estimated Blood Loss: 200 mL

Indications: 34 y.o. female who is known to have pancreatitis with formation of pseudocysts. She deteriorated
clinically on 3/8 and was taken to OR for abdominal exploration. At that time, 3L of foul smelling pus that was
suctioned.
Procedure: The patient was brought to the Operating Room and placed on the operating table in the supine
position. Patient was already intubated, had foley catheter and was on scheduled antibiotics. Bilateral sequential
compression devices were in place. Abthera wound vac was taken down and the abdomen was prepped and
draped in the usual sterile manner.  A critical pause was carried out. Sponges that were intentionally packed
under liver were removed. No pus was noted. We irrigated left and right gutters with 6L of fluids.  
Small bowel was inspected and there is an area of ileum that was noted to be grossly necrotic with a sharp
demarcation at the terminal ileum at the previous suture repair. The entire small bowel was run from the
ligament of Treitz to the cecum and the only area of necrosis was approximately 1-2 feet long of ileum including
most of the terminal ileum. A GIA stapler blue load was used to staple across the terminal ileum at the
demarcated portion leaving approximately 4 cm of terminal ileum that was healthy. Proximally the small bowel
was stapled across in a similar fashion just proximal to the area of demarcation along the healthy pink appearing
bowel. LigaSure device is used to take the mesentery. The specimen was removed.
The decision was made to leave the patient who is in critical condition and on 30 mics of Levophed during the
procedure in discontinuity. We irrigated the RUQ with 3L of sterile normal saline and confirmed hemostasis. We
then placed 2 19F JP drains in the pancreatic pseudocysts and were then secured to skin to left of wound using
2.0 nylons. An Abthera sponge was then placed. The patient was returned to the ICU in critical condition.

3/12 patient was taken back to the operating room for wound closure at 0730 with out of room time at 1030am. Over
the following few days, patient's ventilator was adjusted according to blood gas results, and patient’s respiratory status
was stable.
OP NOTE #3 Procedure Date: 3/12
Procedure: Planned Re-Exploratory Laparotomy with Primary Fascial Closure of the Abdomen; ostomy
creation
Pre-operative Diagnosis: Pancreatic pseudocyst
Post-operative Diagnosis:  Pancreatic pseudocyst; Small bowel ischemia
Anesthesia Type: General
Estimated Blood Loss: minimal
Indications: This is a 34 y.o. female who previously underwent emergent laparotomy for abdominal
compartment syndrome secondary to infected pancreatic pseudocyst required a planned laparotomy after the
abdomen was left open with a negative pressure wound vac over the last 48 hours and improved hemodynamic
status.  Attempted fascial closure was recommended to further prevent loss of domain and risk of fistula.  The
indications, risks, and possible complications of the procedure were explained to the patient who voiced
understanding and wished to proceed with the surgery. The natural history of the disease process was explained
to the family as the patient was intubated.  Risks including, but not limited to, bleeding, infection, anesthesia
complication, DVT, PE, MI, CVA, failure of operation, hernia, need for re-operation and even death were all
discussed.
Procedure Details:  The patient was taken to the Operating Room and placed on the Operating Table in supine
position. After general anesthesia was obtained, the abdomen was prepped and draped in a sterile manner.
 Bilateral sequential compression boots were in place.  A Foley catheter was already in place.  A nasogastric tube
was already in place.  The patient had been receiving antibiotics prior to incision.  A critical pause was carried
out.  
The ABThera wound vac was removed. The peritoneum was entered carefully to avoid injury to the intra-
abdominal organs. Copious warm irrigation was used to break up lose adhesions and the abdomen was explored
looking for any retained instruments or sponges from the prior operation and none other were found. The
stomach was adhered with omentum and fused with the pseudocyst capsule.  The ascending, transverse and
descending colon were healthy.  
The patient bled easily from the friable tissues that were tenuous from severe inflammation.  Two JP drains were
seen entering the left flank and into the lesser sac.  We did not feel comfortable bringing up a feeding tube
because we could not identify the entire anatomy of the stomach.   
The area of the proximal small bowel resection had approximately 1 foot of bowel that was questionable
therefore the decision was made to resect this. This is done with Endo GIA the mesentery was taken with the
LigaSure. Specimen was passed off. A 2 cm circular incision was made in the right lower quadrant carried down
to the fascia which was incised 2 fingerbreadths was passed to the fascia and the proximal segment of ileum was
brought through this for an ileostomy.
The abdominal contents were placed back with in the abdominal cavity in their natural orientation.  The skin was
undermined to release the anterior fascia and better identify healthy edges of the fascia.  The fascia was then
closed using looped Maxon 1 sutures. In a running fashion.  Hemostasis was achieved with electrocautery and
the wound copiously irrigated with normal saline. The skin was left open.  Then my attention was turned to the
ileostomy it was created with brooking stitches using 3-0 Vicryl sutures followed by simple interrupted 3-0 Vicryl
sutures. The ostomy appliance was applied. A sterile dressing was then applied and covered with sterile
dressings.  All sponge, instrument, and needle counts were correct.  Xray was taken as protocol and again
confirmed to retained instruments.  Airway pressures remained stable at the end of the case.  The patient was
taken to the Surgical Intensive Care Unit on pressors in good condition.  The family was updated upon
completion of the case.

SURG PATH FINAL REPORT: OR Case #3, 3/12

GROSS: Received in formalin, labeled "small bowel," is a 30 cm in length, 4 cm in circumference small bowel.  A
0.5 cm serosal defect with suture is present in the distal portion of the small bowel, 4-5 cm from distal margin. 
The mucosa surrounding the defect is slightly deeper in color and hemorrhagic. The serosa is brown-gray. 
Attached mesenteric fat runs the length of the specimen up to 4 cm. 
DIAGNOSIS: Small bowel, resection: Severe acute ischemic enteritis with patchy mucosal necrosis.

3/20 CT was completed for persistent fever and elevated white cell count despite being on antibiotics. CT Thorax
exhibited concern for multifocal pneumonia, LUL cavitation/necrosis, and LLL PE. Due to PE finding patient was placed
on heparin gtt.

3/21 Patient underwent a tracheostomy due to prolong ventilator dependence and poor pulmonary hygiene with
increased secretions. Bronchoscopy performed after tracheostomy placement that revealed purulent secretions in the
airway.

4/7 Tolerating tube feeding, continues to fail daily CPAP trials, JP drains removed. Removed from SLED for the first time
since it was placed.

4/13 Severe edema throughout arm. Thrombus surrounding the PICC line in upper arm brachial vein consistent with
occlusive DVT. Anticoagulation therapy initiated.

4/14 completed treatment for pneumonia.

4/17 discharge to LTAC.