1. Clinopathological Conference 神經外科 徐賢達

2. 廖 o o  Age : 77 years old  Sex : female  Date of Admission : May 25, 2005  Chief complaint : low back pain with radiation to both legs for several years  Ph: 1)uremia on regular hemodialysis 2) CAD 3) peptic ulcer

8. Preoperative data  報告項目報告值單位 下限值 上限值  WBC 4.6*10^3/uL 3.89.8  RBC 5.18*10^6/uL 4.26.2  Hb 11.2g/dL 1318  Ht 36.8% 3853  MCV 71.0fL 8298  MCH 21.6pg 2732  MCHC 30.4% 3136  PL 117*10^3/uL 120320  RDW-CV 17.5% 1215  PDW fL 1016  MPV fL 913  P-LCR % 2045  *10^3/uL 3.89.8  PT 9.4sec 10.713  Control 10.1sec.  INR 0.93  APTT 25.4 536.5

9. Preoperative data  報告項目報告值 單位 下限值上限值  AST (GOT) 42 U/L <38  ALT (GPT) 29 U/L <41  BUN 28 mg/dL620  CRE 5.2 mg/dL0.71.2  Na 138 mmol/L136145  K 4.5 mmol/L3.55.1  GLU-AC 138 mg/dL70115

10. Echocardiography  M – mode : 51.9% LVEF  2D :50.2% LVEF  Conclusion : decreased LV,RV function

11. Preoperative anesthetic assessment  ASA status : III  Specific anesthetic preparation : post- operative intensive care

12. Operation  L3-5 laminectomy  L3-5 transpedicle screw fixation and postero-lateral bone fusion  Blood loss : 2500 c.c  Urine : nil  Transfusion : FFP => 4 units, PRBC => 4 units

13. Postoperative course Day 1(June,6 to 7AM June,7)  GCS : E4VTM6  MP : all Gr. 5  Drainage : 480 cc  NG : coffee ground  I/O : 1504/503  BP: around 105-143/42-68 mmHg

14. Postoperative course(11pm June 6)  報告項目報告值單位下限值上限值  pH 7.3427.347.45  pCO2 20.6▼mmHg3545  pO2 196.6▲mmHg83108  HCO3 11.2▲mmol/L7.347.45  TCO2 11.8▲mmol/L7.347.45  ABE -12.7▼mmol/L7.347.45  Beecf -14.7▼mmol/L7.347.45  SBC 14.2▲mmol/L7.347.45  O2 sat. 99.7▲%7.347.45

16. Postoperative course(8am June 7 to 7am June 8)  Drainage : 3000 cc  NG : coffee ground 910 cc  Urine : nil  FFP => 6 units, PRBC => 8 units  I/O : 4638/4048

17. Postoperative course(8am June 7 to 7am June 8)  BP drop beginning at 9 am (71/35)=> dopamin 10 cc/hr to 40 cc/hr  GCS : E4VTM5 to E1VTM2

18. Postoperative course(8am June 8 to 9pm June 8)  GCS: E1VTM1  BP kept with dopamin and levophed  Metabolic acidosis  Elevated CK, GOT  Cardiac arrhythmia  Expired at 10: 40 pm

19. Postoperative course(1am June 7)  報告項目報告值單位下限值上限值  Na 140mmol/L 136 146  K 4.21mmol/L 3.5 5.1  BUN 46.6▲mg/dL 6 20  CRE 6.15▲mg/dL 0.7 1.2

20. Postoperative course(1am June 7)  報告項目報告值單位下限值上限值  WBC 16.7▲*10^3/uL 3.8 9.8  RBC 1.64▼*10^6/uL 4.2 6.2  Hb 4.0▼g/dL 1318  Ht 13.4▼% 3853  MCV 81.7▼fL 8298  MCH 24.4▼pg 2732  MCHC 29.9▼% 3136  PL 146*10^3/uL 120320  RDW-CV 21.6▲% 1215  PDWfL 10 16  MPVfL 9 13  P-LCR% 20 45  N.band 3% 0 3  N.seg. 85▲% 45 70  Lym. 10▼% 25 40  Mono. 2% 2 8  Eosin. 0▼% 1 3  Baso. 0% 0 1  Aty.Lym.% 0 1  N.RBC /100WBC  Meta. %  Myelo. %  Promyelo. %  Blast %  Monocytoid %

21. Postoperative course(6am June 7)  報告項目報告值單位下限值上限值  pH 7.175▼7.347.45  pCO2 19▼mmHg3545  pO2 205.4▲mmHg83108  HCO3 7▼mmol/L7.347.45  TCO2 7.6▲mmol/L7.347.45  ABE -18.9▼mmol/L7.347.45  BEecf -21.6▼mmol/L7.347.45  SBC 10.3▲mmol/L7.347.45  O2 sat. 99.5▲%7.347.45

22. Postoperative course(2pm June 7)  報告項目報告值單位下限值上限值  pH 7.3667.347.45  pCO2 24.7▼mmHg3545  pO2 166.7▲mmHg83108  HCO3 14.2▲mmol/L7.347.45  TCO2 15.0▲mmol/L7.347.45  ABE -9.0▼mmol/L7.347.45  BEecf -11.4▼mmol/L7.347.45  SBC 17.2▲mmol/L7.347.45  O2 sat. 99.5▲%7.347.45

23. Postoperative course(2pm June 7)  報告項目 報告值單位 下限值上限值  WBC 16.8▲*10^3/uL 3.89.8  RBC 3.13▼*10^6/uL 4.26.2  Hb 9.4▼g/dL 1318  Ht 27.5▼% 3853  MCV 87.9fL 8298  MCH 30.0pg 2732  MCHC 34.2% 3136  PL 89▼*10^3/uL 120320  RDW-CV 17.7▲% 1215  PDW fL 1016  MPV fL 913  P-LCR % 2045  N.band 22▲% 03  N.seg. 52% 4570  Lym. 14▼% 2540  Mono. 5% 28  Eosin. 0▼% 13  Baso. 0% 01  Aty.Lym.% 01  N.RBC /100WBC  Meta. 7 %  Myelo. %  Promyelo. %  Blast %  Monocytoid %

24. Postoperative course(11pm June 7)  報告項目 報告值  Color Dark green.  Clarity Turbid.  OB Strong positive.

25. Postoperative course(4am June 8)  報告項目報告值單位下限值上限值  Hb 9.4g/Dl 13 18  Ht 29.6% 38 53

26. Postoperative course(4am June 8)  報告項目報告值單位下限值上限值  pH 7.221▼ 7.34 7.45  pCO2 24.1▼mmHg 35 45  pO2 77.1▼mmHg 83 108  HCO3 9.9▲mmol/L 7.34 7.45  TCO2 10.7▲mmol/L 7.34 7.45  ABE -15.5▼mmol/L 7.34 7.45  BEecf -18.0▼mmol/L 7.34 7.45  SBC 12.5▲mmol/L 7.34 7.45  O2 sat. 92.7▲% 7.34 7.45

27. Postoperative course(8am June 8)  報告項目報告值單位下限值上限值  Na 140mmol/L 136 146  K 4.57mmol/L 3.5 5.1  TBI 1.21mg/dL <1.0  AST (GOT) 5039U/L <38

28. Postoperative course(12am June 8)  報告項目報告值單位下限值上限值  C K 8967▲IU/L 38 174  CK-MB U/L 7 25

29. Postoperative course(2pm June 8)  報告項目報告值單位下限值上限值  TBI 1.7mg/dL<1.0  DBI 0.75▲mg/dL 00.2  ALT (GPT) 2006U/L<41  CK-MB 337▲U/L 725  Troponin I 6.86ug/L 0< 0.10

30. Postoperative course(9pm June 8)  報告項目報告值單位下限值上限值  pH 6.993▼ 7.34 7.45  pCO229.4▼mmHg 35 45  pO2 108.7▲mmHg 83 108  HCO3 7.2▼mmol/L 7.34 7.45  TCO2 8.1▲mmol/L 7.34 7.45  ABE -22.1▼mmol/L 7.34 7.45  BEecf-24.4▼mmol/L 7.34 7.45  SBC 8.4▲mmol/L 7.34 7.45  O2 sat. 94.5▲% 7.34 7.45

31. Discussion  Acute coagulation disorders –A. preoperative period  Bleeding or clotting manifestations in the patient  Chronic conditions (liver disease, renal disease, hematologic and oncologic disorder, collagen disease, decreased perfusion as a result of CHF, Vit K deficiency or low protein reserves caused by poor nutrition)  Family history  medications

32. Discussion  Acute coagulation disorders –B. during surgery  Dilution  Acute situations of trauma, hypoxia  Metastatic carcinoma  Thoracic, GU, GI, oral, neurosurgical procedures  Incomplete surgical control  Exogenous anticoagulants

33. Discussion  Acute coagulation disorders –C. postoperative period  Any preexisting abnormality will carry over into postoperative period if not corrected  Vitamin K deficiency due to prolonged IV therapy  DIC secondary to bacterial infection  Thrombocytopenia secondary to heparin therapy

34. Discussion  Stress ulcer –Condition mechanism 1.Mechanical ventilation ischemia 2.COPD hyperacidity 3.Shock ischemia 4.Low cardiac output ischemia 5.Prolonged bowel rest barrier disruption