Veterans Affairs - WB Andrew Young

Introduction Complication: Death Procedure: Small bowel resection Primary Diagnosis: Intra-abdominal abscess

WB 73yo man with left lower quadrant pain x 3 weeks ▫Associated with nausea, no emesis ▫Decreased PO intake over last several days with worsening pain ▫Seen by PCP the week prior and CT ordered and scheduled for next week No fevers or chills No recent weight loss

WB PMeHx: CAD, DM, HTN, XOL, PVD, Angina, COPD PSurgHx: CABG in 1998, L iliac angioplasty Meds: Pletal, HCTZ, Isosorbide, NTG, Lisinopril, Norvasc, ASA 81, Plavix Soc: 1.5 ppd

Exam / % RA NAD, AAOx3 Heart: RRR Lung: CTA Abd: soft. Mild TTP in LLQ. No rebound or guarding. +BS. Rectal: no blood, masses.

Laboratory Data: Na: 132 K: 3.1 Cl: 93 CO2: 31 BUN: 15 Cr: 1.2 Glucose: 120 Ca: 8.3 ECG: ST dep in lateral leads (unchanged) WBC: 7.7 Hgb: 11.0 Plt: 196 Troponin: 0.4  1.04 Lactate: 1.8 ECHO 2010: EF 60%

Initial treatment Consult cardiology regarding probably ACS ▫Load with ASA/Plavix Cardiology stated likely demand due to intra- abdominal process. Admit to medicine ▫Requested CT scan for r/o mesenteric ischemia

Operating Room Exploration: ▫Abscess walled off with omentum ▫Area of necrosis 1x1 cm in mesentery which was contiguous with lumen ▫Kissing area in nearby loop with 0.5cm area of necrosis and purulent drainage Procedure: ▫Small bowel resection – 13cm ▫Primary anastomosis

Pathology Mucosal ulceration Transmural perforation Acute on chronic inflammation Acute serositis Culture – pan-sensitive E. Coli

Post Operative Course Extubated post operatively POD 1 ▫Hemodynamically stable ▫Out of bed to chair ▫Beta-blocker begun per cardiology

POD 2 ▫Noted low urine output in AM ▫Hypotension to SBP. ▫Fluid challenge ▫Central line placed – CVP 9 ▫Respiratory distress – intubated ▫Troponin ~ 30; ▫ECHO – LV severely reduced function – EF 20% ▫Cardiology paged – declined intervention ▫V-tach  V-fib  Cardiac arrest – coded and expired

Analysis of Complication Avoidable? ▫Possibly – PCI Would avoiding the complication change the outcome for the patient? ▫Yes Contributing factors: ▫CAD, Previous CABG, Smoker

Post-operative MI Troponin is preferred bio-marker ▫AHA, ACC, ESC, WHF ▫ECG and symptoms may not be reliable When to check? ▫75% of MI occur within 48 hours of surgery ▫65% are asymptomatic Supportive care: ▫Decrease cardiac oxygen demand  Beta blocker & alpha 2 agonists ▫Thrombolysis, CABG, PCI Thygesen et al. Universal definition of Myocardial Infarction. Circulation Nov 27;116(22): Epub 2007 Oct 19 Deveraux et al. Characteristic and Short-Term Prognosis of Perioperative Infarction in Patients Undergoing Noncardiac Surgery. Ann Intern Med. 2011; 154: Chong et al. Incidence of post-operative troponin I rises and 1-year mortality after emergency orthopaedic surgery in older patients. Age and Ageing 2009; 38:

Complication Myocardial infarction ▫Cardiogenic shock  Arrhythmia  Death What to do different?

Cardiac Risk – Elective cases 50k patients will have perioperative MI Identify patients at elevated risk: ▫Unstable coronary syndromes: unstable angina, recent MI ▫Poor functional status, renal insufficiency, CHF, DM, ischemic heart disease Versus those that are not at elevated risk ▫Asymptomatic patients with one risk factor (family history of CAD, smoking, high cholesterol, obesity, inactivity) *except DM Fliesher LA et al. Clinical Practice. Lowering cardiac risk in non cardiac surgery. NEJM Mangano et al. Effects of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. NEJM. 1996