m & m for bowel ischemia after evar

Morbidity & Mortality ConferenceMorbidity & Mortality Conference

Bowel Ischemia after Abdominal Aortic Aneurysm Stent-grafting

心臟血管外科 陳勁辰 醫師台北慈濟醫院02/24/2016

Sex: MaleSex: Male Age: 72 yearsAge: 72 years Date of admission: 11/07/2015Date of admission: 11/07/2015 Dates of surgery/procedure: Dates of surgery/procedure: 11/07/2015, 12/07/2015, 12/14/201511/07/2015, 12/07/2015, 12/14/2015 Date of death: 12/14/2015Date of death: 12/14/2015

Patient data

CC: Abd pain for 3 daysCC: Abd pain for 3 days PH: CRI=6+ but UO++; Gout; CAD s/p POBASPH: CRI=6+ but UO++; Gout; CAD s/p POBAS Course:Course:

11/07/2015: EVAR11/07/2015: EVAR 11/25/2015: HD11/25/2015: HD 12/02/2015: ICU-> Ward12/02/2015: ICU-> Ward 12/05/2015: CTA: supra-EVAR Ao rupture12/05/2015: CTA: supra-EVAR Ao rupture 12/07/2015: Chimney & TEVAR12/07/2015: Chimney & TEVAR 12/14/2015: Rescue Chimney (SMA); Mortality12/14/2015: Rescue Chimney (SMA); Mortality

Brief summary

Cons: alertCons: alert VS: BP=177/89, HR=70, BT=35.9C, RR=20VS: BP=177/89, HR=70, BT=35.9C, RR=20 Abdomen: soft, midline pulsatile massAbdomen: soft, midline pulsatile mass EKG: sinus, 74/min, no ST changeEKG: sinus, 74/min, no ST change Lab: Hb=9.6, WBC=10.3k, Cre=6.3 (no HD)Lab: Hb=9.6, WBC=10.3k, Cre=6.3 (no HD)

ER (4am, 11/07/2015)

CTA (11/07/2015)

CTA (11/07/2015)

EVAREVAR

Endovascular aortic repairEndovascular aortic repair

Operation: EVAR (11/07/2015)

Operation: EVAR (11/07/2015)

Postop CoursePostop Course

PneumoniaPneumonia Progressive deliriumProgressive delirium Strong Abx useStrong Abx use Diuretic-responsive UO=2000 kcal/dayDiuretic-responsive UO=2000 kcal/day BUN/Cre =200/7BUN/Cre =200/7 NG pump feeding 1500 kcal/dayNG pump feeding 1500 kcal/day

CXR (11/16/2015)

Postop CoursePostop Course

11/07: EVAR11/07: EVAR 11/25: Hemodialysis; improving11/25: Hemodialysis; improving 12/01: MV extubation12/01: MV extubation 12/02: ICU -> ward; NG & oral12/02: ICU -> ward; NG & oral 12/05: Pre-MBD CTA12/05: Pre-MBD CTA !!! Supra-renal artery Ao rupture!!!! Supra-renal artery Ao rupture!

CXR (12/05/2015)

CTA (12/04/2015)

CTA (12/04/2015)

Chimney Technique Chimney Technique

Op2: ChTEVAR (12/07/2015)

Postop2 CoursePostop2 Course

12/07: Chimney SMA & TEVAR, sacrificing bil 12/07: Chimney SMA & TEVAR, sacrificing bil renal arteries; PermCathrenal arteries; PermCath

12/08: NG pump 800kcal/day, abd soft, bowel 12/08: NG pump 800kcal/day, abd soft, bowel sounds activesounds active

12/09: HD; GCS: M6; MV extubation12/09: HD; GCS: M6; MV extubation 12/10: NG 1500 kcal/day, Abx: Tapi, Vanco, 12/10: NG 1500 kcal/day, Abx: Tapi, Vanco,

Diflucan; WBC=13k, CRP=27, CK=554, Diflucan; WBC=13k, CRP=27, CK=554, lipase=93, Lac=1.4lipase=93, Lac=1.4

CXR (12/11/2015)

Postop2 CoursePostop2 Course

12/11: Diarrhea 2335 g/day, WBC=8.4k, 12/11: Diarrhea 2335 g/day, WBC=8.4k, ABG=7.32/157/34/19/-9, NIPPV useABG=7.32/157/34/19/-9, NIPPV use

12/12: NG 1500 kcal/day, abd soft & flat, 12/12: NG 1500 kcal/day, abd soft & flat, diarrheadiarrhea

12/13: NG 1500 kcal/day, diarrhea stopped 12/13: NG 1500 kcal/day, diarrhea stopped after Imodium, CRP=34, PCT=47, WBC=8.4kafter Imodium, CRP=34, PCT=47, WBC=8.4k

Postop2 CoursePostop2 Course

12/14: Shock, re-ETT, Lac=3.4, WBC=7.2, 12/14: Shock, re-ETT, Lac=3.4, WBC=7.2, CK=21, CRP=18, lipase=137CK=21, CRP=18, lipase=137

CT workup: ischemia bowel! SMA chimney CT workup: ischemia bowel! SMA chimney kinkingkinking

Cath rescue: SMA re-chimneyCath rescue: SMA re-chimney 12/14: Treatment futility; support withdrawal; 12/14: Treatment futility; support withdrawal;

MortalityMortality

CXR (12/14/2015)

CTA (12/14/2015)

CTA (12/14/2015)

CTA (12/14/2015)

Rescue (12/14/2015)

Rescue (12/14/2015)

Rescue (12/14/2015)

Possible Causes of Mortality

ShockBowel ischemiaKinked chimney to SMADelayed diagnosis & treatmentHesitated hemodialysis (Prolonged toxinemia)

手術適應症 (2nd) 是否恰當 --> Yes手術前評估是否完整 --> Yes手術中麻醉是否洽當 --> Yes加護病房之照護洽當否 --> Yes?死亡原因之根本分析 ? Bowel ischemia整體而言 , 本案例可以改進之處為何 ? Alertness; Technique本案例學到什麼 ? Timely management!

How to do better?

Thank you!Thank you!

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