MANILA DOCTORS HOSPITAL

Department of Internal Medicine

United Nations Avenue

CCU Conference

Turning Blue

April 4, 2017
12:00NN -2:00 PM
MBFI Hall
Manila Doctors Hospital

Reporter:
Olivia Faye J. Listanco
rd
3 Year Medical Resident

Reactors:
Dr. Dante Morales Dr. Virgilio Banez
Dr. Elaine Alajar Dr. Luminardo Ramos
Dr. Elmer Llanes Dr. Gino Quizon
Dr. Ian Estanislao Dr. Des Roman
Dr. Albert Albay Dr. Ronald Santos
Dr. Noel Viado Dr. Arlene Afaga
 Moderator:
Dr. Marjorie Obrado

CASE PROTOCOL

General Data: This is a case of FD, a 78-year- old male, married, Catholic, businessman from Malabon, Metro Manila.

Chief Complaint: Epigastric pain

History of Present Illness:

2 week history of recurrent abdominal pain localized at the epigastric area and described as gnawing occurring
few minutes after eating. Patient then sought consult with a surgeon at private hospital and claimed to have normal results
on workup done. He was given unrecalled medications which afforded little relief.
During interval history still had recurrence of epigastric pain.
Last January 23, 2017, patient sought consults at the ER for the abdominal pain. Patient was admitted under the
GI service and managed as a case of acid peptic disease. He also underwent video guided esophagoscopy and
colonoscopy, which showed erosive gastritis and colonic diverticulitis. Patient was started on Pantoprazole 40mg tab OD
pre breakfast, Cefuroxime 500mg BID, and Bisacodyl TID. Patient was discharged last January 24, 2017, with resolution
of abdominal pains.
During interval history still had recurrence of epigastric pain which was minimally relieved with medications.
Day of admission (1/26/17), patient had severe steady epigastric pains radiating to the left lower quadrant unrelieved with
medications, hence patient was brought the ER. Patient had last bowel movement two days prior to admission. No
reported history of vomiting, melena, diarrhea, or changes in stool caliber.

Review of Systems:
General: (-) fever (-) weight loss (+) anorexia
HEENT: (-) retro orbital pain, (-) diplopia
Respiratory: (-) intermittent cough, (-) hemoptysis, (-) dyspnea
Cardiac: (-) chest pain (-) lightheadedness/ dizziness (-) bipedal edema
GI: (-) diarrhea, (+) constipation, (-) hematochezia, (-) melena
Genitourinary: (-) dysuria, (-) hematuria, (-) discharge, (-) decrease in UO
Neuro: (-) seizure, (-) dizziness, (+) loss of consciousness

Past Medical History:

Denies diabetes, hypertension or bronchial asthma
No allergies
No previous MI/ stroke
No history of kidney disease, creatinine done 1/16/17 was 140mol/L

Personal and Social History:

No vices
Denies history of illicit drug use

Baseline functional capacity: Able to do activities of daily living independently. He denies failure or anginal symptoms.

Physical Examination on Admission

General: Conscious, coherent, in pain, not in respiratory distress
Vital Signs: BP 200/100 HR 95 RR 18 Temp 38.9C O2sat 99% at room air
HEENT: Anicteric sclerae, pink palpebral conjunctivae, (-) neck vein engorgement, no cervical lymphadenopathy
Respiratory and Chest: Equal chest expansion, clear breath sounds
Cardiac: Adynamic precordium, tachycardic rate, regular rhythm, distinct S1/S2, PMI at 6 th ICS, left anterior axillary line;
no murmurs
GI: Soft, hypoactive bowel sounds, tenderness on left lower quadrant, flabby abdomen, (-) palpable masses
Extremities: (-) bipedal edema, no cyanosis
Neurological Exam: unremarkable

Course at the ER:

(1/26/17)
At the ER, patient was in severe abdominal pain. Blood pressure was 200/100, normo-cardic and with adequate
oxygen saturation. Patient was initially given Tramadol 50mg IV, which afforded relief from the epigastric pain and
eventual lowering of BP. Initial test done showed leukocytosis (WBC 43.870) with neutrophilic predominance. Creatinine
was elevated at 178mol/L, and electrolytes were normal. Twelve-lead ECG showed Sinus bradycardia, non-specific ST-T
wave changes. Whole abdominal plain x-ray showed signs of ileus and no reported signs of pneumoperitonium. Blood
culture was also done. ABG showed mixed respiratory alkalosis and metabolic acidosis with adequate oxygenation. Initial
impression was peptic ulcer disease vs acute diverticulitis, acute kidney injury probably secondary to systemic infection
response syndrome, mixed hemorrhoids, functional constipation and reactive hypertension.
Patient was admitted at the ward under the GI service. Patient was started with Ciprofloxacin 200mg IV Q12 and
Metronidazole 500mg, Pantoprazole 40mg IV OD, HNBB 10mh IV Q8, Ranitidine 50mg IV Q8, Bisacodyl suppository,
Pinaverium 50mg tab TID and Paracetamol 50omg tab Q4 PRN for fever. Abdominal pain was controlled with
antispasmodic and tramadol. Patient was also referred to the renal service for clearance for the contemplated whole
abdomen CT scan with oral and IV contrast. Patients risk for contrast induced nephropathy was 14%, and risk for HD was
0.12%. IV hydration was continued and N-acetylcysteine 1.2gm IV Q12 was started. .

(1/27/17)
 On the 1st HD, patient still had epigastric pains temporarily relieved with bowel movement and medications. He
still had febrile episodes Tmax 38C and rest of vital signs were within normal range. Patient was in basic sinus rhythm.
Abdominal PE was soft but with tenderness on deep palpation on the lower quadrants. Tramadol was increased to Q8
round the clock for further control of pain. Repeat creatinine showed further increased at 256mol/L. Patient was given
bicarbonate drip 6 hours prior to procedure.

(1/28-29/17)
On the 2nd HD, patient had stable vital signs but still with abdominal pains. Patient was in basic sinus rhythm.
Whole abdomen CT scan showed splenic and kidneys infarction and thrombus formation in the thoracic aorta and
suggestively within the distal segment of the superior mesenteric artery. Impression at this time was arterial thrombosis,
descending thoracic aorta to abdominal aorta, distal and superior mesenteric artery, T/C malignancy vs cardiac in origin;
AKI probably renovascular segment and infrarenal ischemia.
Patient was then referred to the vascular service. Patient was then put in NPO and started on enoxaparin 0.6cc SQ OD,
then adjusted to 0.4cc SQ OD, and ciprofloxacin was shifted to Piperacillin Tazobactam 2.25gm IV Q6.
Patient was initially referred to the TCVS service, but eventually referred to general surgery service. Surgical
impression was acute mesenteric infarction and was scheduled for exploratory laparotomy, possible bowel resection.
Cardiopulmonary evaluation was done as an emergency procedure and enoxaparin was discontinued. Patient
was then cleared by GI, cardiology, and renal services for the procedure. Two-D echo done showed concentric Left
ventricular remodeling with segmental wall motion abnormality and with preserved systolic function, diastolic profile
suggestive of impaired left ventricular relaxation.
Patient underwent emergency explore laparotomy segmental resection of the jejunum and ileum. Intraoperative
surgical finding was red to dusky patches at the ileocecal segment up to 10cm from the ileocecal valve, segmental
gangrene in the jejunum approximately 60cm from the ligament of Treitz. Patient had episodes of hypotension and was
hooked to dopamine at 10mcg/kg, intraoperatively. No reported arrhythmia during the procedure. Post procedure patient
was admitted at the ICU.
At the ICU, patient had vital signs within normal limits and a basic rhythm was in sinus. Post-op CBC showed
further slight decrease in the degree of leukocytosis but still with neutrophilic predominance and adequate hemoglobin
and hematocrit. Piperacillin tazobactam and metronidazole were continued. Creatinine remained elevated at 210mol/L
and IV hydration, NAC were continued. Hypokalemia was also noted at 3.1mmol/, hence 40meq KCL was incorporated in
the IVF. Hypomagnesaemia at 0.60mmol/L was corrected with one cycle of MgSO 4. He was also given unfractionated
Heparin 3600 units IV bolus, then maintained at 700 units/hr. Heparin drip was titrated with serial PT and Rashke protocol
to attain target partial prothrombin time (PTT) ratio of 2.0-2.5. He was maintained on mechanical ventilator support, IV
hydrations and down titration and eventual discontinuation of inotropic was done. NPO was resumed and TPN was
started. Surgery service planned to do re-assessment of the bowel segments after 24-48 hours.

(1/30/17)
On the 4th HD (1st day post op), patient was still intubated with stable vital signs and adequate urine output.
Patient was in basic sinus rhythm. He had no complaints of hypotension, desaturation, fever, or bleeding episodes.
Abdominal PE was soft, hypoactive bowel sounds, tenderness on surrounding pot op site. Fluid balance remained positive
hence IV furosemide doses were given. Adequate control of abdominal pain and post-operative pain was done.
Preliminary blood culture result was negative; Piperacillin tazobactam and metronidazole were continued. Repeat PTT
had ratio on 1.7 and heparin drip was continued at 900 u/hr.
Vascular cardiology services planned to repeat CT angiogram of the abdomen prior to second-look for the re-
evaluation and requested to be referred back to TCVS for possible embolectomy or revascularization. Renal-wise, patient
was assessed to have high risk for kidney injury of re-exposure to IV contrast dye but the benefits outweighed the risk
hence patient was cleared for the procedure. Bicarbonate drip was again given prior to the imaging study. Repeat CT
angiogram of the abdomen showed the thrombus formations in the aorta (t10 and t11 levels) and distal superior
mesenteric artery which exhibits complete occlusion.
Patient underwent re-exploration with segmental resection of the jejunum with end to end anastomosis and IJ
catheter insertion. Intra operative findings included, small anastomotic leak at the distal jejuno-ileal anastomosis. The
terminal ileum and cecum remained pinkish and viable while the area proximal to the distal anastomosis bowel was dusky
with demarcation of color at approximately 10cm from the proximal anastomosis. TCVS reported strong middle colic and
ileo colic artery and proximal jejunal artery pulses. Dusky jejunal segment approximately 20cm resected then created a
new jenuno-ileal distal anastomosis. Estimated length of the small intestine from the ligament of Treitz to the ileocecal
valve was 75cm. intraoperatively; no hypotension, arrhythmia, or desaturation was reported.
At the ICU, patient had with normal vital signs and was in basic sinus rhythm. Heparin drip was resumed at
900units/hr. NPO was maintained and parenteral nutrition and IV hydration were continued. Ventilatory support was then
started to be down titrated.

(1/31/17)
On 5th HD (1st day post reopening), patient had stable vital signs, tolerating CMV mode on mechanical ventilator,
and with adequate urine output. No hypotension, arrhythmia, or desaturation. On PE, patient had minimal bibasal
crackles, non-distended neck veins but with positive fluid balance, hence furosemide IV bolus was given. Abdomen was
soft, hypoactive bowel sounds with tenderness on the left hemiabdomen. Repeat CBC showed relatively unchanged
levels of leukocytosis, and PTT ratio was 3.05. Heparin drip was maintained at 600units/hr. 24 hour Holter monitoring was
done.

(2/1/17)
On the 6th HD (2nd day post op), patient had stable vital signs, and tolerating CPAP mode on mechanical ventilator.
On PE, lungs showed persistent basal rales and chest x-ray done showed poor inspiratory film with no active infiltrates.
No fever or changes in appearance of the ET secretions was reported. Antibiotics were continued.
Patient had incidental finding of intermittent episodes of atrial fibrillation however 12 lead ECG showed normal
sinus rhythm, non-specific ST-T wave changes. Troponin I and TSH levels done yielded normal values. Review of the
2decho showed indications of CAD and initiation of antiplatelet, statin, and ACE inhibitor once with clearance with other
services and no bleeding episode occur. Heparin drip was at 400units/hr. No reported associated palpitations, dizziness or
chest pains.
Patient had adequate urine output but still with positive fluid balance. On PE, neck veins were not distended,
bibasal rales and with beginning grade 1 bipedal edema. Furosemide 40mg IV Q8 was started and IV rate was
decreased.

(2/2/17)
 On the 7th HD (3rd day post op), patient had stable vital signs, and tolerating T-piece at Inspiron 28 side flow 8lpm.
No recurrence of arrhythmia desaturation, fever or hypotension reported. Patient was extubated and tolerated 4lpm via
nasal cannula. TPN and antibiotics were continued and NPO was maintained.
Abdominal PE showed, normoactive bowel sounds and no tenderness. No reports of bleeding were made.
Patient had had flatulence bowel movement at this time.
Vascular service input included Holter result of sinus rhythm with non-sustained MFAT. Repeat PTT ratio showed
3.3 and heparin was discontinued and enoxaparin 0.4cc SQ Q12 was started. Hypercoagulable work up was
contemplated.

(2/3-4/17)
On the 8th HD (4th day post op), patient has episode of non-sustained ventricular tachycardia for 6 seconds hence
Carvedilol 6.25mg tab OD was started. No recurrence of arrhythmia was reported after. Abdomen PE remained
unremarkable. Patient was allowed sips of water. Antibiotics, enoxaparin, and TPN were continued. Repeat CBC showed
further improvement in the degree of leukocytosis and creatinine. Albumin however remained low at 16.1mmol/L. Patient
was then transferred to regular room.

(2/5/17)
On the 9th HD (5th day post op), patient was noted to have increased BP ranges at 130-50/80-100mmHg hence
Enalapril 5mg tab OD and Carvedilol was increased to 1 tan BID. Patient was noted to have basic sinus rhythm with
episodes of skipped beats, MgSO4 drip was started. Vascular service planned to start anticoagulation with Warfarin once
cleared with all services. Rest of the vital signs was unremarkable. Patient was tolerating sips of water. No abdominal
pains diarrhea or decreased urine output were made.

(2/6/17)
On the 10th HD (6th day post op), vital signs were stable with adequate urine output. Patient had episodes of
watery bilous bowel movement at 10x/ day. Patient was given loperamide and fecalysis was requested. Surgery service
requested for repeat CT scan of the abdomen with IV contrast to rule out re-infarction. Patient was started with Warfarin
2.5mg tab ODHS and enoxaparin was continued as well. Piperacillin tazobactam was continued but Metronidazole was
discontinued.

(2/7-8/17)
On the 11th HD (7th day post op), vital signs were stable with adequate urine output with note of decreased in
episodes of diarrhea. Patient was again started on bicarbonate drip for the preparation for the whole abdomen CT scan
with IV contrast. Imaging showed generalized mild ileus and evidences of peritoneal irritation of the remaining small bowel
segments and development of abdominal ascites. Findings of unchanged thrombus formations in the thoracic aorta and within
the distal segment of the superior mesenteric artery and unchanged findings of possible splenic and renal infarctions as well as
multiple hepatic and renal cysts were also noted. PT/INR 1.43 and warfarin was increased to 2.5mg1 tan ODHS. Repeat
lab showed increased in WBC to 40.22 from 36.35, and hypokalemia at 3.4mmol/L. KCL incorporation in the IVF was
done.
Patient was also referred to the hematology service, consideration for hereditary thrombophilia and
myeloproliferative disorder were made. Jak 2 mutation assay, factor VLeiden, Prothrombin 620210A mutation assay were
made.
(2/9-10/17)
On the 11th HD (9th day post op), vital signs were stable with adequate urine output. There was a note of fever
Tmax 38,4C and had complaints of epigastric pains minimally relieved with ranitidine and pantoprazole but no recurrence
of diarrhea. On PE, lungs had bilateral crackles and abdomen was soft and distended. Blood cultures were repeated.
Piperacillin tazobactam was shifted to Meropenem 1mg IV Q8 and Enoxaparin was resumed at 0.4cc SQ ODHS.

(2/11/17)
On the 13th HD (11th day post op), patient was referred for tachypnea and with desaturation as low as 79% after a
bout of vomiting. O2 was initially increased to 6lpm but patient further went into desaturation hence patient was intubated.
BP was initially stable but hypotension was noted post intubation, and norepinephrine drip was started at 1.2meq and
antihypertensive medications were discontinued. Also noted to have no urine output for past 4 hours and was
unresponsive to furosemide IV bolus. Furosemide drip and dopamine renal dose were started as well. Impression at this
time was acute respiratory failure secondary to HAP with aspiration component, R/O bowel re-infarction, and acute renal
failure secondary to infection. Patient was transferred to the ICU.

(2/12/17)
On the 14th HD (12th day post op), patient was still on inotropic support and was anuric. Repeat CBC showed
anemia at hemoglobin 86 and further increase in the leukocytosis ay 92.10. Patient had1 u pRBC transfused. Blood
culture initial result was negative. Initiation of dialysis with albumin infusion was done too.
Patient had episode of bradycardia as low as 36bpm which then converted to pulseless electrical activity. ACLS
was done for 3 minutes with one dose of epinephrine 1mg IV. Rhythm was the reverted to SVT with BP at 100/70 and
Adenosine 6mg IV was initially given followed by Verapamil 2.5mg IV. After which rhythm was converted to sinus.
ACLS was again after a few hours for 6 minutes, rhythm was pulseless electrical activity. Post ACS patient was noted to
GCS 3 with pupils 2-3mm briskly reactive to light. Family was then appraised on the events and prognosis of the patient
and they opted to hold resuscitation in the recurrence of another CP arrest but they maintained to be medically
aggressive.

(2/13/17)
On the 15th HD (13th day post op), patient was at GCS 3 and on maximum dose of inotropic support. Mechanical
ventilator was maintained on CMV mode. Repeat last showed further increased in the levels of creatinine and CBC
showed resolved anemia but with persistent high WBC. Patient then underwent second dialysis session.
Post dialysis patient had episodes of sinus bradycardia as low. He was given Atropine 0.5mg IV for 2 doses. Heart
rate responded to 50bpm but in lieu of recent events family the opted to withdraw medical aggressiveness. Patient expired
at 2/13/17, 10:37PM.

Nothing follows