- Joined
- Mar 6, 2006
- Messages
- 18
- Reaction score
- 0
I would appreciate a view on this:
A 76 year old man has elective surgery to remove gall stones using laproscopic surgery. He has no history of heart problems.
Haemoglobin levels are as follows:
9:30am 13.6 (surgery started at 9:30 and ends at 11:30am)
2pm 4.4
3pm 3.2
Estimated blood loss during surgery = 500ml
Op began 9:30am - first cut, Hg level was 13.6
1. During the op the gall bladder wall was noted to be very thickened and the gall bladder was welded to the liver surface with dense adhesion involving omentum and along the lesser curve.
2. The adhesions wee broken down gently and were patently quite fibrotic and vascular.
3.It proved very difficult to even grip the gall bladder and different grapples had to be used. The decision was taken to proceed from different angles.
4. The gall bladder was finally lifted off the liver bed using diathermy.
5. The gall bladder was retrieved via the umbilical port.
6. At the end of the op there was no significant ooze from the liver.
Time BP
09:00 110/70
09:05 100/58
09:10 90/52
09:15 80/48
09:20 92/59
09:25 92/52
09:30 100/50 First CUT
09:35 120/69
09:40 140/82
09:45 130/78
09:50 140/80
09:55 140/80
10:00 132/74
10:05 131/72
10:10 138/68
10:15 130/65
10:20 122/58
10:25 110/55
10:30 110/54
10:35 110/54
10:40 110/54
10:45 110/56
10:50 120/58
10:55 120/58
11:00 120/62
11:05 111/59
11:10 113/50
11:15 112/50
11:20 90/47
11:25 80/32
11:30 80/32
11:35 92/40
11:40 88/38
RECOVERY
Time BP
11:55 62/41
12:00 74/44 500ml Gelofusin TEMP 34 degrees Celcius
12:06 76/51
12:10 100/58
12:15 85/53
12:20 90/54
12:25 83/61
12:30 92/66
12:35 99/61 Gelofusin ended
12:45 114/68 Dex Saline 1 litre
13:00 99/66
13:10 70/48
13:20 72/52 Ephedrine 3mg/6mg Dex Saline
13:40 65/39 Ephedrine 6mg IV
13:50 88/59
gap 14:20 62/34
gap 14:25 51/34
1/2 hour 14:30 60/46 Frusemide
Readings ended
11:55 Recovery BP 62/41 Low
12:00 BP 74/44 Anaesthetist informed
Gelofusin 500ml over 30mins
BP increased slowly
Temperature 34 degrees - given warming blanket
13:00 Temperature 35 degrees
ECG performed
13:30 Unable to get further peripheral lines
Blood pressure decreasing
Vomited
Ultrasound carried out by
SMALL AMOUNT OF PERITONEAL FLUID no untoward fluid
14:15 Catheterised - 14" and attached to urometer
14:30 40ml IV Frusemide given
CVP line inserted
Desaturated and intubated
CPR commenced in Recovery! CPR in recovery
14:45 Transferred to theatre
Abdomen opened
15:50 Died
SURGEON NOTES AFTER OPERATION
Gall bladder welded to liver
Fibrotic and vascular
Hard to graple
Lifted off
3 large surgicel to gall bladder bed looked fairly dry
Check Hb at 3pm
12:30 Hypotensive in recovery
Opiate related?
Myocardial?
Bleed?
NOTES (RADIOLOGIST)
13:45 Small amount of free peritoneal fluid
Small haematoma near gall bladder bed
OPEN SURGERY NOTES 16:30 RETROSPECTIVE
14:45 Start --- OPENED UP AGAIN
Left lobe of liver, anterior surface breached inadvertently
1-1.5l of heavily blood-stained washout
3x4x5 clot in gall-bladder bed
2 pieces of surgicel
2 superficial venous bleeding points in middle of gall-bladdder bed
Superficial Anterior tear in liver
Stutured - reasonable hameostatic control
Gall-bladder bed bleeding points stutured
Left lateral thoractomy
No further active bleeding was seen
Died 16:00
ANAETHETIST- RETROSPECTIVE
12:00 Called to review blood pressure (70Hg Systolic)
Gelofusin 0.5l over 30mins, then review
13:10 Called again due to Hypotension (70/48)
Morphine given
Gelofusin 500ml IV
Dext Saline 300ml IV
Suspect Post Operative Hypovotaemia
Opiate related hypotension
Acute Myocardial ischemia
ECG
If Hb is less than 7.5 give 2 units of blood
13:15 Velflon inserted and blood sample taken
13:20 Theatre lost stopped.
2 units of blood
See cardiologist
Give fluids - gelofusin 1l started
Catherise
CVP Line
Ultrasound
Refer to ITU/MDU
14:00 Cardiologist busy. ECG reviewed simus rhytm
Heart rate 80
14:10 CVP line inserted
14:20 Tachypnoeic
Hypotensive
Skin pale, sweating
O2 down to 90.96%
ITU called
Intubate
Inotropic support with CVP line
Could not insert art line few times
No ITU beds
14:30 Hb 4.4 Stated retrospectively at 18:30
14:35 Intubate
BP unrecordable
14:40 Cardiac arrest
ECG Simus Rythmn severe
Heart rate 110
No pulse
CPR
14:45 * Separate records, cardiac arrest in Theatre
14:50 * Separate records, 2 units of blood given *
15:00 Hb 4.4 Stated 3.2 retrospectively at 18:30
Start blood transfusion
15:05 CPR
Abdomen distended
Explore abdomen
Blood in abdomen was 1.5-2litres
Taken to theatre
Chest opened
Blood transfusion 13 units of blood
15:25 * Separate notes open cardiac massage *
15:40 No recordable pulse for 1 hour
Pupils dilated
15:40 * Separate notes, 1st DC shock 10-30-50
15:45 * Separate notes, 2nd DC shock 50-50-50
15:50 CPR stopped and pronounced dead
---------------
Blood sample taken at 13:15
CLAIMED NEVER REACHED LAB AND LOST
Claimed taken a sample at 2:30 - Hg 4.4 Results at 3:30pm
Claimed taken a sample at 3:00 - Hg 3.2
Why take 3rd sample if no results have been provided?
Seems odd!
If the first sample had not been lost Hg would have been low,
Blood transfusion may have been immediate different outcome?
When abdomen was distended and second op undertaken the anaesthetist wrote 1.5 to 2litres of blood.
The surgeon claimed blood stained fluid
Was the second op necessary? The patient was as good as dead.
Was it to cover up a mistake?
What was the cause of the abdomen becoming distended full of blood?
Where did the blood come from?
Pathologist claimed modest blood loss
All doctors claimed modest blood loss
Inquest undertaken and all doctors colluded modest blood loss
After inquest, hospital admits severe blood loss and claims it lost the first blood sample, it never reached the lab.
AUTOPSY
An autopsy was undertaken.
The pathologist made a point in his report that there was no evidence of poor surgical technique.
He also stated the op began at 11:30. Really? That is when it ended.
He could not even get this correct.
It is the way he interpreted it.
He also stated modest-post operative blood/fluid loss.
Really? He seems the only one who said that.
Internal Examination
Pericardial cavity contained 150ml of blood stained fluid.
Some haemorrhage into the pericardial fat on the anterior surface of the left ventricle. Sectioning of heart muscle reveals 2 foci of intramuscular haemorrhage each 0.5cm across and in the interventricualar septum and one in the anterior left ventricle.
Respiratory System.
The larynx, trachea and main bronchi contains blood stained fluid.
Lungs congested and heavy in keeping with pulmonary oedema.
Pulmonary arteries contain no thromboemboli.
GI System
50ml blood clot collected in lesser sac.
100ml bloodstained fluid within right side of abdominal cavity.
Liver essentially normal, A 10x6cm diameter raw granular area corresponding to the gall bladder bed. No adherent blood clot to suggest chronic ooze or untoward bleeding
Occasional surgical clips noted in this area.
Clips across cystic duct.
No adherent blood clot to this area and no apparent significant blood loss relating to this area of autopsy. Slicing of liver - no evidence of trauma.
GI System
Very small insignificant right sided haemorrhage in perinephric fat.
Small amount of blood is present in the collecting system of both kidneys.
Urinary catheter noted in situ
CNS
Brain normal, On section, no evidence of haemorrhage or stroke.
HISTOLOGY
Heart - Recent haemorrhage is confirmed between myocardial fibres, but there is no associated acute myocardial ischaemia and no myocartis or vascualitis
Lungs acute vascular congestion and pulmonary oedema only
Comments
Gall baldder tightly stuck to underside of liver by dense fibrous adhesions.
Thus operation technically difficult.
After operation, episodes of intra-abdominal bleed or cardiac malfunction.
CONCLUSION
This man suffered acute left ventricular failure precipitated by a laproscopic cholecystectomy. Although the operation was technically difficult there are no features to suggest poor or careless surgical technique has contributed to the outcome. Given that he had little evidence of significant pre-existing heart condition, and given that fluid/blood loss was relatively modest post operatively, the severity of his heart problems are difficult to account for.
Cause of death
Death in my opinion was due to:
1. Acute left ventricular failure
2. Complicating laproscopic cholecystectomy
Is the reason for death reasonable?
How can he state fluid/blood loss was relatively modest post operatively?
Surely, the correct cause of death was acute left ventricular failure due to excessive blood loss.
Is this cause of death correct? Surely, one should say he bled to death?
Are there any other comments regarding the autopsy/pathology report?
A 76 year old man has elective surgery to remove gall stones using laproscopic surgery. He has no history of heart problems.
Haemoglobin levels are as follows:
9:30am 13.6 (surgery started at 9:30 and ends at 11:30am)
2pm 4.4
3pm 3.2
Estimated blood loss during surgery = 500ml
Op began 9:30am - first cut, Hg level was 13.6
1. During the op the gall bladder wall was noted to be very thickened and the gall bladder was welded to the liver surface with dense adhesion involving omentum and along the lesser curve.
2. The adhesions wee broken down gently and were patently quite fibrotic and vascular.
3.It proved very difficult to even grip the gall bladder and different grapples had to be used. The decision was taken to proceed from different angles.
4. The gall bladder was finally lifted off the liver bed using diathermy.
5. The gall bladder was retrieved via the umbilical port.
6. At the end of the op there was no significant ooze from the liver.
Time BP
09:00 110/70
09:05 100/58
09:10 90/52
09:15 80/48
09:20 92/59
09:25 92/52
09:30 100/50 First CUT
09:35 120/69
09:40 140/82
09:45 130/78
09:50 140/80
09:55 140/80
10:00 132/74
10:05 131/72
10:10 138/68
10:15 130/65
10:20 122/58
10:25 110/55
10:30 110/54
10:35 110/54
10:40 110/54
10:45 110/56
10:50 120/58
10:55 120/58
11:00 120/62
11:05 111/59
11:10 113/50
11:15 112/50
11:20 90/47
11:25 80/32
11:30 80/32
11:35 92/40
11:40 88/38
RECOVERY
Time BP
11:55 62/41
12:00 74/44 500ml Gelofusin TEMP 34 degrees Celcius
12:06 76/51
12:10 100/58
12:15 85/53
12:20 90/54
12:25 83/61
12:30 92/66
12:35 99/61 Gelofusin ended
12:45 114/68 Dex Saline 1 litre
13:00 99/66
13:10 70/48
13:20 72/52 Ephedrine 3mg/6mg Dex Saline
13:40 65/39 Ephedrine 6mg IV
13:50 88/59
gap 14:20 62/34
gap 14:25 51/34
1/2 hour 14:30 60/46 Frusemide
Readings ended
11:55 Recovery BP 62/41 Low
12:00 BP 74/44 Anaesthetist informed
Gelofusin 500ml over 30mins
BP increased slowly
Temperature 34 degrees - given warming blanket
13:00 Temperature 35 degrees
ECG performed
13:30 Unable to get further peripheral lines
Blood pressure decreasing
Vomited
Ultrasound carried out by
SMALL AMOUNT OF PERITONEAL FLUID no untoward fluid
14:15 Catheterised - 14" and attached to urometer
14:30 40ml IV Frusemide given
CVP line inserted
Desaturated and intubated
CPR commenced in Recovery! CPR in recovery
14:45 Transferred to theatre
Abdomen opened
15:50 Died
SURGEON NOTES AFTER OPERATION
Gall bladder welded to liver
Fibrotic and vascular
Hard to graple
Lifted off
3 large surgicel to gall bladder bed looked fairly dry
Check Hb at 3pm
12:30 Hypotensive in recovery
Opiate related?
Myocardial?
Bleed?
NOTES (RADIOLOGIST)
13:45 Small amount of free peritoneal fluid
Small haematoma near gall bladder bed
OPEN SURGERY NOTES 16:30 RETROSPECTIVE
14:45 Start --- OPENED UP AGAIN
Left lobe of liver, anterior surface breached inadvertently
1-1.5l of heavily blood-stained washout
3x4x5 clot in gall-bladder bed
2 pieces of surgicel
2 superficial venous bleeding points in middle of gall-bladdder bed
Superficial Anterior tear in liver
Stutured - reasonable hameostatic control
Gall-bladder bed bleeding points stutured
Left lateral thoractomy
No further active bleeding was seen
Died 16:00
ANAETHETIST- RETROSPECTIVE
12:00 Called to review blood pressure (70Hg Systolic)
Gelofusin 0.5l over 30mins, then review
13:10 Called again due to Hypotension (70/48)
Morphine given
Gelofusin 500ml IV
Dext Saline 300ml IV
Suspect Post Operative Hypovotaemia
Opiate related hypotension
Acute Myocardial ischemia
ECG
If Hb is less than 7.5 give 2 units of blood
13:15 Velflon inserted and blood sample taken
13:20 Theatre lost stopped.
2 units of blood
See cardiologist
Give fluids - gelofusin 1l started
Catherise
CVP Line
Ultrasound
Refer to ITU/MDU
14:00 Cardiologist busy. ECG reviewed simus rhytm
Heart rate 80
14:10 CVP line inserted
14:20 Tachypnoeic
Hypotensive
Skin pale, sweating
O2 down to 90.96%
ITU called
Intubate
Inotropic support with CVP line
Could not insert art line few times
No ITU beds
14:30 Hb 4.4 Stated retrospectively at 18:30
14:35 Intubate
BP unrecordable
14:40 Cardiac arrest
ECG Simus Rythmn severe
Heart rate 110
No pulse
CPR
14:45 * Separate records, cardiac arrest in Theatre
14:50 * Separate records, 2 units of blood given *
15:00 Hb 4.4 Stated 3.2 retrospectively at 18:30
Start blood transfusion
15:05 CPR
Abdomen distended
Explore abdomen
Blood in abdomen was 1.5-2litres
Taken to theatre
Chest opened
Blood transfusion 13 units of blood
15:25 * Separate notes open cardiac massage *
15:40 No recordable pulse for 1 hour
Pupils dilated
15:40 * Separate notes, 1st DC shock 10-30-50
15:45 * Separate notes, 2nd DC shock 50-50-50
15:50 CPR stopped and pronounced dead
---------------
Blood sample taken at 13:15
CLAIMED NEVER REACHED LAB AND LOST
Claimed taken a sample at 2:30 - Hg 4.4 Results at 3:30pm
Claimed taken a sample at 3:00 - Hg 3.2
Why take 3rd sample if no results have been provided?
Seems odd!
If the first sample had not been lost Hg would have been low,
Blood transfusion may have been immediate different outcome?
When abdomen was distended and second op undertaken the anaesthetist wrote 1.5 to 2litres of blood.
The surgeon claimed blood stained fluid
Was the second op necessary? The patient was as good as dead.
Was it to cover up a mistake?
What was the cause of the abdomen becoming distended full of blood?
Where did the blood come from?
Pathologist claimed modest blood loss
All doctors claimed modest blood loss
Inquest undertaken and all doctors colluded modest blood loss
After inquest, hospital admits severe blood loss and claims it lost the first blood sample, it never reached the lab.
AUTOPSY
An autopsy was undertaken.
The pathologist made a point in his report that there was no evidence of poor surgical technique.
He also stated the op began at 11:30. Really? That is when it ended.
He could not even get this correct.
It is the way he interpreted it.
He also stated modest-post operative blood/fluid loss.
Really? He seems the only one who said that.
Internal Examination
Pericardial cavity contained 150ml of blood stained fluid.
Some haemorrhage into the pericardial fat on the anterior surface of the left ventricle. Sectioning of heart muscle reveals 2 foci of intramuscular haemorrhage each 0.5cm across and in the interventricualar septum and one in the anterior left ventricle.
Respiratory System.
The larynx, trachea and main bronchi contains blood stained fluid.
Lungs congested and heavy in keeping with pulmonary oedema.
Pulmonary arteries contain no thromboemboli.
GI System
50ml blood clot collected in lesser sac.
100ml bloodstained fluid within right side of abdominal cavity.
Liver essentially normal, A 10x6cm diameter raw granular area corresponding to the gall bladder bed. No adherent blood clot to suggest chronic ooze or untoward bleeding
Occasional surgical clips noted in this area.
Clips across cystic duct.
No adherent blood clot to this area and no apparent significant blood loss relating to this area of autopsy. Slicing of liver - no evidence of trauma.
GI System
Very small insignificant right sided haemorrhage in perinephric fat.
Small amount of blood is present in the collecting system of both kidneys.
Urinary catheter noted in situ
CNS
Brain normal, On section, no evidence of haemorrhage or stroke.
HISTOLOGY
Heart - Recent haemorrhage is confirmed between myocardial fibres, but there is no associated acute myocardial ischaemia and no myocartis or vascualitis
Lungs acute vascular congestion and pulmonary oedema only
Comments
Gall baldder tightly stuck to underside of liver by dense fibrous adhesions.
Thus operation technically difficult.
After operation, episodes of intra-abdominal bleed or cardiac malfunction.
CONCLUSION
This man suffered acute left ventricular failure precipitated by a laproscopic cholecystectomy. Although the operation was technically difficult there are no features to suggest poor or careless surgical technique has contributed to the outcome. Given that he had little evidence of significant pre-existing heart condition, and given that fluid/blood loss was relatively modest post operatively, the severity of his heart problems are difficult to account for.
Cause of death
Death in my opinion was due to:
1. Acute left ventricular failure
2. Complicating laproscopic cholecystectomy
Is the reason for death reasonable?
How can he state fluid/blood loss was relatively modest post operatively?
Surely, the correct cause of death was acute left ventricular failure due to excessive blood loss.
Is this cause of death correct? Surely, one should say he bled to death?
Are there any other comments regarding the autopsy/pathology report?
