2. Agenda
• Patient’s Data & Case Summary.
• Clinical course and events.
• Evidence Based Reviews in Surgery
3. Patient’s Data
&
Case Summary.
Admission Date 28/10/2023. Hour 8:02 pm
Date of expiry 23/11/2023. Hour 10.36 pm
Total span of the patient's hospital stay 27 days
57 yrs. female admitted through ER with chief
complaints,
Pain abdomen (Epigastric tenderness)
Repeated vomiting
Fever
The patient was initially admitted through an
emergency in Female Medical Ward D7 since
she was known case of ESRD on haemodialysis
on every alternated day.
She had a history of repeated admissions to
nephrology ward for HD.
4. Patient’s Data
&
Case Summary.
Signifinfant Comorbidities
• HTN,DM,CKD on HD + CKD-MBD due renal
hyperparathyroidism
• Persistant Iron Defeciency Anemia due to ESRD
• AVF for HD on right arm.
• Past Surgical Hx Lap Chole + LSG and right kidney
surgically removed (CAT-CT scanning proven.)
• Left side diabetic foot small ulcer at foot dorsum
(PVD likely).
• The patient also had past Hx of CVA with mild
hemiparesis and The patient had difficulty walking
and was almost bedbound.
5. Clinical course
&
events.
SINCE this patient was under the care of a
multidisciplinary team we will highlight the
important events in more details.
Date 28-10-23 to 31-10-23
After Admission in ward 7 nephrology department
following management steps were taken out.
Prompt arrangement of Haemodialysis as a
routine session.
Referral to DF and wound care (debridement +
tissue c/s )
Gastroenterology was consulted, Endoscopy
done shows post sleeve pan erosive Gastritis,
duodenitis, esophagitis GERD Grade A.
6. Clinical course
&
events.
Date 28-10-23 to 31-10-23
We General Surgery were consulted for
Pain Epigastrium.
CT Abdomen and pelvic shows 7x7x4 cm
left lobe segment 4 likely liver abscess.
7. Clinical course
&
events.
Date 28-10-23 to 31-10-23
• Intervention Radiologist consulted for USG
guided Pig tail insertion initially 15ml thick
pus aspirated and then more 10 ml take for
c/s.
• After some time, during the ward round, up
to 100 milligrams were recorded showing
successful intervention,
• However, the quantity markedly decrease
in next 5 days and the last ready just 10 ml
/24 hours.
8. Clinical course
&
events.
Date 31-10-2023 to 05-11-2023
Intervention Radiologist is contacted for up-sizing the
pigtail from 8.00 FR to 10 FR and advised flushing with
saline daily.
Date 05-11-2023 to 11-11-2023
Reapeat CT abdomen shows progressive cousre with
sustained loculies 6.2x11x6 cm within sigment 4 and 3.
However, the pigtail was in situ within the anterior loculus
3.5x2x5.5 cm.
So,2nd Pig tail is inserted
9. Clinical course
&
events.
Date 11-11-2023 to 20-11-2023
• Both the drains were well functional but the discharge
was increasing day by day and the colour was greenish
yellowish biliary type.
• It raised the suspicion of intrahepatic biliary fistula due
to persistent hepatic locules in the follow-up ultrasound
abdomen.
• Gastro informed for ERCP But they suggested to
involve HB Dept.
• HB dept. Suggest for ERCP and CBD stenting.
• Gastro did ERCPS,P/O ERCP patient was kept in
SICU then shifted back surgical ward D-9 and was
under care of Unit-B2.
• Haemodialysis was continued daily or every other day
as needed.
ERCP FINDINGS:
ERCP done
CD cannulation done
CBD cholangiogram showed mildly dilated BD,
possible intrahepatic biliary leakage
sphincterotomy done
CBD stent 7 fr, 7 cm inserted with good biliary
drainage
10. Clinical course
&
events.
Date 20-11-2023
• Post ERCP Patient labs parameter coming
toward normal level.
• Abdomen soft and lax.
• Orally taking food wel tolerated.
• Vitally stable BP 120/80 HR-86 BPM.
• Over all patient shows transient good
outcome.
• But pigtail drainage shows still persistant
high out put e.g 1/2-180/nill ml then 4ml/38
ml.
Labs
WBC-12.9
HB-8.2
Platelets-229
Amylase-104
Lipase-160
Creatinine-428
11. Patient’s Data
&
Case Summary.
Date 21-11-2023
Unfortunately this morning our patient had a severe
epileptic seizure/TCS
Probably due to ESRD-MBD
• CA-1.95 (2.2-2.65)
• PHOSPHORUS-1.48 (0.78-1.58)
Attended by Nephro on call
Tab Caltrate p/o TDS
Ct brain virtual venography requested
Inj Rocephin
HD on next day
Blood transfusion
Surgical intervention to remove septic focus
Repeat lab CBC and ADM. Prof
Vancomycin trough
12. Patient’s Data
&
Case Summary.
• Date 21-11-2023 Evening round
• S/B Surgeon on-call
• Quite stable,doing well ,Having no active
issue
• BP-120/80 Pulse-86bpm afibrile 37 C
• He was seen by Gastro as well and there
was nothing needed to do
• (CST-------TFO)
LABS
Wbc 12.7()
HB-8
LIPASE 102 (160)
AMYLASE 38 (104)
13. Clinical course
&
events.
• Date 22-11-2023 Morning Round
• Dialysis was going on during the morning
round but the patient's condition was not
looking good.
• The patient was drowsy, unable to respond
to verbal commands.
• S/B Neurology on call her recent
complains Fits-GTC (4 days ago she had
Fits-GTCS during HD and she stayed in
ICUS for one day.)
• tablet valproic acid (Depakin 500 mg)
• F/UP in OPD
15. Patient’s Data
&
Case Summary.
Date 22-11-2023 Evening SICU shifting
The patient's condition deteriorated all of a
sudden in ward D-9.
SICU informed and patient is S/B SICU on call
GCS E3+V3+M bed bound
BP-70/43
PULSE-105 BPM
SPO2-96% +8 Lit O2
Inj-Levophed 10mg/hour
Patient is shited to SICU
Some radiological work up in sicu (USB,PAN
CT)
16. SICU
Clinical course
&
events.
Date 23-11-2023 SICU Managements details
• During the SICU stay we actively followed the patient
and were in close contact with MDT colleagues.
• Cardiologist consulted for suspicion septic
cardiomyopathy and echo findings (Bil.Vent sluggish
contraction EF-50%,RV dilatation with global
hypokinesia, advise to rule out PE.
• Hepitico-biliary team again informed but they denied
from surgical intervention.
• IR Informed to do bedside USG as we had suspicion
of biliary peritonitis or to assess the current pigtail
functionality.
• IR did usg abd, no residual peritoneal collection and
both the pigtails are in situ in the right position
17. SICU
Clinical course
&
events.
• Date 23-11-2023 SICU Managements details
on 23/11/2023 due to severe tachycardia & severe
hypotension, intubated to mechanical ventilation.
Inotropic & Fluid Resuscitation started.
Reviewed by cardiologist as she has septic cardiomyopathy.
Patient was reviewed by surgeon who asked to do pan CT to
rule out Pulmonary embolism or bowel ischemia, report came
with stationary coarse, no significant issues.
patient has severe metabolic acidosis with very high Lactate
level more than 15.
So CRRT was started for 24 hrs without UF but patient
condition deteriorated so CRRT was held.
The condition of the patient was continuously deteriorating and
inotropic requirements were increasing.
On 23/11/2023, pt developed cardiac arrest, CPR was done as
per ACLS protocol but with no response.
Medications during stay: COLISTIN, MERONAM,
VANCOMYCIN, AMIKACIN, ECALTA, LOSEC, KEPPRA.
ALBUMIN, DOBUTAMINE, LEVOPHED &VASOPRESSIN
Death was declared at 10:36 PM.
18.
19.
20. Evidence Based Reviews in Surgery
regarding
Liver abscess in ESRD+HD
• An untreated hepatic abscess is nearly uniformly fatal as a
result of complications that include sepsis, empyema, or
peritonitis from rupture into the pleural or peritoneal spaces, and
retroperitoneal extension. Treatment should include drainage,
either percutaneous or surgical.
• Shock with multisystem organ failure is a contraindication for
surgery.
Open surgery can be performed by either of the following two approaches:
1:-A transperitoneal approach.
2:-For high posterior lesions, a posterior trans pleural approach can be used.
3:-A laparoscopic approach.
In selected pt.
Minimally invasive
Reduce morbidity
4:Interventional Radiologist/PCD
(Size > 5cm)
Morbidity was comparable for the two procedures (LAP vs PCD)
But those treated with surgery had fewer secondary procedures and fewer treatment
failures
