PERI-OPERATIVE MORTALITY REVIEW

MINISTRY OF HEALTH MALAYSIA (SURGICAL FORM)

INTRODUCTION

This form is to be filled for all deaths occurring within total length of hospital
stay following a surgical or gynecological procedure performed under general
or regional anesthesia. Also included are death in operation theatre prior to
the induction of anaesthesia.

Kindly read the e-POMR Guideline 01 for instructions to fill-in and submit the form. Thank you.

CASE PROFILE
--------------------------------------------------------------------------------------------- POMR COORDINATOR -----------------------------------------------------------------------------------

Hospital Code HTJ1111573 Case Code

Date of Birth 21/04/1985 Date of Mortality 31/05/2022

Date of admission 27/04/2022 Ethnicity Malay

Gender Male
Female

Age 37 Years 0 Months 6 Days

Date of form issued 17/6/2022

Co-ordinator's
Initial

------------------------------------------------------------------------------------------ PRIMARY DEPARTMENT -----------------------------------------------------------------------------------

Primary Department Orthopedic

Department(s) General Surgery Paediatric Surgery

involved in the
Cardiothoracic surgery Urology
patient management
ICU/ HDW/ CCU Anesthesiology
Plastic Surgery Gynecology
Obstetric Orthopedic
Ophthalmology ENT
Neurosurgical Endocrine surgery
Vascular surgery Emergency & Trauma
Medical
Others Nephro
 Pre-operative status

Co-morbid Factor Diabetes Mellitus Coronary Artery Disease

Malignancy Cerebrovascular accident (CVA)
Hypertension Left Ventricular dysfunction
Heart Failure Coma
Severe Head Injury Chronic Lung Disease
Chronic Liver Disease Chronic Kidney Disease
AIDS Valvular Heart Disease
Uncontrolled Asthma Anaemia
Others ASD with pulmonary hypertension in failure,Bronchial Asthma

Risk Factor Prematurity Smoking Obstructive Sleep Apnoea

Cachexia IVDU Cardiac Arrhythmia
Obesity Bed-ridden
Dehydration Hypovolaemia
Congenital abnormalities Severe Sepsis
Others

Blood Pressure Systole 117 mmHg Diastole 65 mmHg

Pulse Rate 89 bpm Temp 37 'C Respiration 22 Breath/min

Weight 130 Kg

Birth weight* Kg Gestational Age Full term

(At Birth)
Pre term weeks

Signs on admission

Jaundice Pale Dehydrated Cachexic Cyanosed

Intubated Others
SOB,URTI

GCS for Head Injury / Coma :

Eyes ( /4) 4 Verbal ( /5 ) 5 Motor ( /6) 6

T
Total GCS ( /15) 15
C
For Trauma,
significant injury
sustained
Instruction : Click on the Calculate RTS button to get the proper RTS value

Revised Trauma 7.8408

Score (if applicable) % Probability of Survival
98.8
 Investigations

FBC On Admission Pre-operative

Hb 12.2 g/dl Hb 9.6 g/dl

TWC 12.0 x103/µL TWC 11.4 x103/µL

Platelet 187 x103/µL Platelet 238 x103/µL

Renal Profile On Admission Pre-operative

Na+ 127 mmol/L Na+ 137 mmol/L

K+ 3.65 mmol/L K+ 4.03 mmol/L

Urea 14.53 mmol/L Urea 22.1 mmol/L

Se. Creatinine 358 µmol/L Se. Creatinine 426 µmol/L

Blood Sugar On Admission Pre-operative

RBS 28 mmol/L RBS 9 mmol/L

Coagulation Profile On Admission Pre-operative

INR 1.14 Ratio INR 1.24 Ratio

PT 12.4 Sec PT 13.6 Sec

APTT 45.1 Sec APTT 39.5 Sec

On Admission Pre-operative

ABG -pH : 7.4

pco2 : 35
ABG --pH : 7.492
pco2 : 37.9
po2 : 257 po2 : 79.9
HCO : 18 HCO : 28.4
Lac : 2.98 Lac : 0.78

On Admission Pre-operative

ECG Normal Normal

Abnormal Abnormal

Details RBBB with right axis deviation concurrent with

bifasicular block
Details

X-rays / imaging

On Admission Pre-operative

Details clear Details clear

(If applicable) (If applicable)
Other investigations

On Admission Pre-operative

Details - Details -

ASA Category 4

FIRST OPERATION

If more than 1 surgery performed, kindly indicate in the narrative report

Date of First 28/04/2022

Operation

Time started 13:57 Time ended 15:37

Operation category Elective Type of anesthesia LA

Emergency GA
Regional
Other

Pre-Operative Infected Left Diabetic Foot Ulcer with OM

diagnosis

Post-Operative Necrotising Fasciitis of left foot

diagnosis

Operative Procedure wound debridement and ray amputation of left big toe

Number of surgery 2
during this admission
before mortality

Surgeon Status

Specialist Clinical Specialist ( Under Gazzettement )

MO HO

Supervisor Yes No
Informed?

Location of In OT In Hospital At Home

Supervisor
Not Available
Anaesthetist Status

Specialist Clinical Specialist ( Under Gazzettement )

MO HO
AMO

Intra-operative complications?

None Excessive Bleeding Contamination

Other organ injury Hypotension Anesthesia adverse event
Others

POST OPERATIVE CARE

Managed in ICU/ Yes No Ventilated Post-Op? Yes

HDW
No

Post-Op Complication

None Hypotension Bleeding

Nausea/Vomiting Reintubation Atelectasis
Pneumonia Hypothermia Ileus
Anastomotic Leak Sepsis Surgical Site Infection
Wound Breakdown Multi-organ Failure Superficial thrombophlebitis
DIVC Deep Vein Thrombosis Pulmonary Embolism
CVA Pressure Ulcer Acute Urinary Retention
Renal Failure Post Spinal Headache Transfusion Reaction
Adverse Drug Reaction Seizures Others

FINAL OPERATION

Date of Final 04/05/2022

Operation

Time started 20:47 Time ended 22:44

Operation category Elective Type of anesthesia LA

Emergency GA
Regional
Other

Pre-Operative Necrotising Fasciitis of left foot

diagnosis

Post-Operative Necrotising Fasciitis of left foot

diagnosis

Operative Procedure left below knee amputation

Surgeon Status

Specialist Clinical Specialist ( Under Gazzettement )

MO HO

Supervisor Yes No
Informed?

Location of In OT In Hospital At Home

Supervisor
Not Available

Anaesthetist Status

Specialist Clinical Specialist ( Under Gazzettement )

MO HO
AMO

Intra-operative complications?

None Excessive Bleeding Contamination

Other organ injury Hypotension Anesthesia adverse event
Others

POST OPERATIVE CARE

Managed in ICU/ Yes No Ventilated Post-Op? Yes

HDW
No

Post-Op Complication
None Hypotension Bleeding
Nausea/Vomiting Reintubation Atelectasis
Pneumonia Hypothermia Ileus
Anastomotic Leak Sepsis Surgical Site Infection
Wound Breakdown Multi-organ Failure Superficial thrombophlebitis
DIVC Deep Vein Thrombosis Pulmonary Embolism
CVA Pressure Ulcer Acute Urinary Retention
Renal Failure Post Spinal Headache Transfusion Reaction
Adverse Drug Reaction Seizures Others
 DEATH

Place of Death

Wad ICU/HDW OT/Recovery room

Post Mortem? Done Not Done

Summary of Post -
Mortem findings (If
post-mortem done)

Cause of Death multiorgan failure secondary to sepsis

Narrative Report

Give a summary of the sequence of events leading to and contributing to the death.

Highlight the following points:

a) Presenting signs and symptoms
b) Factors that led to the deterioration and death of the patient.

DO NOT WRITE NAMES OF HOSPITALS OR PERSONS INVOLVED

37/malay/male
ADL independent previously
Admitted since 27/4/22

U/L
1. Bronchial asthma
2. Diabetes Mellitus
3. Hypertension
4. ASD with pulmonary hypertension in failure
5.Post covid Cat 2b
6.H/o admission in Jan 2022 for decompensated CCF secondary to non compliance to ROF

Initially admitted to ICU intubated from ED for

1. cardiogenic shock 2' to acute decompesated heart failure with pulmonary edeme 2' to pnemonia and non compliance to ROF
2. compesated metabolic acidosis 2' to 1

was admitted initially to general ward then subsequently tranferred to ICU 28/04/2022 for critical care for a month
until 29/5/2022.He was then tranferred back to general ward

Issue upon death

1. CRE Klebsiella pneumoniae bacteremia

Blood C&S: (6/5)(11/5): CRE Klebsiella pneumoniae
Blood C&S: (14/5)(16/5)(17/5)(19/5): NG
Abx hx: IV meropenem 2g OD (9/5-17/5)
IV Polymycin B 1000000BD (9/5-17/5)

2) Left foot Necrotising fascitis

-initial presentation upon referral(swelling of left foot,erythematous,warm,firm,dusky discolouration of great,2nd and 3rd toes,ulcer at plantar aspect,a/w hemopurulent discharge.Proceed with ray
amputation of left great toe.On 3/5/22 noted further progression of wound(necrotic edges with pus discharge,pocket extending to hindfoot,multiple blisters over plantar aspect.
Done BKA on 4/5/2022,D10 of admission
Tissue & bone C&S (28/4): strep agalactiae
EOD dressing of left BKA stump
Abx hx:IV Augmentin 1.2g TDS x 2 days
IV Unasyn 2g TDS x 2/7
IV Clindamycin 600mg TDS x 5 days
IV Cloxacillin 2g QID x 2 days
He was initially covered with broad spectrum abx,then abx changed accordingly to blood,bone and tissue C+S accordingly

3)Sacral & b/l gluteal sore (ungradable)

Under wound team
EOD dressing with hydrosyn + gel + foam

4)Acute decompensated Heart failure with pulmonary edema secondary to pneumonia with non compliance to ROF
ECHO(13/5): EF 61%, normal chamber size, no hypokinetic area, mild LVH

5)non oligouric AKI secondary to CRE Klebsiella pneumoniae bacteremia

Last SLEDD 24/5

6)pulmonary embolism
ctpa 29/5/22
Impression:
Right distal main pulmonary artery thromboembolism

7)Poor GCS recovery since D17-20 of admission

GCS ranging from 7-10,progressively detoriating
Trachy done on 14/5

on 31/05/22
Informed by SN, patient had no chest rise.
Attended STAT at 4.59am
Informed MO oncall,at 5.00am

Upon examination
E1VTM1, no spontaneous breathing, no chest rise
Pulse not palpable
Noted BP 53/25, PR & SPO2 unrecordable
Cardiac monitoring shows straight line
Lungs no breath sound heard

CPR commenced at 5.00pm, done for 30 mins

Given IV adrenaline 1mg x3
Called pt's sister, explained regarding current situation, pt's sister understood
Death Category :
CPR stopped at 5.32am
Cardiac monitor shows flat line
1 2 3
Pupils fixed dilated, no Spontaneous Breathing, no pulse palpable 4A 4B 5 6 7
Death pronounced at 5.32am (31/5/22)
Cause of death: multiorgan failure secondary to sepsis
Date 17/06/2022

Place your attachments here :

Comments by Head of Department/Unit or Specialist In-charge

Highlight if there were any :

i. Inappropriateness of treatment
ii. Delays or problems during the management
iii. Areas that could have been improved

None

Death Category :

1 2 3 4A 4B 5 6 7

If you were to manage a similar case in the future, suggest how would you do it differently for a better outcome?

No Different Don't Know

Possible changes in management that could have given a better outcome

Date 16/06/2022
Verified by pdfFiller

HOD's
Initial
A.Rauf
08/22/2022

Please tick under which category this case is most appropriately discussed ( DRG )

Paeds Neuro Ortho Trauma

Cardiothoracic General Surgery O&G Others

Anaesthetist Form Yes No

Required?
 TO BE FILLED IN BY POMR ASSESSORS ONLY

--------------------------------------------------------------------------------------------- POMR MEETING -----------------------------------------------------------------------------------

Comments by
Assessor

Death Category :

1 2 3 4A 4B 5 6 7

Contributory Factors in POMR

Anaesthetic Surgical

Pre-operative Pre-operative

Inadequate assessment Inadequate assessment

Inadequate optimisation of pre-existing Inadequate optimisation of pre-existing
medical / surgical condition medical / surgical condition
Lack of supervision / inappropriate grade Lack of supervision
anaesthetist
Inadequate facilities
Weakness of organising system
Delay in surgery
Fatigue
Inappropriate decision

Intra-operative Intra-operative

Inappropriate technique Inappropriate procedure

Lack of skill Lack of supervision
Inadequate management of anaesthetic Inadequate skill
complications
Inadequate facilities
Inappropriate fluid management
Inappropriate drug selection / administration
Adverse drug reaction
Equipment failure
Poor reversal
Inadequate facilities / assistance to cope
with crisis

Post-operative Post-operative
Inadequate monitoring in recovery room Inappropriate post-operative
management
Failure to recognise need to provide
continued post-operative monitoring / Inadequate monitoring
intervention in HDU / ICU Failure to recognise complications early
Failure to provide post-operative care due
Inadequate facilities for management of
to shortage of ICU beds
critically-ill patients
Inappropriate post-operative management
in HDU / ICU
 TO BE FILLED IN BY POMR ASSESSORS ONLY

Committee Decision

Date