1. General Surgery M&M meeting 07/11/2007 26/10/1428 Sultan Al Sheikh

2. DOA 13/04/28 (30/4/2007) 844895 62 y, SA, M known to have BA C/O  Diarrhea 1/12  12/day  Black, watery, fresh blood  Ass Anorexia, Wt loss 15 kg in 2/52

3. Sought Medical advice in a private clinic CT Abdomen report  Mass at hepatic flexure  Liver metastasis

4. O/E  V/S stable  Chest Ex good AE no added sounds  CVS Ex S1 +S2 + 0 no LL edema  ABD Ex soft lax abdomen +ve BS LABS  CBC U&E LFT Coagulation N  CEA 18.76

5. 14/04/28 (1/5/2007) Colonoscopy  Severe Ulcerations suggestive for UC  Poor Bowel prep Repeat colonoscopy

6. 15/04/28 (2/5/2007) CT reviewed  Thickened wall of colon at hepatic flexure  Inflamed mesentery  Focal Liver lesion most likely a focal fatty liver MRI recommended  Done 2 days later and confirmed the Liver’s fatty focal lesion

7. 19/04/28 (6/5/2007) Colonoscopy repeated  Severe colitis  Sever deep ulcerations  Severe pseudo polyps necrosis & reddish pus-like fluid  CD

8. Biopsy  Active chronic colitis  With extensive ulcerations  No granuloma  Vasculitis and thrombi of small vessels  No dysplasia or malignant cells

9. 20/04/28 (7/5/2007) CVL inserted TPN started PPD done Negative IV Methyl prednisolone Cipro & flagyl Daily AXR

10. 21/04/28 (8/5/2007) 9 BMs blood AXR dilated left colon

11. 22/04/28 (9/5/2007) 8 BMs T 37C BP 140/80 mmHg HR 85/min RR 20/min spO2 95% on RA

12. 23/04/28 (10/5/2007) 5 BMs Imuran started 50mg OD PPD –ve

13. 27/04/28 (14/5/2007) No blood in BMs for 3 days Defecation is less Infleximab was planned for next week Na 131 K 5.9 Creat 65 Urea 3.8 TPN adjusted

14. 5/05/28 (21/5/2007) CT done after slow bowel prep  Diffused wall Thickening of colon  Focal irregular circumferential thickening at hapatic flexure  Small amount of free air  No free fluids or collection  No leak or inflammatory changes  Suggestive of sealed perforated viscus

17. 7/05/28 (23/5/2007) CT scan repeated  No progression in the disease  air under diaphragm  Colonic dilatation still the same  Diffused wall thickening less than before 2 BMs without blood Clear liquid diet started the next day Ampicllin was started

20. 15/05/28 (1/6/2007) Diarrhea twice Fresh blood 50 cc last BM Suffering Pain and distention Tachycardia Tachypnea Toxic Mega colon

21. 15/05/28 (1/6/2007) Family and the patient were spoken to Surgery was considered Complications explained  Death quoted at 5%  DVT PE MI Stroke  Infections Pneumonia UTI Wound Pt consented for surgery the next day

22. 16/05/28 (2/6/2007) Laprotomy Sub total colectomy + Ileostomy Colon distended with adhesions Colon was perforated during surgery 3 PRBCs given

23. 16/05/28 (2/6/2007) D1 post op in ICU Extubated Awake talking oreinted Sips of water In 1621 Out 830 Na 136 K 4.7 Creat 54 Urea 3.6 WBC8.4Hb 112Plt 182 PT22.2 INR2.00 APTT 49

24. CXR 16/05/28 (2/6/2007)

25. 17/05/28 (3/6/2007) D2 post op 4PM  Pt transferred to the floor 6PM  started having SOB sweating LOC and became disoriente HR 110-130 BP 120/66 RR 23 spO2 99% on NC 5l O2

26. 17/05/28 (3/6/2007) Chest Ex  AE Bilateral crackles and Wheezes CVS Ex NAD Abd Ex  Soft lax  Ileostomy bag  2 drains  Rectal drain

27. 17/05/28 (3/6/2007) 8PM Transferred to HDU RBS 2.4 50cc D50 RBS 7 CXR  L consulidations  Bilat infeltration ECG  Sinus tachy Impression  BA Volume overload hypoglycemia

28. CXR 17/05/28 (3/6/2007)

29. 18/05/28 (4/6/2007) D3 post op 3AM Confused A fib MOC  Tachycardia  observation

30. 18/05/28 (4/6/2007) 7:30AM Pt confused V/S HR 140-150 BP 100/60 T 38.0 RR 25 WBC 15.2 Hb 114 plt 102 PT 24.7INR 2.3APTT 41.7

31. 18/05/28 (4/6/2007) CT brain and neurology cons ID consultation ECG and Cardiology Consultation Blood C/S Pseudomonas 3 days later

32. 18/05/28 (4/6/2007) CT  No ischemia  No bleeding  Brain atrophy Normal to age Neurology  Disoriented to TP  Ischemic encephalopathy  EEG slow activity

33. CT Brain

34. 18/05/28 (4/6/2007) Cardiology  No A fib  Sinus tachy d/t ventolin  No signs of heart failure  Lasix and space ventolin ID  Tazocin 3.375 cont Flagyl  DC cipro

35. 18/05/28 (4/6/2007) 3PM Transferred to SICU HR 150-175 BP 100/65 80s CVP 8 T 38.7 RR 25 NE and suction started Cardiology asked to taper NE CXR pneumonia Vs overload

36. CXR 18/05/28 (4/6/2007)

37. 18/05/28 (4/6/2007) 11:30 PM  Drowsy  Responding to painful stimuli only  HR 65 BP 70/50  Intubated Later  A Fib  Electro Cardioversion

38. 19/05/28 (5/6/2007) D4 post op NE 20 mcg Tazocin Flagyl hydrocortisone albumin Amiodarone started Sedated intubated Drains: R Nil L 10 cc Rectal Nil In 2700 out 1150

39. 19/05/28 (5/6/2007) BP 110/63 HR 125 RR18 PEEP 7 CVP 5 T 36.8 post paracetamol Chest: AE bilat crips and wheezes WBC 15.3 Hb 10.1 Plt 160 ECHO was Normal

40. 19/05/28 (5/6/2007) 4PM pH 7.17 pCO2 60.8 pO2 107 O2 sat 98% HCO 21.7 FiO2.80 PEEP 15 RR 24

41. 19/05/28 (5/6/2007) 8:50 PM Na 138 K 4.8 Creat 198 Urea 11.9 Dopamin 15mcg

42. CXR 19/05/28 (5/6/2007)

43. 20/05/28 (6/6/2007) D5 post op Nephrology  ARF Septic shock  Dialysis  Input 6244 UOP 298 ID  CS G-ve bacilli sensitive to Tazo Mero Imip  DC Tazo start Meropenim

44. 20/05/28 (6/6/2007) A fib Cardioversion HR 135/min BP 105/60 NE 20 mcg Dopamine 15 mcg

45. CXR 20/05/28 (6/6/2007)

46. 21/05/28 (7/6/2007) D6 post op BP 100/45 T 35.2 RR 30/min HR 130 spO2 94% Epinephrine added

47. 21/05/28 (7/6/2007) WBC 8.9 Hb 7.8 plt 38 Na 133 K 3.6 Creat 152 Urea 10.3 pH 7.23 pO2 72 pCO 54 HCO 20 IV IGg considered ID agreed but pharmacy refused

48. 22/05/28 (8/6/2007) D7 post op IGg started Epi NE Dopa and Fenylephrine at max Dialysis ultra filtration prisma

49. 22/05/28 (8/6/2007) BP 52/41 HR 125 T 37.1 CVP 21 RR 34 PEEP 20 pH 7.059 pO 64 pCO 56 HCO 15.8  After bicarb boluses PT 24.3 INR 2.25 APTT 45

50. 23/05/28 (9/6/2007) D8 post op 2AM  Coded  Resuscitation 25 mins Direct Cause of Death  Cardiac arrest Final Diagnosis  Septic shock, ARDS, ARF, Coagulopathy

51. THANK YOU