MORBIDITY AND MORTALITY

Objectives:
• To present a case of a patient with Intraoperative inadequate block for Epidural
anesthesia
• To discuss considerations and assessment of Intraoperative inadequate block for
Epidural anesthesia
• To discuss management of Intraoperative inadequate block for Epidural anesthesia

CONSULTANT in Charge
RESIDENTS in Charge:
General Data:
• This is a case of B, R, 20 year old/female, Filipino, Single, Roman Catholic, Born on
June 18, 2003, Residing in Navotas, Metro Manila, Admitted last January 14, 2024 in our
institution

Chief complaint: abdominal pain

History of Present Illness:

1 week prior to admission:
- Epigastric pain, Pain scale of 7-10/10
- Lasting for 2-5mins
- Characteristic of “Mabigat na parang hinihiwa” as stated by the patient
- Aggravated by food intake especially fatty foods
- Alleviated by rest
- Non radiating
- Any time of the day
- with associated nausea.

3 days Prior to admission

Still with above symptoms with
- One episode of vomiting of previously ingested food
- Sought consult at a private physician and was prescribed omeprazole 40mg tab OD for
unrecalled duration and with unrecalled antibiotics as stated by the patient
- Provided temporary relief of pain from 7-10/10 to 2-3/10
1 day prior to admission
- Persistence of symptoms now with associated yellowish discoloration of the skin. Hence
planed for consult and was subsequently admitted.

Past Medical History:

No history of
(-) Hypertension
(-) Heart Disease
(-) Asthma
(-) Pulmonary Tuberculosis
(-) Pneumonia
(-) Diabetes
(-) Allergy
Personal and Social History:
Occasional Alcoholic beverage drinker, non-smoker, no food preferences and denies illicit drug
use.

Family History: No family history of hypertension, No asthma, tuberculosis, diabetes, thyroid

problem, neurologic disorders, cancer, liver diseases

SURGICAL AND ANESTHETIC HISTORY

• January 2023 – ERCP – under TIVA – unremarkable
• No known complication with anesthesia among family members

OBGyne history: nulligravid

M – 16 y/o
I – regular
D – 2 – 3 days
A – 2 – 3 moderately soaked pads
S – hypogastric pain

Review of Systems:
General: (-) fever, (-) headache
Cutaneous: (-) rashes, (-) pruritus
Respiratory: (-) DOB, (-) crackles, (-) wheezes, (-) rhonchi,
Cardiovascular: (-) chest pain, (-) easy fatigability, (-) cyanosis, (-) palpitation
Gastrointestinal:(-) diarrhea, (-) hematochezia
Genitourinary: (-) change in color or amount of urine, (-) dysuria
Musculoskeletal: (-) muscle stiffness, (-) muscle pain
Hematopoietic: (-) easy bruisability, (-) bleeding
Neurologic: (-) headache, (-) seizure, (-) tremors
General Conscious, coherent, not in cardiorespiratory distress, ambulatory, GCS 15
Vital signs BP 100/70mmHg, CR: 80bpm RR: 18cpm T: 37.0 O2 sat 98-99%
Wt:40 kg Ht 1.57m BMI: 16kg/m2
(+) Jaundice, warm to touch, good skin turgor
Skin
HEENT Icteric sclerae, Pink palpebral conjunctivae, No naso-aural discharge, No
lymphadenopathy

Mallampati: I hard and soft palate viewed both palatine tonsils and the whole
uvula, No Obstructive sleep apnea, no reduced mobility of cervical spine,
Mouth opening >3cm, Able to prognathy, Thyromental distance >3 finger
breaths, Full dentitions
Chest Symmetrical Chest Expansion, clear breath sounds, no intercostal retractions
Heart Adynamic precordium, normal rate, regular rhythm, no murmur
Abdomen Flabby, Normo-active bowel sounds, Soft, nontender on palpation
Extremities No gross deformity, no cyanosis, no edema, full equal pulses
Neurologic GCS 15, no motor and sensory deficit
Exam
Bleeding Reference 1/13/24
parameters Range

Prothrombi 9.10-12.10 11.50

n time

% activity 10-150 121

INR 0.9

APTT 25.4-38.4 29.5

CBC Normal 1/13/24

Values
Hemoglobin 110 – 150 153
Hematocrit 0.370 – 0.44
0.450

WBC 4.6 – 10 12.5

Platelet 150-400 431
Blood type A+
Serum Reference 1/13/24
Electrolyte Range
s
Sodium 135-148 136.0

Potassium 3.5-5.3 4.5

Chloride 98-107 99.8

BUN 2.8-7.2 1.77

Crea 65-120 49.6

Liver fun 1/13/24 Reference

Range
ALT 593 0-31

AST 230 0-32

Total Bilirubin 107.72 2-21

Direct Bilirubin 87.81 0-5.13

Indirect bilirubin 19.9 2-15.78

Alkaline 138.67 52-171

phosphatase
CBC Normal 1/17/24
Values
Hemoglobin 110 – 150 130
Hematocrit 0.370 – 0.39
0.450

WBC 4.6 – 10 11.16

Platelet 150-400 396
Bleeding Reference 1/25/24
parameters Range

Prothrombin 9.10-12.10 12.50

time

% activity 10-150 113

INR 1.05
APTT 25.4-38.4 36.9

CBC Normal 1/25/24

Values
Hemoglobin 110 – 150 110
Hematocrit 0.370 – 0.32
0.450

WBC 4.6 – 10 10.4

Platelet 150-400 495

Serum Reference 1/25/24

Electrolyte Range
s
Sodium 135-148 140.0

Potassium 3.5-5.3 4.39

Chloride 98-107 106.5

BUN 2.8-7.2 1.88

Crea 65-120 47.9

Chest Xray:
heart not enlarged
Aorta unremarkable

ECG: normal sinus rhythm

HBT: Cholecystolithiasis, extrahepatic duct ectasia

Pancreatic and bile duct parasitism
Normal ultrasound of the Liver
No active parenchymal infiltrates
Atheromatous aorta
Osteodegenerative changes

Anesthetic Diagnosis:
ASA III- BMI <18, occasional alcoholic drinker
Mallampati II

Clinical Diagnosis:
Obstructive Jaundice Rule out Choledocholithiasis, Rule out Hepatitis infection, not in
cholangitis, Chronic calculous cholecystitis s/p ERCP (January 2024)

Surgical Plan:
For Elective Open Cholecystectomy with CBDE

Anesthetic Plan:
Epidural anesthesia

Course in the Ward:

 On the first hospital day (A Day prior the procedure), patient was admitted and was
notified for Elective Open Cholecystectomy with CBDE. Consent for anesthesia was secured,
was put on NPO 8 hours prior to cutting time, Secured with Intravascular Line Gauge 18 with
good flow, Laboratory and Diagnostic exams were requested, (CBC, Bun, Crea, Sodium,
Potassium, Chloride, Chest Xray, lipid profile, bleeding parameters) and 12-L ECG, 1 unit of
packed red blood cell properly typed and cross matched was secured for possible OR use,
Omeprazole 40mg IV once on NPO 30 minutes prior to NPO was given, Cefuroxime 1.5g
30mins prior to OR was given, intravenous fluids was also initiated. Vital signs of Blood
Pressure of100/70, heart rate of 70-80s, respiratory rate of 18, temperature of 36.9C.

On the second hospital day, patient was transferred to OR and was hooked to
monitors (Pulse oximeter, BP cuff, ECG) and oxygen facemask at 4 LPM, vital signs were noted
with Blood pressure of 130/90, Heart Rate of 90, Respiratory Rate of 18 and Oxygen Saturation
of 99%. Patient was placed on the left lateral decubitus position. Midazolam 1mg IV was given.
Lumbar interspace was palpated and identified, and asepsis and anti-sepsis was done. Epidural
catheter was inserted in single attempt at the level of L1-L2 interspace on a cephalad position,
5cm in epidural space and 5cm at the skin. No noted blood or CSF at the catheter. After
inserting the epidural catheter, patient was put on a supine position. Test dose was given via
epidural catheter using Lidocaine + Epinephrine. After negative test dose was noted,
Bupivacaine Isobaric 0.5% 5ml was given via epidural catheter as initial dose after 5mins
another 5ml was given. Sensory block was assessed and was noted at level of T4. 15mins after
administering the last dose of Bupivacine isobaric, another dose of midazolam 1mg IV was
given. Surgical procedure was then started, the patient did not experience any pain, no
elevation of blood pressure and pulse rate noted. Intraoperative blood pressure ranged from
130/90 mmHg-100/70mmHg, Heart rate 80-90 bpm and 02 saturation 99%. After 45 minutes,
another bupivacaine isobaric 0.5% 5ml was given as third dose and another 5ml was given after
1 hour after the third dose, still the patient had stable vital signs and did not experience any
pain. The surgeon requested for C-arm and we waited 1 hour for it to arrive. After 1 hour after
the C Arm arrived, another top up of 2.5ml was given and the surgical was then continued.
Approximately 2 hours from the start of the procedure, the patient experienced pain and the
surgeons was unable to retract the surgical site. I decided to give ketamine 50mg (1ml)
2 hour and 30 minutes from the start of the procedure a rise of Blood pressure was
noted and desaturation with lowest at 80% and the surgeon was having a difficult time
retracting. My co resident decided to convert to endotracheal anesthesia, patient was pre-
oxygenated and was inducted using Fentanyl 75 mcg (1mg/kg) IV, Propofol 30 mg (1.5mg/kg) IV
given in titrated doses, and Rocuronium 35 mg (0.6 mg/kg) IV and was maintained on
Sevoflurane at 2-3 vol% the patient was intubated with ET 7.0 via direct laryngoscopy, with ET
secured at level 19 using blade mac 3, cuff was inflated, equal breath sounds were noted upon
auscultation. The patient was placed on volume-controlled ventilation with TV 6 mL/kg (IBW),
RR 12, I: E 1:2, PEEP 5, FiO2 100%.
The entire procedure lasted for 5 hours. Total blood loss was 100ml, Urine output of
100ml. Epidural catheter removed, blue tip seen. Patient is for transfer to PACU still intubated
and sedated using midazolam drip (94ml pnss plus 30mg midazolam) due to episodes of
desaturations, upto 90% upon trial of removing ET tube.

At the PACU, patient was sedated and intubated with good pain control. Patient’s vital
signs monitored every 15mins. Was put on NPO with PLR 1L to run for 8hrs. After 1 hour of
PACU stay, patient’s ABG was received with a result of metabolic acidosis fully compensated
and was extubated awake. The patient was monitored and was transferred back to ward with
the following vital signs, 120/80mmHg, O2 sat 96-99%, Temperature of 36.5C. Main service
noted decrease in urine out for 4 hours and was transferred to SICU for monitoring.

At the SICU, patient is conscious, coherent, able to answer questions appropriately,

was able to sit and practice deep breathing exercises, with no fever, jaundice. Approximately 12
hours post-op, patient experienced abdominal pain with pain scale of 4/10 and was given
paracetamol 1g IV for 2 more doses and Nalbuphine 10mg IV every 6 hours as needed for pain.
Pain score was eventually went down to 0-2/10. IV fluids continued and eventually after 5 hours
patient’s urine output was recorded with 63ml/hr. With vital signs of BP 120/70, HR 80s-90s, RR
of 19, O2 sat of 99-100%.

On the second hospital day, patient had no subjective complaints, was conscious,
coherent, was able to sit and practice deep breathing exercises and with good pain control.
Main service ordered to have sips of water due to noted flatus on the patient. Antibiotics were
continued and the patient was transferred back to ward.

On the third hospital day, management were continued and was deemed fit for
discharged with oral antibiotics and pain medications prescribed as take home medications.

Final Diagnosis: Obstructive Jaundice, Choledocholithiasis, Rule out Hepatitis infection,

not in cholangitis, Chronic calculous cholecystitis s/p ERCP

ASA III- BMI <18, occasional alcoholic drinker

Mallampati II