Case 7 - 16 Y/O FEMALE WITH "TANKING" BLOOD PRESSURE [Surgery, Peds, Medicine]

[sozme]

I/NF CASE #7
Relevant to: General Surgery, Medicine, Pediatrics

Will ask for help from general surgeons (@Winged Scapula ) and pediatricians/peds intensivists (@BigRedBeta) on this one.
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Links to previous:
Case 1 Case 2 Case 3
Case 4 Case 5 Case 6
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16-year-old female with a history of colorectal adenocarcinoma 2° to a rare hereditary cancer syndrome and morbid obesity is nine hours’ S/P exploratory laparotomy and adhesiolysis following admission from the E.D. for suspected small bowel obstruction.

You are called at 2307 and informed that patient’s BP has "tanked" to 91/42 and HR 104. Other vital signs are evidently stable. She is reporting no chest pain, SOB, dizziness, or fever/chills, and according to nurse seems drowsy. She currently is on D5 ½ NS at 125 mL/hr and 1 L/min LFNC. She is able to ambulate to and from bathroom with assistance from the nurse. When asked why she is on NC, nurse reports unspecified “breathing problems” in PACU immediately following procedure.

When you evaluate the patient at the bedside, she is completely asymptomatic and says she feels “fine except for the tube in my nose”. Exam is essentially unremarkable. Hemoglobin taken 2 hours ago is 12.3, Hct 39%.

Vital signs record:
112/74 @ 2105
110/78 @ 1806
107/69 @ 1504
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UPDATE #1
UPDATE #2/RESOLUTION

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[Psai]

I would tell the nurse to get a full set of vitals and recheck blood pressure and pulse.

 

[Cello]

Pull every last tooth out

 

[sliceofbread136]

Two things that immediately come to mind are sepsis or a bleed. Would get repeat vitals, cbc, bcx. If repeat bp is low give a bolus.

 

[evilbooyaa]

Pull every last tooth out

I don't understand this. Referencing a previous case?

First obvious answer is to get full re-check of vitals. Assuming vitals are still the same:
What were the other vitals (HR mainly) at the earlier times? How much has come out of her NG Tube (is she dehydrated from significant NGT output)? What's her UOP since the surgery? Foley/measured in hat/unmeasured?
What was her last hemoglobin pre-op?

She's on D51/2NS @ 125 - what's her weight? That's not isotonic so it's not really going to be appropriate maintenance fluid if she's dehydrated. If vitals are still same and patient asx, document in chart, give 1L NS bolus, switch fluids to D5LR (no surgeons use NS). Re-check vitals 30-60 mins after bolus, and call regardless of what they are, or if patient has any symptoms (warning signs: abd. pain, fever, malaise, sweats)

Ex-lap for adhesiolysis? Possible early missed bowel injury (similar to anastomotic leak)?
What's the status of her colorectal carcinoma? When did she have surgery for that? Recently? Anything to resemble a fresh anastomosis, to suggest anastomotic leak?

Two things that immediately come to mind are sepsis or a bleed. Would get repeat vitals, cbc, bcx. If repeat bp is low give a bolus.

Too early post-op for sepsis. Bleed is possible, and if bolus doesn't help, I'd re-check a hemoglobin to be about 4 to 6 hours after the previous one was drawn (no point doing it sooner, IMO).

 

[Slack3r]

Too early post-op for sepsis. Bleed is possible, and if bolus doesn't help, I'd re-check a hemoglobin to be about 4 to 6 hours after the previous one was drawn (no point doing it sooner, IMO).

Nec fasc? Although not with a benign abdomen.

 

[Winged Scapula]

Nec fasc? Although not with a benign abdomen.

She's morbidly obese: don't be fooled by the "benign exam". These patients can hide a lot of pathology.


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[ACSurgeon]

Recheck vitals. BP can be considered normal for patient her age.

Hypotension post op:

- hypovolemia (dehydration is misnomer) usually from under resuscitation is most common. Evaluate intake during operation. How long was she obstructed for? Patients with SBO come in sometimes 5-8 Liters behind (losses AND poor intake). Bleeding is always possible and beware of the "stable" hct. Patients bleed whole blood and it can take up to 24 hrs for you to see a change in hct.

Other things on the differential in order
- PE (more common than sepsis POD 0, unless patient was in the hospital for days before surgery).
- MI (in older patients, not this patient).
- sepsis: look at the wound if febrile. Pan-culture only if patient was inpatient for days or had foley or other reasons for sepsis. For someone coming from home, a necrotizing wound infection is the only cause of infection POD 0. Any patient undergoing laparotomy is subject of missed bowel leak (enterotomy or anastomosis). You'd expect abdominal Sx.

In any hypotensive patient: the heart (MI,PE), the vessels (sepsis) or volume (hypovolemia from hemorrhage or under-resuscitation) are the cause. Evaluate your patient and decide what's most common and start there, but work in series. A lactate (or bicarb on a chemistry) is my favorite to follow.

 

[sliceofbread136]

I don't understand this. Referencing a previous case?

First obvious answer is to get full re-check of vitals. Assuming vitals are still the same:
What were the other vitals (HR mainly) at the earlier times? How much has come out of her NG Tube (is she dehydrated from significant NGT output)? What's her UOP since the surgery? Foley/measured in hat/unmeasured?
What was her last hemoglobin pre-op?

She's on D51/2NS @ 125 - what's her weight? That's not isotonic so it's not really going to be appropriate maintenance fluid if she's dehydrated. If vitals are still same and patient asx, document in chart, give 1L NS bolus, switch fluids to D5LR (no surgeons use NS). Re-check vitals 30-60 mins after bolus, and call regardless of what they are, or if patient has any symptoms (warning signs: abd. pain, fever, malaise, sweats)

Ex-lap for adhesiolysis? Possible early missed bowel injury (similar to anastomotic leak)?
What's the status of her colorectal carcinoma? When did she have surgery for that? Recently? Anything to resemble a fresh anastomosis, to suggest anastomotic leak?



Too early post-op for sepsis. Bleed is possible, and if bolus doesn't help, I'd re-check a hemoglobin to be about 4 to 6 hours after the previous one was drawn (no point doing it sooner, IMO).

I'm no surgery expert, but atleast for the shelf I remember bacteremia from a surgical error (colonic perf) could present fairly early according to onlinemeded

 

[Smurfette]

Does she have a PCA for pain control, or an epidural?
And since no one has asked, what's her urine output?

 

[alpinism]

First recheck vitals. If still abnormal: EtCO2, ABG, ECG, Liter bolus, RUSH exam.

Without more info there's a pretty large initial DDx (blood loss, third spacing, dehydration, perforation, infection, embolism, infarction, arrhythmia, drug side effect, etc...)

A lot would depend on how the patient looked clinically but I'd be more aggressive with reported drowsiness and breathing problems. In any event the above tests are quick, cheap, and effective ways to get a sense of her underlying physiologic status while also helping to rule out a lot of badness at the same time.

 

[HereWeGo21]

Toxic shock syndrome?

 

[BigRedBeta]

Thanks for the shout out @sozme

Context matters a lot - she's obese but has she had stigmata of this prior to her trip to the OR like HTN? Has her pain control finally caught up with her? Did her HR come down from 125 to 104 or has it gone up from 65 to it's current spot. The lack of knowing the reason why she needs the O2 highlights the importance of proper handoff if the patient is moving from one service to another and when coming out of the OR/PACU.

No one over the age of 8 weeks should be on anything other than NS (except for GI cases with liver pathology/ascites) as we now have sufficient evidence that in both surgical and medical pediatric patients should not be on hypotonic fluids, but this is a slow practice change for many institutions.

EtCO2,ECG...RUSH exam

Be careful about shotgun medicine. You should know the limitations of your tests, what you're looking for, and how you're going to use both normal and abnormal results:

Slipstream EtCO2 - how are you going to interpret this, what are you going to tweak if it's 12 or 62 in a patient that otherwise appears fine? Are you going to be reassured if it's 40?
ECG looking for what exactly? Admittedly it's an underused test in pediatrics, but curious what you think you might find.
What's the evidence for a RUSH exam in pediatric patients? Yes, her weight is "adult sized" but you aren't sure that her BMI only means she's 4' 6" and 68kg.

In any hypotensive patient: the heart, the vessels or volume are the cause.

I like your thought process, it does all come back to BP = CO x SVR, but keep in mind that BP does not always correlate with end organ perfusion or Oxygen Delivery.

 

[sozme]

UPDATE #1

I would tell the nurse to get a full set of vitals and recheck blood pressure and pulse.

94/54, HR 103, Temp 98.8, SpO2 100%, RR 18

Ex-lap for adhesiolysis? Possible early missed bowel injury (similar to anastomotic leak)?
What's the status of her colorectal carcinoma? When did she have surgery for that? Recently? Anything to resemble a fresh anastomosis, to suggest anastomotic leak?

Here is the information you are able to get from the surgery PAs note in the EMR within 2 minutes:

She had a hemicolectomy 1.5 years ago. Since that time, has suffered recurrent, intermittent obstruction due to focal band adhesion.

Does she have a PCA for pain control, or an epidural?
And since no one has asked, what's her urine output?

No PCA, no epidural. Pain is controlled with Norco 10/325 q4h, which she received 4 hours ago.
Her UOP is essentially normal.

When you examine her, she seems slightly lethargic, but skin is warm and dry. She is able to converse with you but seems to fall asleep frequently. Arousable to light tactile stimuli and shouting. She says she's not in pain. She keeps asking where her mother is, even after you remind her several times that her mom went to sleep at home for the night.

Nurse: Can you please do something??????????? Should I call a rapid response????

 

[SouthernSurgeon]

UPDATE #1



94/54, HR 103, Temp 98.8, SpO2 100%, RR 18


Here is the information you are able to get from the surgery PAs note in the EMR within 2 minutes:

She had a hemicolectomy 1.5 years ago. Since that time, has suffered recurrent, intermittent obstruction due to focal band adhesion.



No PCA, no epidural. Pain is controlled with Norco 10/325 q4h, which she received 4 hours ago.
Her UOP is essentially normal.

When you examine her, she seems slightly lethargic, but skin is warm and dry. She is able to converse with you but seems to fall asleep frequently. Arousable to light tactile stimuli and shouting. She says she's not in pain. She keeps asking where her mother is, even after you remind her several times that her mom went to sleep at home for the night.

Nurse: Can you please do something??????????? Should I call a rapid response????

Who the F* puts a patient nine hours postop from an ex lap for SBO on oral pain meds?

She's either bleeding/underresuscitated or over narcotized. The latter is easy to diagnose - give narcan and assess for response. If the former, she needs resuscitation and potentially reoperation.

 

[Psai]

call senior

Rectal exam for blood, EKG, cbc, bmp, trop, blood cultures, ua, abg, type and screen, chest x-ray, 1 L NS

I'm most worried about a leak or a bleed. Could be an infection but I doubt it. less concerned about pe and mi although I do think they need to be ruled out.

I want a ct a/p w/o contrast

Check med list

 

[SouthernSurgeon]

call senior

Rectal exam for blood, EKG, cbc, bmp, trop, blood cultures, ua, abg, type and screen, chest x-ray, 1 L NS

I'm most worried about a leak or a bleed. Could be an infection but I doubt it. less concerned about pe and mi although I do think they need to be ruled out.

I want a ct a/p w/o contrast

Check med list

CT has essentially no role on POD0. If your index of suspicion is high enough to be ordering a CT, you should be back in the OR already.

 

[alpinism]

Thanks for the shout out @sozme

Context matters a lot - she's obese but has she had stigmata of this prior to her trip to the OR like HTN? Has her pain control finally caught up with her? Did her HR come down from 125 to 104 or has it gone up from 65 to it's current spot. The lack of knowing the reason why she needs the O2 highlights the importance of proper handoff if the patient is moving from one service to another and when coming out of the OR/PACU.

No one over the age of 8 weeks should be on anything other than NS (except for GI cases with liver pathology/ascites) as we now have sufficient evidence that in both surgical and medical pediatric patients should not be on hypotonic fluids, but this is a slow practice change for many institutions.



Be careful about shotgun medicine. You should know the limitations of your tests, what you're looking for, and how you're going to use both normal and abnormal results:

Slipstream EtCO2 - how are you going to interpret this, what are you going to tweak if it's 12 or 62 in a patient that otherwise appears fine? Are you going to be reassured if it's 40?
ECG looking for what exactly? Admittedly it's an underused test in pediatrics, but curious what you think you might find.
What's the evidence for a RUSH exam in pediatric patients? Yes, her weight is "adult sized" but you aren't sure that her BMI only means she's 4' 6" and 68kg.



I like your thought process, it does all come back to BP = CO x SVR, but keep in mind that BP does not always correlate with end organ perfusion or Oxygen Delivery.

Ugh NS is the Coca-Cola of IV fluids. I'd much rather use LR, especially in sick patients.

In my book ETCO2 is just another "vital sign" rather than a "diagnostic test." I'm assuming she never had it done though since its not included in most nursing vital sign assessments. IMO every sick patient should have end tidal monitoring. I could write a whole paragraph as to why but here's a good overview -
http://www.tamingthesru.com/blog/prehospital-medicine/the-glories-of-end-tidal-co2

ECG is looking for signs of PE and Ischemia. RUSH is looking for causes of hypotension. Both tests look for things that are possible in sick post OP patients regardless of peds or adult. Plus I'd argue that physiologically a 16yo is an adult or at least a borderline adult. Now If this was a 12yo then sure you could argue that more evidence is needed in this case.

 

[TooMuchResearch]

Who the F* puts a patient nine hours postop from an ex lap for SBO on oral pain meds?

She's either bleeding/underresuscitated or over narcotized. The latter is easy to diagnose - give narcan and assess for response. If the former, she needs resuscitation and potentially reoperation.

I'm much more worried about under resuscitation.

But definitely worth a shot to give 0.04 mg Narcan first and see what happens.

 

[jd989898]

What does under resuscitation mean?

 

[TooMuchResearch]

What does under resuscitation mean?

Basically not enough fluid put back into the person who just lost fluid. There are fluid losses from having the open belly in the OR, blood loss from surgery, etc.

Sometimes they come back from the OR many liters down. There are lots of ways to help guide clinical decision making in the possibly under-resuscitated patient which you'll learn in the ICU if you need it - clinical exam, bedside ultrasound of various parts of the vasculature, arterial line waveform, etc. Never hurts to check lactate (or base excess maybe if that's your thing...it isn't mine), but don't let a normal lactate allow you to relax too much.

If you think they might be bleeding, and you're not the surgeon, call the surgeon.

 

[e30ftw]

If you're an intern, order a liter of NS/LR and call your senior.

my impression:

This patient should never have been on low dose oxygen post op. She is hypercapneic causing lethargy and mild hypotension.

D/C O2.

ABG if you want to torture her.

1L NS

Reeval.

 

[chizledfrmstone]

CBC?

Was she put on steroids in the past?

Is there anyway to check Cortisol levels?

 

[evilbooyaa]

I missed the morbid obesity - if she's morbidly obese why in the world is she on 125ml/hr? Maintenance fluids need to be calculated, and she needs to receive likely a few liters bolus (LR, not NS), especially if she's had repeated episodes of SBO (and if this is her first surgery for the SBO). Need to review how much fluid she's received during hospital stay so far.

Hemicolectomy 1.5 years ago seems far enough back that I wouldn't worry about the anastomosis.

How is she on an NGT with oral pain meds? D/C those and switch to IV PRNs at lower dose.

Baby dose of narcan might help (0.04, NOT 0.4)
What's her belly exam? (Not fully reliable especially if she's obese or over-narcotized)

What's "fine" for UOP? 35cc/hr for her is not 'fine' given her weight (need a number for her weight, IMO)

And yes, agree with @SouthernSurgeon that there is no role for CT here. It's going to show post-operative change with some air. If you're worried enough to CT (honestly, I'm not at this point) then its time for bright lights, cold steel.

Final recs - I still give a liter bolus (or more depending on her ins since admission) of LR, notify senior of possible bad brewing, and increase her maintenance fluids up. Maybe give her the baby dose of Narcan as mentioned. I switch her to IV pain meds at lower doses, as honestly, she should be in SOME pain POD#0 after a surgery like this. Stay close, have nurses check on her at least every hour, every 30 minutes preferentially. Call with vitals in 30 minutes after bolus (and maybe Narcan).

I maintain no role for repeat CBC as the last one was only 2 hours ago. Rectal exam won't show anything - if she's bleeding it's 90%+ into her belly IMO, not into the lumen. I'm hard pressed to do an ABG on somebody with a fine O2 sat. I think shotgunning a bunch of tests without waiting to see how your interventions play out in someone who is slightly out of it but not in extremis (from both a signs and symptoms perspective) is a bit extreme.

Again - if she's been in the hospital for < 24 hours, the likelihood of the sepsis work-up being positive is incredibly low.

 

[BigRedBeta]

Ugh NS is the Coca-Cola of IV fluids. I'd much rather use LR, especially in sick patients.

In my book ETCO2 is just another "vital sign" rather than a "diagnostic test." I'm assuming she never had it done though since its not included in most nursing vital sign assessments. IMO every sick patient should have end tidal monitoring. I could write a whole paragraph as to why but here's a good overview -
http://www.tamingthesru.com/blog/prehospital-medicine/the-glories-of-end-tidal-co2

ECG is looking for signs of PE and Ischemia. RUSH is looking for causes of hypotension. Both tests look for things that are possible in sick post OP patients regardless of peds or adult. Plus I'd argue that physiologically a 16yo is an adult or at least a borderline adult. Now If this was a 12yo then sure you could argue that more evidence is needed in this case.

No qualms from me about LR. It's underused in pediatrics where I'm still very much battling people trying to give 1/4NS or 1/3NS based on decades old teaching. LR triggers PTSD from their M3 surgical clerkship in too many pediatricians and in quite a few pediatric institutions is not stocked on the floors.

I know the potential benefits of an ETCO2, but my point is, particularly in a non intubated patient, that the numbers are fraught with inaccuracy - open mouths, washout from NC flow, secretions, deadspace ventilation, hypoventilation, chronic CO2 retention - all reasons that the data may not represent what you think it does. Getting an ABG concurrently certainly provides you greater certainty and the opportunity to troubleshoot/diagnose and a starting point for tracking trends, but I would hesitate to consider ETCO2 without other values of your PCO2 substantial enough to either reassure me or move me to action.

As for her age and physiology - the only thing we can say with any certainty is she's in a grey area. Yes there's a likely continuum from age 10 to age 21 and magically turning 18 doesn't suddenly make you have a completely different set of physiologic principles. The next layer of complexity though is that kids mature at different rates so not all 16 year olds are the same distance away from adult physiology. Hence, there should be a reliance on diagnostic exams that have been validated in the appropriate patient population.

The other thing about her age is that even if her physiology were identical to a 35 year old, her co-morbidities and pre-test probabilities are not. I've only ever seen MI in kids who have a congenital heart defect - usually anomalous coronary origins, left coronaries usually present in infancy. The one ARCAPA was a teenager, but it's an exceedingly rare diagnosis. Her risk of PE is higher, particularly if she's on OCPs, but without a higher O2 requirement and a HR that barely counts as tachycardic? Even so, my understanding is that even in adults EKG findings for PE are very limited in terms of sensitivity and specificity.

 

[chizledfrmstone]

Baby dose of narcan might help (0.04, NOT 0.4)

Just trying to learn. Why does it matter?

 

[evilbooyaa]

Just trying to learn. Why does it matter?

It's the dosing. 0.4mg is what's normally on the crash carts for when you think somebody is so over-narc'd that they're not breathing due to it.
0.04 is when you think somebody is over-narc'd but are still awake, and you're just trying to perk them up a little.

The downside of 0.4mg is that it completely blocks everything for the duration of Narcan, so the patient (who has used narcotics since her surgery) is going to have a block of all pain-blocking effects, and is going to be in severe pain (as if she had received NO pain medication throughout her entire surgery), which doesn't help the situation.

You want to start with a low dose because if it is that they're over narc'd, they will become more alert without having complete blockage of all receptors.

 

[Slack3r]

The downside of 0.4mg is that it completely blocks everything for the duration of Narcan, so the patient (who has used narcotics since her surgery) is going to have a block of all pain-blocking effects, and is going to be in severe pain (as if she had received NO pain medication throughout her entire surgery), which doesn't help the situation.

Might help her BP some...

 

[TooMuchResearch]

Just trying to learn. Why does it matter?

And in a different scenario, you don't necessarily want the guy who just overshot his heroin (which probably contains illicit fentanyl) vomiting and throwing punches, just breathing more.

But if near dead and blue, go for 2... milligrams. Up to 10 mg if fentanyl.

 

[WheezyBaby]

If you're an intern, order a liter of NS/LR and call your senior.

my impression:

This patient should never have been on low dose oxygen post op. She is hypercapneic causing lethargy and mild hypotension.

D/C O2.

ABG if you want to torture her.

1L NS

Reeval.

I like the combo of under resuscitation and hypercarbia. She's got multiple reasons. Abd surg / pain, narcs, possible OHS / OSA. Orthostatics, exam, LR bolus, VBG, lytes, H/H, repeat H/H after resusc. And yea, satting 100% on 1L NC... cut the O2

Edit: prob no checking bladder pressure with her feeling okay, but with her being somewhat out of it, I'd keep it in mind

 

[Radetzky]

Good case for discussion- as an surgical intern (bit different in my part of the world where interns rotate through various specialties) hypotension seemed to be the most common reason to be called to see someone post-op.

Two things that alert me to the idea this might not be your simple post-op under fluid resuscitation are 1. this unspecified breathing problem in PACU 2. the fact that when 16 year olds become both hypotensive and tachycardic they are a lot more intravascularly deplete than your average geriatric patient.

That said at this stage I would bolus with normal saline 1L (given that with SBO she may well have high chloride losses from vomiting), cut the opiates, and take off the O2 and see what happens to the sats. Also is there an anesthetic record available which details how much fluid was given intra-op, and events, what happened in PACU etc? All this is with the proviso of quick reassessment following the bolus and more aggressive investigation thereon-in if this fails to make the situation better.

Hypoventilation/OSA given her obesity and anaesthetic meds is important to consider, although observation of the RR/any upper airway noises should be somewhat reassuring.

Any other meds (pre and post op)?

 

[BigRedBeta]

but don't let a normal lactate allow you to relax too much.

This is an important point in the physiology of shock. Before you reach anaerobic metabolism and lactate production, a decrease in O2 Delivery is countered by increased extraction of oxygen from the blood by the tissues. Unfortunately, without a central line (ideally something that's in the right atrium - femoral lines, which are more typical in pediatrics, on occasion are useful for trending, but the absolute value is not a good measure) to get a mixed venous sat, there's not much lab data that you can query to assess this.

 

[TooMuchResearch]

This is an important point in the physiology of shock. Before you reach anaerobic metabolism and lactate production, a decrease in O2 Delivery is countered by increased extraction of oxygen from the blood by the tissues. Unfortunately, without a central line (ideally something that's in the right atrium - femoral lines, which are more typical in pediatrics, on occasion are useful for trending, but the absolute value is not a good measure) to get a mixed venous sat, there's not much that lab data you can query to assess this.

I had a septic shock patient yesterday with normal lactate.

 

[BigRedBeta]

@sozme Let's get this one going again.

What happened to our vitals after the bolus? What are the results of our labs?

 

[cbrons]

@sozme Let's get this one going again.

What happened to our vitals after the bolus? What are the results of our labs?

Yes please. Less cancer in the Allo threads with more educational stuff like this please.

Sent from my SM-N910P using SDN mobile

 

[sozme]

@sozme Let's get this one going again.

What happened to our vitals after the bolus? What are the results of our labs?

UPDATE #2
Here is what the Intern did.

• He ordered serum lactate, CMP, CBC.
• He ordered 500 mL bolus of LR.
• Lactate returned as normal. Other labs were essentially unchanged compared to previous.
• 500 mL bolus of LR was given, with no appreciative change in VS.
• One hour later, she was more or less the same on exam. He ordered a CT abdomen.
• Before the CT was performed, the nurse called the senior resident who cancelled it.
• The senior showed-up two hours after this all began. At this time, the patient was more or less alert and talking (and cursing at staff for sticking her multiple times).
• The senior changed to a more conservative IV prn regimen and changed her IVFs.

I will leave it that. Thank you to our wonderful attendings and residents who participated.

I learned or was reminded of quite a lot from the responses. Some of them include:

Usefulness of POD-0 CT:

CT has essentially no role on POD0. If your index of suspicion is high enough to be ordering a CT, you should be back in the OR already.

Morbid obesity and false assurance with "unremarkable" exam:

She's morbidly obese: don't be fooled by the "benign exam". These patients can hide a lot of pathology.

General considerations

Recheck vitals. BP can be considered normal for patient her age.

Hypotension post op:

- hypovolemia (dehydration is misnomer) usually from under resuscitation is most common. Evaluate intake during operation. How long was she obstructed for? Patients with SBO come in sometimes 5-8 Liters behind (losses AND poor intake). Bleeding is always possible and beware of the "stable" hct. Patients bleed whole blood and it can take up to 24 hrs for you to see a change in hct.

Other things on the differential in order
- PE (more common than sepsis POD 0, unless patient was in the hospital for days before surgery).
- MI (in older patients, not this patient).
- sepsis: look at the wound if febrile. Pan-culture only if patient was inpatient for days or had foley or other reasons for sepsis. For someone coming from home, a necrotizing wound infection is the only cause of infection POD 0. Any patient undergoing laparotomy is subject of missed bowel leak (enterotomy or anastomosis). You'd expect abdominal Sx.

In any hypotensive patient: the heart (MI,PE), the vessels (sepsis) or volume (hypovolemia from hemorrhage or under-resuscitation) are the cause. Evaluate your patient and decide what's most common and start there, but work in series. A lactate (or bicarb on a chemistry) is my favorite to follow.

End-Tidal CO2:

I know the potential benefits of an ETCO2, but my point is, particularly in a non intubated patient, that the numbers are fraught with inaccuracy - open mouths, washout from NC flow, secretions, deadspace ventilation, hypoventilation, chronic CO2 retention - all reasons that the data may not represent what you think it does. Getting an ABG concurrently certainly provides you greater certainty and the opportunity to troubleshoot/diagnose and a starting point for tracking trends, but I would hesitate to consider ETCO2 without other values of your PCO2 substantial enough to either reassure me or move me to action.

Patient age/test considerations:

As for her age and physiology - the only thing we can say with any certainty is she's in a grey area. Yes there's a likely continuum from age 10 to age 21 and magically turning 18 doesn't suddenly make you have a completely different set of physiologic principles. The next layer of complexity though is that kids mature at different rates so not all 16 year olds are the same distance away from adult physiology. Hence, there should be a reliance on diagnostic exams that have been validated in the appropriate patient population.

The other thing about her age is that even if her physiology were identical to a 35 year old, her co-morbidities and pre-test probabilities are not. I've only ever seen MI in kids who have a congenital heart defect - usually anomalous coronary origins, left coronaries usually present in infancy. The one ARCAPA was a teenager, but it's an exceedingly rare diagnosis. Her risk of PE is higher, particularly if she's on OCPs, but without a higher O2 requirement and a HR that barely counts as tachycardic? Even so, my understanding is that even in adults EKG findings for PE are very limited in terms of sensitivity and specificity

Dosing naloxone for over-narcotized patients:

It's the dosing. 0.4mg is what's normally on the crash carts for when you think somebody is so over-narc'd that they're not breathing due to it.
0.04 is when you think somebody is over-narc'd but are still awake, and you're just trying to perk them up a little.

The downside of 0.4mg is that it completely blocks everything for the duration of Narcan, so the patient (who has used narcotics since her surgery) is going to have a block of all pain-blocking effects, and is going to be in severe pain (as if she had received NO pain medication throughout her entire surgery), which doesn't help the situation.

You want to start with a low dose because if it is that they're over narc'd, they will become more alert without having complete blockage of all receptors.

I will follow-up with a summary post. But in the mean time, can someone speak about the following:

• What would've been appropriate post-operative pain control to start with in this case? PCA?
• Liberal use of supplemental oxygen

 

[WheezyBaby]

UPDATE #2
Here is what the Intern did.

• He ordered serum lactate, CMP, CBC.
• He ordered 500 mL bolus of LR.
• Lactate returned as normal. Other labs were essentially unchanged compared to previous.
• 500 mL bolus of LR was given, with no appreciative change in VS.
• One hour later, she was more or less the same on exam. He ordered a CT abdomen.
• Before the CT was performed, the nurse called the senior resident who cancelled it.
• The senior showed-up two hours after this all began. At this time, the patient was more or less alert and talking (and cursing at staff for sticking her multiple times).
• The senior changed to a more conservative IV prn regimen and changed her IVFs.

I will leave it that. Thank you to our wonderful attendings and residents who participated.

I learned or was reminded of quite a lot from the responses. Some of them include:

Usefulness of POD-0 CT:


Morbid obesity and false assurance with "unremarkable" exam:


General considerations


End-Tidal CO2:


Patient age/test considerations:


Dosing naloxone for over-narcotized patients:


I will follow-up with a summary post. But in the mean time, can someone speak about the following:

• What would've been appropriate post-operative pain control to start with in this case? PCA?
• Liberal use of supplemental oxygen

I routinely turn off O2 that nursing starts if there's any question it's not needed. If they have a true requirement I want the patient to prove it to me so I know their actual situation. You can shrug it off as comfort O2, but that can lead to it just getting uptitrated without calls until youve missed an opportunity for early intervention on whatever's causing an O2 requirement. It's important to determine intermittent (mucous plugging, laryngomalacia, OSA, hypoventilation, etc) vs continuous O2 requirement (shunt, atelectasis, mucous plugging, PNA, PE etc). All that said, if I can prove it's "comfort o2" I don't really mind it outside of some congenital heart and pulmonary disease.

As far as pain control, it varies a lot by patient. I wouldn't give PCA for an ex lap, particularly to this patient. I like po oxy and morphine / dilaudid / fentanyl for breakthrough. Toradol is great if you have no renal concerns

 

[evilbooyaa]

UPDATE #2
Here is what the Intern did.

• He ordered serum lactate, CMP, CBC.
• He ordered 500 mL bolus of LR.
• Lactate returned as normal. Other labs were essentially unchanged compared to previous.
• 500 mL bolus of LR was given, with no appreciative change in VS.
• One hour later, she was more or less the same on exam. He ordered a CT abdomen.
• Before the CT was performed, the nurse called the senior resident who cancelled it.
• The senior showed-up two hours after this all began. At this time, the patient was more or less alert and talking (and cursing at staff for sticking her multiple times).
• The senior changed to a more conservative IV prn regimen and changed her IVFs.

I will follow-up with a summary post. But in the mean time, can someone speak about the following:

• What would've been appropriate post-operative pain control to start with in this case? PCA?
• Liberal use of supplemental oxygen

I still maintain CBC is a waste, but whatever. 500ml bolus of LR is pissing in the wind for hypovolemia in a morbidly obese 16 year old in general, especially one that has had an SBO for god knows how long. 1L x 3 q1-2 hours. Yes, no need for CT Abd on POD#0, pretty much ever.

I routinely turn off O2 that nursing starts if there's any question it's not needed. If they have a true requirement I want the patient to prove it to me so I know their actual situation. You can shrug it off as comfort O2, but that can lead to it just getting uptitrated without calls until youve missed an opportunity for early intervention on whatever's causing an O2 requirement. It's important to determine intermittent (mucous plugging, laryngomalacia, OSA, hypoventilation, etc) vs continuous O2 requirement (shunt, atelectasis, mucous plugging, PNA, PE etc). All that said, if I can prove it's "comfort o2" I don't really mind it outside of some congenital heart and pulmonary disease.

As far as pain control, it varies a lot by patient. I wouldn't give PCA for an ex lap, particularly to this patient. I like po oxy and morphine / dilaudid / fentanyl for breakthrough. Toradol is great if you have no renal concerns

WTF @ bolded. What in the world would a patient need to have to give a PCA for? Patient was just ex-lapped for an SBO and you want to give her oral pain medications?

My goodness, POD#0 you give this lady a PCA (take your pick) with low numbers (although expect that you may have to uptitrate to control pain given her weight). You keep the NGT in her nose, make her NPO (including medications), and give her IV only. Everyone's terrified of giving patients a PCA until you realize that they make your life (or the nurses' [who then make your life]) hell with poorly managed pain control and q1-2 hour PRN pain medications.

I agree with no "comfort O2" as possible.

 

[SouthernSurgeon]

I routinely turn off O2 that nursing starts if there's any question it's not needed. If they have a true requirement I want the patient to prove it to me so I know their actual situation. You can shrug it off as comfort O2, but that can lead to it just getting uptitrated without calls until youve missed an opportunity for early intervention on whatever's causing an O2 requirement. It's important to determine intermittent (mucous plugging, laryngomalacia, OSA, hypoventilation, etc) vs continuous O2 requirement (shunt, atelectasis, mucous plugging, PNA, PE etc). All that said, if I can prove it's "comfort o2" I don't really mind it outside of some congenital heart and pulmonary disease.

As far as pain control, it varies a lot by patient. I wouldn't give PCA for an ex lap, particularly to this patient. I like po oxy and morphine / dilaudid / fentanyl for breakthrough. Toradol is great if you have no renal concerns

WTF indeed.

Patients POD0 from major abdominal surgery get either a PCA or an epidural.

Especially in the setting of a bowel obstruction where (a) you want to minimize oral intake and (b) enteral absorption is compromised.

Toradol and IV Tylenol are nice adjuncts. In the rare opioid naive patients that gets you by or at least reduces narcotic requirements

 

[WheezyBaby]

I still maintain CBC is a waste, but whatever. 500ml bolus of LR is pissing in the wind for hypovolemia in a morbidly obese 16 year old in general, especially one that has had an SBO for god knows how long. 1L x 3 q1-2 hours. Yes, no need for CT Abd on POD#0, pretty much ever.



WTF @ bolded. What in the world would a patient need to have to give a PCA for? Patient was just ex-lapped for an SBO and you want to give her oral pain medications?

My goodness, POD#0 you give this lady a PCA (take your pick) with low numbers (although expect that you may have to uptitrate to control pain given her weight). You keep the NGT in her nose, make her NPO (including medications), and give her IV only. Everyone's terrified of giving patients a PCA until you realize that they make your life (or the nurses' [who then make your life]) hell with poorly managed pain control and q1-2 hour PRN pain medications.

I agree with no "comfort O2" as possible.

WTF indeed.

Patients POD0 from major abdominal surgery get either a PCA or an epidural.

Especially in the setting of a bowel obstruction where (a) you want to minimize oral intake and (b) enteral absorption is compromised.

Toradol and IV Tylenol are nice adjuncts. In the rare opioid naive patients that gets you by or at least reduces narcotic requirements

Brain fart on po oxy, obviously not appropriate. I defer to y'all on pca. In my (considerably) more limited experience for kids coming up after abdominal surgery they go to a unit where q2 med admin isn't burdensome on nursing, and the pain has not seemed poorly controlled. PCA's I've more commonly seen for significant spine surgeries

 

[WheezyBaby]

"Kiddos" are a different deal. We do a lot of nurse controlled PCAs at my hospital but that relies on good nursing care.

The patient in question here is an obese 16 yo...in other words an adult.

Woah don't group me into the kiddos group. I'm guilty only of using kiddo when I have no idea what the gender of the kid is. Both of your other comments are fair

 

[evilbooyaa]

WTF indeed.

Patients POD0 from major abdominal surgery get either a PCA or an epidural.

Especially in the setting of a bowel obstruction where (a) you want to minimize oral intake and (b) enteral absorption is compromised.

Toradol and IV Tylenol are nice adjuncts. In the rare opioid naive patients that gets you by or at least reduces narcotic requirements

I've heard IV Tylenol is a wonder drug, but my hospital never had it despite the request of all the surgeons. Convincing a patient to take rectal tylenol (after an upper GI case) instead of loading up more on narcotics was a losing endeavor more often than not.

I won't pretend to have knowledge of pediatric patients. However, as SS stated, an obese 16 year old, at least from a pain control perspective, is not a pediatric.

 

[Instatewaiter]

ECG is looking for signs of PE and Ischemia.

First, your pre-test probability of ischemia in a 16 year old without CHD is essentially zero. You're not finding ischemia on that EKG.

Second, an EKG for PE isn't exactly sensitive or specific and even worse in a non-adult... especially because she is16 she probably still has juvenile T waves so that takes out a lot of the signs of RV strain. Add to this the fact that the surgeon is ordering the EKG, you might as well flip a coin. It would be quicker and equally as helpful

So fine, get it to define your rhythm but don't expect it to be much more helpful for other things

 

[BigRedBeta]

I've heard IV Tylenol is a wonder drug, but my hospital never had it despite the request of all the surgeons. Convincing a patient to take rectal tylenol (after an upper GI case) instead of loading up more on narcotics was a losing endeavor more often than not.

I won't pretend to have knowledge of pediatric patients. However, as SS stated, an obese 16 year old, at least from a pain control perspective, is not a pediatric.

Wouldn't go that far on IV acetaminophen, but it's a useful option. The literature out there is generally favorable but there are some studies that aren't which helps the non-believers make the case against stocking it.

PCA's are underutilized in many pediatric institutions. It's a bit of a viscous cycle - the pain service is usually only one who can order them (or occasionally the PICU) so the residents don't get any experience ordering them, then when they're attendings they don't feel comfortable so they don't order them, leaving them to the pain service, rinse and repeat. A 16 y/o is exactly the type of patient who should be on a PCA in my book.

 

[deleted393595]

I/NF CASE #7
Relevant to: General Surgery, Medicine, Pediatrics

Will ask for help from general surgeons (@Winged Scapula ) and pediatricians/peds intensivists (@BigRedBeta) on this one.
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Links to previous:
Case 1 Case 2 Case 3
Case 4 Case 5 Case 6
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16-year-old female with a history of colorectal adenocarcinoma 2° to a rare hereditary cancer syndrome and morbid obesity is nine hours’ S/P exploratory laparotomy and adhesiolysis following admission from the E.D. for suspected small bowel obstruction.

You are called at 2307 and informed that patient’s BP has "tanked" to 91/42 and HR 104. Other vital signs are evidently stable. She is reporting no chest pain, SOB, dizziness, or fever/chills, and according to nurse seems drowsy. She currently is on D5 ½ NS at 125 mL/hr and 1 L/min LFNC. She is able to ambulate to and from bathroom with assistance from the nurse. When asked why she is on NC, nurse reports unspecified “breathing problems” in PACU immediately following procedure.

When you evaluate the patient at the bedside, she is completely asymptomatic and says she feels “fine except for the tube in my nose”. Exam is essentially unremarkable. Hemoglobin taken 2 hours ago is 12.3, Hct 39%.

Vital signs record:
112/74 @ 2105
110/78 @ 1806
107/69 @ 1504
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UPDATE #1
UPDATE #2/RESOLUTION

Internal pelvic bleeding.