Week 4 Clinical Case

Case Details

Mr Gerant McWhirter is a 77 year old man who has been admitted to ICU after a Hartmann’s procedure for faecal peritonitis secondary to perforated diverticular disease.

Past Medical History:

Chronic Renal Failure – Creatinine 136 pre-op Smoker

Previous triple coronary artery bypass grafting (2012) Alcoholic related liver disease (Child-Pugh Grade B) Recent weight loss (current weight 48kg)

Operation note:

Peritoneal soiling – full wash out performed. Diseased section of sigmoid colon resected. Rectal stump and end colostomy created.

Medicines include:

SC Heparin 5000 BD                                                  Tazocin QDS

Paracetamol 1g QDS                                               Morphine PCA                                                          No Known Drug Allergies

Admission bloods:

Haematological values Analysis		Reference range
Haemoglobin	96 g/L	130-180 g/L
Leucocytes (WBC)	18.1 x109/L	4-11 x109/L
Platelets	252 x109/L	150-350 x109/L
Prothrombin time Ratio	1.1	1-1.2
Activated partial thromboplastin time	1.0	1-1.2
Fibrinogen	2.3 g/L	1.5-4 g/L

Biochemical Analysis	Result	Reference range
Na	143 mmol/L	134-144 mmol/L
K	4.6 mmol/L	3.5-5 mmol/L
Urea	7.9 mmol/L	2.5-6.6 mmol/L
Creatinine	144 umol/L	60-120 micromol/L
Bilirubin	30	<21 micromol/L
ALT	101	<41 units/L
AST	159	<45 units/L

You are called to see the patient 12 hours post-op due to tachycardia, hypotension and high airway pressures.

A: COETT 8.0

B: VCV 400X16 PEEP 5. Dyssynchronous. See-saw movements of chest and abdomen. SpO2 88% on FiO2 0.6. Peak airway pressure 38cmH2O. Trachea central, percussion normal.

Chest auscultation clear.

C: Pallor. Peripherally cool and mottled. Peripheral capillary refill 6 seconds, central capillary refill 3 seconds. HR 140, thready pulse. BP 85/55. Urine output since theatre, initially 40 ml/hr – last three hours 20ml/5ml/5ml.

D: Sedated with Propofol/Alfentanil. Pupils equal and reactive to light. Blood sugar 6.3 E: Abdomen tense and distended. Temperature 38.1oC

Arterial Blood Gas

Arterial blood gases Analysis	Results	Reference range
Hydrogen ion	53 nmol/L	37-45 nmol/L
PaCO2	3.6 kPa	4.4-6 kPa
PaO2	8.8 kPa	12-15 kPa
Lactate	6.1 mmol/L	0.6-2.4mmol/L
Base deficit	– 4	-2 to +2

Discussion Points

1. What is the likely cause of Mr McWhirter’s deterioration?
2. What would be the most important immediate management steps for Mr McWhirter?

Coagulation Studies

Mr McWhirter’s coagulation results are rung through to the unit:

1. Outline some possible reasons for Mr McWhirter’s coagulation derangement
2. Describe how you might approach blood product transfusion in major haemorrhage – how do you choose which products to administer and when?
3. What other pharmacological and non-pharmacological treatments do we employ in major haemorrhage and why?

Surgery

Mr McWhirter returns to theatre where he is found to have 3L of blood in his abdominal cavity. An arterial bleeder is identified and tied off. In total he receives 4 units of packed red cells, 4 units of FFP, and 1 pool of platelets.

1. What are the serious hazards of transfusion?
2. How can they be avoided?