VCU DEATH AND COMPLICATIONS CONFERENCE Brief Overview of Case MVC, hemoperitoneum, cirrhosis Withdraw care, death, variceal bleed.
Download ReportTranscript VCU DEATH AND COMPLICATIONS CONFERENCE Brief Overview of Case MVC, hemoperitoneum, cirrhosis Withdraw care, death, variceal bleed.
Slide 1
VCU
DEATH AND COMPLICATIONS
CONFERENCE
Slide 2
Brief Overview of Case
MVC, hemoperitoneum, cirrhosis
Withdraw care, death, variceal bleed
Slide 3
Introduction for Every Case
Complication
death
Procedure
2/25 – exlap, splenectomy, transverse colectomy, packing of abd, VAC
2/25 – reopening abd, control of bleeding from diaphragm lac,
packing
2/28 – removal of packs
3/1 – banding of 5 esophageal varices
3/2 - TIPS
Primary Diagnosis
MVC – splenic laceration, transverse colonic injury
Cirrhosis
Slide 4
Clinical History
BRIEF Clinical History
44 y/o
PMH: DM, cirrhosis (?NASH)
2/25 – MVC into tree at high speed
Cardiac arrest, OR – splenectomy, transverse colectomy, packing, VAC,
ortho injuries
Cirrhosis, intraabd varices
Admission – hgb 10.6, plts 65, INR 1.8-2.3, Cr 0.67
ARF, Cr 1.77 – CVVH
Hypotension on pressors
Resp failure
Increased LFTs, TB
Neuro?
Slide 5
Clinical History
BRIEF Clinical History
3/1 variceal bleeding (hgb 6.8), Blakemore tube placed, EGD banding,
TIPS (portosystemic gradient 15-4mmHg)
3/2 fixed dilated pupils, ARF, increased vent requirements, pressors
Withdraw care, death
Slide 6
Analysis of Complication
•
Was the complication potentially avoidable?
–
•
No – traumatic injuries, cirrhosis
What factors contributed the complication?
–
Underlying disease
Slide 7
Evidence Based Literature
Cirrhosis and trauma: a deadly duo.
Am Surg 2005
Review: 61 cirrhosis/156 controls
Increased LOS, increased transfusion
requirements/24h, mortality (33%/1%)
55% deaths due to depsis
Mortality
Childs
A = 15%, B = 37%, C = 63%
Slide 8
Evidence Based Literature
Liver cirrhosis in patients undergoing laparotomy
for trauma: Effect on outcomes
JACS 2004
46 pts with cirrhosis, matched with 2 controls (based
on age, gender, MOI, ISS
Mortality = 45/24%
ISS<15 = 29/5%
ISS 16-25 = 56/11%
ICU stay = 11.5/6.6d
Slide 9
Evidence Based Literature
Cirrhosis and trauma are a lethal combination.
World J Surg 2009, USC/LAC
Review 10 yrs - 36,038 trauma registry patients, 468
(1.3%) had a diagnosis of cirrhosis
Mortality = 12/6%
ARDS, trauma-associated coagulopathy, and septic
complications were significantly more common in the cirrhotic
group
For the subgroup of patients who underwent emergent
abdominal exploration, the mortality rate increased to 40%
compared with that of noncirrhotics at 15%
Slide 10
Sengstaken-Blakemore tube
Passed into esophagus and
gastric balloon is
inflated inside the
stomach. A traction of 1 kg
is applied to the tube so
that the gastric balloon
will compress on the GE
junction to reduce the
blood flow to esophageal
varices. If the use of
traction alone cannot stop
the bleeding, the
esophageal balloon is also
inflated to help stop the
bleeding. The esophageal
balloon should not remain
inflated for more than six
hours, to avoid necrosis.
VCU
DEATH AND COMPLICATIONS
CONFERENCE
Slide 2
Brief Overview of Case
MVC, hemoperitoneum, cirrhosis
Withdraw care, death, variceal bleed
Slide 3
Introduction for Every Case
Complication
death
Procedure
2/25 – exlap, splenectomy, transverse colectomy, packing of abd, VAC
2/25 – reopening abd, control of bleeding from diaphragm lac,
packing
2/28 – removal of packs
3/1 – banding of 5 esophageal varices
3/2 - TIPS
Primary Diagnosis
MVC – splenic laceration, transverse colonic injury
Cirrhosis
Slide 4
Clinical History
BRIEF Clinical History
44 y/o
PMH: DM, cirrhosis (?NASH)
2/25 – MVC into tree at high speed
Cardiac arrest, OR – splenectomy, transverse colectomy, packing, VAC,
ortho injuries
Cirrhosis, intraabd varices
Admission – hgb 10.6, plts 65, INR 1.8-2.3, Cr 0.67
ARF, Cr 1.77 – CVVH
Hypotension on pressors
Resp failure
Increased LFTs, TB
Neuro?
Slide 5
Clinical History
BRIEF Clinical History
3/1 variceal bleeding (hgb 6.8), Blakemore tube placed, EGD banding,
TIPS (portosystemic gradient 15-4mmHg)
3/2 fixed dilated pupils, ARF, increased vent requirements, pressors
Withdraw care, death
Slide 6
Analysis of Complication
•
Was the complication potentially avoidable?
–
•
No – traumatic injuries, cirrhosis
What factors contributed the complication?
–
Underlying disease
Slide 7
Evidence Based Literature
Cirrhosis and trauma: a deadly duo.
Am Surg 2005
Review: 61 cirrhosis/156 controls
Increased LOS, increased transfusion
requirements/24h, mortality (33%/1%)
55% deaths due to depsis
Mortality
Childs
A = 15%, B = 37%, C = 63%
Slide 8
Evidence Based Literature
Liver cirrhosis in patients undergoing laparotomy
for trauma: Effect on outcomes
JACS 2004
46 pts with cirrhosis, matched with 2 controls (based
on age, gender, MOI, ISS
Mortality = 45/24%
ISS<15 = 29/5%
ISS 16-25 = 56/11%
ICU stay = 11.5/6.6d
Slide 9
Evidence Based Literature
Cirrhosis and trauma are a lethal combination.
World J Surg 2009, USC/LAC
Review 10 yrs - 36,038 trauma registry patients, 468
(1.3%) had a diagnosis of cirrhosis
Mortality = 12/6%
ARDS, trauma-associated coagulopathy, and septic
complications were significantly more common in the cirrhotic
group
For the subgroup of patients who underwent emergent
abdominal exploration, the mortality rate increased to 40%
compared with that of noncirrhotics at 15%
Slide 10
Sengstaken-Blakemore tube
Passed into esophagus and
gastric balloon is
inflated inside the
stomach. A traction of 1 kg
is applied to the tube so
that the gastric balloon
will compress on the GE
junction to reduce the
blood flow to esophageal
varices. If the use of
traction alone cannot stop
the bleeding, the
esophageal balloon is also
inflated to help stop the
bleeding. The esophageal
balloon should not remain
inflated for more than six
hours, to avoid necrosis.