A study of Post-operative Complications of Emergency

Assignment Task

Case Study 

Chan, a 74-year-old male, was admitted to the ICU following an abdominal laparotomy for the treatment of Crohn's disease. A small bowel resection was performed, and the patient was extubated after 48 hours and transferred to the surgical ward.

Over a period of 72 hours he was complaining of increasing abdominal pain and distension. Abdominal examination revealed some rebound tenderness and the absence of bowel sounds. On day three post operatively, TPN was initiated via his central venous catheter (left internal jugular), he also required High flow nasal canula (40L and FIO2 40%) for respiratory support. On the fourth day, the intra-abdominal pressure was measured at 18 mmHg (bladder catheter technique using 100 mL 0.9% saline) and the patient had an abdominal CT scan with contrast that suggested the presence of a post-operative ileus.

On his return from the CT scanner, the patient vomited and became very short of breath, suggesting pulmonary aspiration. The MET team was called; he required emergency reintubation and gastric contents were aspirated from the airway.
He was readmitted to ICU and immediately required bronchoscopy and pulmonary lavage with 250 ml of 0.9% Sodium Chloride. Subsequently, he was difficult to ventilate, requiring the following ventilation settings with the aim to achieve a PaO2 of 60 mmHg:

1. Explain the pathophysiology underpinning the physiological data obtained from Chan's vital signs, ABG, CXR and cardiac output studies on Day O. Remember to use all the assessment data available to you in Chan's history and observations.

2. Before obtaining any haemodynamic data other than the CVP and central venous saturation, the consultant was inclined to give Chan at least 20 ml/kg of colloid (4% albumin) and a vasopressor in an attempt to improve his haemodynamics. Does the physiological data obtained from the cardiac output studies on Day O support this management strategy for Chan's problems? Provide a critique of relevant evidence based literature to explain your answer.

After assessment of CO studies, a management strategy was implemented. Dobutamine was commenced at 15 mcg/kg/min and a low dose nor-adrenaline infusion (0.15 mcg/kg/min) was added with a target MAP to greater than 70 mmHg. Three units of blood were administered to maintain a haematocrit of 32%. The patient was treated by fluid restriction, a 20% albumin infusion (12 ml/hour to maintain serum albumin greater than 33 g/L) and a frusemide infusion (2-15 mg/hour to maintain urine output greater than 150 ml/hour). After 48 hours of therapy, the patient was in negative fluid balance and inotropic and vasopressor support was reduced over the next five days as oxygenation improved. The patient was successfully extubated on day 8.

3. Using the data obtained over the following 5 days, explain how this management strategy may have led to Chan's improvement and subsequent extubation, justifying your response with relevant evidence.

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