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- 2. { Mortality Case Discussion15-jan-10- Feb-25 May 2025 Dr Abdullah Resident cardiac surgery AFIC RWP
- 3. Name: CNESyed Muhammad Ali Age : 9 years Date of Admission: 14-01-25 Date of Surgery : 15- 1 -25 Date of Death : 22-01-25 Surgeon : Col Dawood Kamal Anesthetist : Lt Col kaleem Disease : BDG (2015) Dextrocardia, DORV , L TGA, ASD, Large VSD, No antegrade pulmonary flow, Good size PAs Surgery : Completion FONTON Extracardiac CASE 1
- 4. Pre Op Echo: Situssolitus , Dextrocardia, DORV/ L-TGA, Large VSD, ASD, No antegrade pulmonary flow, IVC to RA Cath: Right MAPCAs coiling Pressures: MPA: 13/10/11 LEDP: 10 LPA : 11 Operatives findings: Dextrocardia, Rt BDG, Adhesions PROCEDURE: Extracardiac conduit PTFE 20 mm used, prox anastomosed ro LPA and distal to IVC 5mm fenestration in Graft anastomosed to RA PER OP ECHO: Findings not available
- 5. Day 0: 15/jan shiftedto ITC at 1600hrs Patient kept electively intubated. Afebrile, Multiple episodes of tonic-clonic fits, Twitching on right side. MAP 60-65 mmHg with 0.1 AD & Mil @ 0.1 mics , AD tapered down to @ 0.06 mics , mil increased to @ 0.3mics Urine output total 2450 ml ABGs: PH:7.28- 7.44, PaCO2 29-37.5, PaO2 80-74 Lac 11- 4mmol Drains pleural: 430 ml Total intake: 789 ml output 2880 ml , Negative: 2 L Labs: HB 12.9, TLC 19.9, PLT 141, CREAT 0.6, UREA 21, BIL 1.79, AlT 39 ALP 114, ALB 39 Post Op
- 6. Day 1st & 2nd 16-17/Jan Remained intubated Spont trials on day1 at 1130hrs and day2 2030 hrs , failed, Generalized tonic-clonic fits Sluggish pupil response with intact reflexes GCS 6/10 Febrile in morning, on day 2, 102 F. MAP 55-60 mmhg, with Ad @ 0.06 mics PD passed on17/1 at 2300hr 2D Echo: 16/1 : mod LV function with hypokinetic antero septal wall, Laminar flow in BDG and IVC to PA. No pericardial and pleural effusion CT brain done on 17/1, Subtle effacement of sulci and gyri in temporoparietal lobe suggestive of mild cerebral edema Labs: HB 16.2-14.7, TLC 13.6-26, plt 160-135, creat 0.61-0.78 UREA 25-77 , Bil 2.45-4.23, ALT 41-39, ALP 109-93, ALB 42-39 on day1 & 2 respectively Review by Neurophysician adv inj lerace BD and ophthalmologist – no significant findings 17/1 Blood sent for CS On 17/1
- 7. Urine output: Day 1 2650 ml Day 2 1080 ml Drains output: Day 1 480 ml Day 2 780 ml Total intake and output Day 1 intake 1337 output 3130 ml Day 2 Intak 3102 outpt 4570ml Net fluid balance Day 1 -ve 1793ml Day 2 -ve 1463ml
- 8. DAY 3rd and 4th:18-19 jan Remained intubated, spont trials on day 3 at 15:30 and day 4 at 15:45 hrs, failed due to uncontrolled fits Hemodynamically stable MAP 60-70 mmhg with Ad @ 0.03 mics Neurological status unchanged Urine output decreased to 0-15 ml/ hr and @ 0.1 And 0.4 ml/kg/hr ABGS: PH 7.4-7.3, PCO2 31-35 , PO2 86-94 , Lac 2.1-3.2 Labs: HB 11.5-12.5, TLC11.8-14, Plt 51-39 Creat 3.1-4.13 , UREA 181-202, T-BIL 1.1-1.08, ALT 34-53, ALP 54 CS REPORT 18/Jan. Klebsiella pneumoniae sensitive to colistin Peritoneal Dialysis cycle started Nephrologist review, adv continuation of PD cycles
- 9. NET input &output on day 3rd and 4th Total intake: 6037 ml – 6145 ml Total output:7060 ml – 6985 PD: 1740 ml – 1465 ml Pleural Drains: 470 ml – 590 ml Urine output: 60 ml – 205 ml Balance: 1023 ml –ve – 840 ml -ve
- 10. DAY 5th :20/jan Kept intubated Hemodynamically stable with Increased Inotropic support of Ad@ 0.1 , Nor-Ad @ 0.05 mics ABGs: PH 7.30, pCO2 39.6 , PO2 77.3 , Lac 3.4 Creat and TLC remained in upward trend, 4.2 and 17 respectively. Though urine output improved and PD cycle continued Multiple episodes of fits through out the day. Labs: HB 11.8 , TLC 17 ,PLT 72, CREAT 4.2, UREA 198, BIL 0.87 , ALT 71 , ALB 29
- 11. Intake & Output Intake : 8592 ml output 10030 ml Urine outpt 1070 ml @ 3.3 ml/kg/hr Drains Pleural: 710 PD 8230 ml , PD surplus 780 ml Net balance: -ve 1487ml
- 12. POST ofDay 6th 20/Jan Kept intubated Hemodynamically unstable , pressures dropped at 0915 hrs to 60/30, inotropic support escalated, Ad @ 0.15 , NorAd @ 0.15 and Vaso was added @ 2ml/hr pressures remained borderline over rest of the day , 65/45 mmhg MAP around 45 Neurological status unchanged, Fits continued Urine output normal and PD continued Labs: 11.9 , TLC 16.5, PLT 15, CREAT 3.3, UREA 193, BIL 0.78, ALT 62, ALB 23 URINE for C/S sent
- 13. Net Intake andOutput Intake: 5990 ml output: 7290 Urine output : 2230ml Drains pleural: 1080 ml PD : 4080ml surplus 680 ml Net balance: -ve 1300ml
- 14. Post op day7th Kept intubated Borderline pressures, dopamine was added @ 05 mics And rest of support escalated Ad @ 0.25 and NorAd @ 0.25 Neurological status remained same Downward trend in PaO2 72 – 29 – 6 uptrend in PCo2 35 – last hour 110 – 143 and lactate 3.3 – 9 At 2330 hrs patient collapsed, CPR done but didn’t revived.
- 15. Cause ofDeath Diffuse neuronal injury Sepsis MODS
- 16. Name: S/OMEM Noor ulllah Age: 3 months Weight: 4.2 kg Gender: Male Date of Admission: 29/1/25 Date of Surgery : 04-02-25 Date of Death : 06-02-25 Surgeon: Col Intisar ul Haq Anesthetist: Lt col kaleem Disease: Infracardiac TAPVR with severe pulmonary hypertension, Mod size ASD , Large Size PDA Surgery: TAPVR Repair Infracardiac, PDA Ligation CASE 2
- 17. PreOp echo: Infra Cardiac TAPVR , Mod ASD , Large size PDA , Severe PHT Per Op findings: TAPVR Infracardiac, Tensed RPA, volume overload RV, Confluence of veins on subdiaphragmatic region, Large PDA PER OP ECHO : Distended RV , Mod Biventricular functions. Confluence LA anastomosis wide open Came Off Bypass with High ionotropic support. Tracheal secretions blood stained Shifted to ITC with open chest
- 18. 0 POD: Shifted To ITC Open chest, at 1330hrs Kept intubated MAP 45-50 with inotropic support of Dobuta @ 7 mics , 0.2AD mics , 0.12mics Nor AD and Vaso 0.3 mics ABGs: PH: 7.43, PCO2 : 34 PO2: 197, FiO2 0.8 , Lac Decreasing trend 5.5 – 1.9 Febrile, fever spikes of 101 F at 2215 hrs Labs: TLC 5.3, HB 6.9, PLT 114, Creat 0.6, Urea 24, Alt 33, Alp 103, Bil 0.8
- 19. Intake andoutput: Urine: 845 ml @ 10 ml/kg/hr Pleural Drains: 150 ml Abdominal drain: 150 ml Total intake 497ml Total output 1168 Net balance: -ve 670 ml
- 20. POD 1st: 05/feb Intubated Hemodynamically unstable, MAP 35-45 Supports escalated, Dobuta @7mics, AD @ 0.3mics, NorAd @ 0.2 mics and Vaso @ 0.3 mics ABGS: PH 7.28-7.43, PCO2 upward trend 32-49, PO2 120 , FiO2 0.6 Labs: TLC 13.9, HB 10.2, PLT 106, CREAT 0.34, UREA 41, ALT 34, ALP 93 , BIL 0.8 Chest Re-explored for tamponed effect , no collection or clots found
- 21. Intak andoutput Urine: 885 ml @ 8.7 ml/kg/hr Abdominal drain: 545 ml Pleural Drains: 110 ml Total intake: 900ml Total output: 1590 ml Net balance: -ve 690 ml
- 22. POD 2nd Hemodynamically stable, MAP 55-60 , with high inotropic support, Dob @7 mics, Ad @ 0.3 mics , NorAd @ 0.2 mics kept intubated. Decreasing urine output ABGs : PH 7.24 , PCO2 45, PO2 105, LAC 1.2 Labs: TLC 15.6 HB 12.2, PLT 63000, CREAT 0.32, UREA 48, ALT 39 , ALP 42 , BIL 0.4 , ALB 27 Pleural Drains: 0ml abdominal: 5 ml : urine output 550ml At 23:30 sudden drop in pressures , Bradycardia, Pt collapsed, CPR started and inotrops increased but didn’t revived
- 23. Cause OfDeath Severe PHT Rt ventricular failure biventricular failure
- 24. Name: CNEAmin usman Age: 40 days Gender: Male Date of Admission: 3-2-2025 Date of Surgery: 04-02-25 Date of Death: 4-02-25 Surgeon: Col Intesar ul Haq Anesthetist: Lt col kaleem Disease: TGA, Mod VSD, Small PFO , Small PDA Surgery: ASO, VSD closure, PDA Ligation CASE 3
- 25. Pre Op echo: TGA, mod to large size outlet Muscular VSD, Tiny closing PDA Introp Findings: d – TGA, Aorta anterior, PA posterior, Large PM VSD, Large PDA Intraop Event: Coming off bypass , PaO2 , Spo2 dropped , increased inotropic support, Globally reduced function, coagulopathy, severe acidosis Post OP echo: Poor ventricular contractility LVEF 20-25% TAPSE 3mm, Mod TR, PAP 40 +CVP. PFO shunting Right to left IVS bowing at RV
- 26. Post Op: Shifted to ITC at 2015hrs Day 0: Patient kept intubated MAP 40-50 mmhg with high Inotropic support of AD @ 0.27 mics, Dobuta @ 5 mics & NorAd @ 0.13 mics Urine output 5 ml/kg/hr. ABGs, PH 6.84, PCO2 58-75 upward trend, PaO2 40-18 downward trend & Lactate 20 mmol with ongoing deterioration Pt status gradually deteriorated with low systemic pressures and increasing inotropic support CPR 5 minutes done at 2110hrs , Bradycardia plus low pressures On 5/2/25 at 6:45hrs again collapsed CPR done but didn’t revived.
- 27. Cause ofDEATH Left ventricular failure Cardiopulmonary arrest
- 28. Name: CNEAbdullah Age: 25 days Gender: Male Weight : 3.7 KG Date of Admission: 5/2/25 Date of surgery: 06-02-25 Date of death: 10-02-24 Surgeon: Col Intisar Ul Haq Anesthetist: Lt Col Kaleem Disease: TGA , VSD , ASD , PDA Surgery: ASO + PDA Ligation CASE 4
- 29. Pre Op Echo: d –TGA , MOD PM VSD, Small PDA , Small PFO. Per op Findings : Aorta anterior and pulmonary artery posterior, Mod PM VSD, mod size PDA, Small PFO Procedure: ASO + VSD Closure Per Op ECHO : Poor dilated LV , mod TR , tiny patch leak, PFO bidirectional shunt. Shifted open chest to ITC, severe acidosis low PaO2 & SPO2
- 30. Day 0: Shifted at 2045 hrs MAP of 45-50 with AD @ 0.2 , Nor AD @ 0.05, Dob @ 5 mics. At 0045 hrs pressures dropped went into bradycardia CPR done for 3-5 minutes ABGs: PH 7.20 , PCO2 37, PO2 49 ,FiO2 1.0, sats 80%, Lac 4 Labs: TLC 5.1, HB , 7.8, PLT 394,CRT 0.4, UREA 21, ALT 19, ALP 90, BIL 1.5, ALB 35 , CKMB 109. INTAKE OUTPUT: Urine: 545 @ 11.33 ml/kg/hr Pleural+ Med Drains: 225 ml PD : 175 ml Total intake: 390.4 ml Total output: 862 ml Net : -ve 472 ml
- 31. Post Op day1st and 2nd Intubated, with border line hemodynamics Supports escalated, Dob @ 7.5 mics, Ad@ 0.3 - 0.29 , NorAd @ 0.1 ABGs : PH 7.285-7.35 , PCO2 42-50 upward trend, PO2 58-24 downward trend, FiO2 1.0, Lac 5-3 downward trend Labs: TLC 9.8-10.2, HB 12.7-15.4, Creat 0.51-0.54, Urea 33-45, ALT 42-47, ALP110, BIL 2.3 – 1.7, ALB 34 -27, CKMB 101-129, DIGOX 1.36 PD cycles started on day 2.
- 32. Intake and output Urine:655-820 ml @ 7.3-9.2 ml/hr /kg Drains pleural+mediastinal: 70-50ml PD : 1380 PD surplus 500 ml Net: Intake : 841 – 1545 Output: 1389 – 2215 -ve 538 , 661 ml
- 33. Day 3rdand 4th : Intubated, borderline hemodynamics, deteriorated ABGs , rising lactate with inotropic support of Dob @ 7.42, Ad@ 0.25 & NorAd @ 0.05 Afebrile ABGs: PH 7.3, PCO2 42-51, PO2 42-34, SATS 60%, Lac: 3.5-4.5, FiO2 100%. Labs: TLC 10.4-8, HB 15.3 – 14, plt 110, creat 0.48, urea 38, ALT 72, Bil 1.8. Urine output @ 7.3 ml/kg/hr At 1045 hrs went into bradycardia pressures dropped CPR started but didn’t revived.
- 34. Cause OfDeath Lt ventricular failure Cardiopulmonary arrest
- 35. Name: CNE: Brishna Age: 13 years Gender: Female Date of admission; 17-02-25 Date of surgery: 18-2-25 Date of death: 019-02-25 Surgeon: Col Dawood kamalq Anesthetist: Lt Col Kaleem Disease: Severe MR , mod TR Surgery: MV Replacement CASE 5
- 36. Pre op Echo:EF 50% Thickened and Non Coapting Mitral Valve with severe MR, dilated LA/LV with fair Lvfunction, Mod to severe TR with PG 50 mmHg. Per op Findings : Thickened Mitral leaflet and pericardial adhesions. Per op echo: Well functioning mitral prothetic valve with no significant gradients or paravalvular leak. Came off bypass with high inotropes' 0.2AD, 0.1NorAD Shifted to ITC with open chest
- 37. Day 0: Shifted to ITC at 1715 hrs Kept intubated, Hemodynamically stable with inotropic support of Dob 10 mics tapered to 5 mics, Ad @ 0.23 & NorAd @ 0.1 Good urine output 4570 ml, Drains B/L pleural: 300ml ABGs : PH 7.30, PCO2 34.7, PO2 211, Sats , 99.5%, Lac 11- 18 upward trend Labs: TLC 11.9, HB 8 , PLT 241, CREAT 0.53, UREA 19, ALT 14, ALP 104, BIL 1.4, ALB 39 Total intake: 2195 Total output: 4870 Net –ve 2600 ml
- 38. 1st Post opday: At 9:15 hrs , Pt rhythm became irregular, cardioversion done but failed then went into cardiac arrest, CPR started despite maximum efforts didn’t revived.
- 39. Cause ofDeath Left ventricular failure Arrhythmias
- 40. Name: CNEEshmal Age: 1 month Date of surgery 30-01-25 Date of Death: 10-02-25 Surgeon: Col Intisar Ul Haq Anesthetist: Lt Col Kaleem Disease: TGA, multiple VSDs, Small PFO Surgery: Was planned for ASO but then PA banding and atrial septectomy done due to Adjacent coronary ostias. CASE 6
- 41. Per Op findings:Aorta towards left and PA towards Rt. Anomalous & Adjacent coronary ostias of RCA and LCA with intramural course.PA banding atrial septectomy Done. Day 0 post Op: Kept intubated overnight, MAP 60-65 mmHg with Ad @ 0.14 mics Urine output normal, PD passed – 725 ml ABGs acidotic with decreasing PaO2 and Spo2 and increasing lactate levels, PH 7.29, PCo2 40, PaO2 37, Lac 14 Day 1 post op: Intubated spont trials given failed retaining PCO2 , dropping sats and PaO2. MAP 50-55 mmHg , Ad @0.10, NorAd @ 0.05 mics Urine output normal . PD 500 ML
- 42. Day 2nd , 3rd ,4th Post Op: Intubated With increasing.... High airway pressures With decreasing PaO2 and sats , PaO2 30-35 and sats 50-60 Hemodynamically stable with increasing inotropic support Ad @ 0.15 and NorAd @ 0.1 mics Urine output decreased, PD cycles started On 2 D echo , good Biventricular functions
- 43. POD 5th , 6th ,7th : Kept intubated Hemodynamically stable with episodes of hypotension, with Dob @ 5 mics , Ad @ 0.1 NorAd @ 0.05 C/S report: Klebsiella pneumoniae PO2 and sats still below normal Urine output normal, PD cycles continued POD 8th , 9th , 10th : Intubated, Deteriorating hemodynamics, Septic , CRP 204, TLC 18 PaO2 30-35 Urine output Decreasing trend, PD cycles con
- 44. POD 11th and 12th Intubatedwith increasing airway pressure, increased pressure support Hemodynamically stable with episodes of hypotension ABGs acidotic, with decreasing PaO2 and Spo2 and increasing lactate levels. Urine output Decreasing trend, PD cycles continued Ay 12th POD pt suddenly went into bradycardia and hypotension, CPR done, didn’t revived Cause OF death: LV faulure, Sepsis .