B-A - Mortality Audit Presentation.pptx

Audit

1. Mortality Audit Dr. Bukenya Ali 26th/July/2024

2. OUTLINE CASE PRESENTATION DISCUSSION TAKE HOME MESSAGE

3. CASE PRESENTATION NAME; O.J AGE; 83 SEX; MALE RESIDENCE; KISOKO, TORORO RELIGION; CATHOLIC OCCUPATION; RETIRED N.O.K; O.V (SON) DOA; 10/MAY/2024 16:00HRS…? DOD;13 TH /MAY/2024 18:30HRS

4. An 83Y/M with back ground hx of HTN > 2Yrs, brought in as a referral with a diagnosis of obstructive jaundice, from Mount Elgon Hospital for further management. P/C: Chronic body itching over 5/12 and yellow coloration of the eyes for over 5/12. HPC: Received a pt who was unwell for the past 6/12 Was fully hospitalized x 1/12 from the above referral hospital. C/O Yellow coloration of eyes that was first observed in August 2023 that ahs persisted to date. Associated with generalised body itching Cont . . . Reported passing pale (clay colored) stool x 4/12. However x 4/7, began passing melena stools with no constipation, but with abdominal distention x 2/12 with associated abdominal pain. Reports no vomiting, no nausea but has marked reduction in appetite for food with associated pain and difficulty with swallowing. C/O marked reduction in weight observed over the past 3-4 months. No food or drug allergies;

5. R.O.S GUS; Has had a urinary catheter insitu x 3/52 and notably producing concentrated urine of good amount, draining (per day) ~ 500mls – 1000mls. R/S No cough, no chest pain and No D.I.B. CNS – Care takers report that he has had some confusion of speech, observed for the past 3/7. Vitals: BP = 123/59 mmHg, PR = 65 bpm, SPO2 = 93-94% (RA), RBS = 4.8mmol/l PMHX h/o hospitalization for the past x 1/12, had multiple infusions with Albumin. Background HTN > 2 yrs and been ambulating on Tabs Bendroflumethiazide, Tabs Nifedipine 20mg O.D. However, drugs were withheld x 3/52 ago PSHx . Had blood transfusion 1/7 ago. Had hernia repair and prostate surgery ~ 20 years ago. FSHx Married man with 10 children Occasionally takes alcohol (both local and manufactured breweries). No h/o smoking

6. O/E: Sick looking, Deep jaundice (+++), Yellow skin coloration most marked in the thighs. Mildly dehydrated. Bilateral pitting Odema (++). Vitals: BP = 123/59 mmHg, PR = 65 Bpm, SPO2 = 93-94% (RA), RBS = 4.8mmol/l P/A Moderate distended, with shifting dullness Hepatomegaly measuring ~ 04 cm below the SCM Mild tenderness in Epigastric region. Reduced bowel sound ~ 2 in a minute. DRE: Normal anal sphincter tone, rectum full with hard stool. L/E: Noted a L side neck mass ~ 10x8 cm, firm, non-tender, fixed to underlying tissues, No temp. differences or gradients

7. CNS – Reduced levels of consciousness with GCS of 14/15 (V = 4, E =4 and M= 6) PAL. R/S – Not in any respiratory distress. RR – 20 breaths per minute, equal bilateral air entry with minimal basal crepitations bilaterally. CVS: Heart sounds 1 and 2 normal. No murmurs. Note: Abd U/S scan done on 06 th of Apr 2024,with conclusion of BPH, biliary obstruction, due to obstruction at the ampulla of vater . Cholecystitis, Lt. renal cortical cysts and supra-umbilical hernia. on 06 th of Apr 2024 On 24 th of Apr 2024, Albumin = 23.0 (from 35 to 50) Impression / Issues An 83Y/M with background hx of HTN with; Jaundice. ?? Surgical jaundice. ?? Hypoalbuminemia. ?? Upper G.I.T bleeding (new onset of melena stool). ?? Hepatic Encephalopathy stage I

8. PLAN 1) Admit pt to St. Gonzaga. 2) Do: CBC, RCT, LFTs, RFTs, Ca2+, PO4 , Mg2+, Urinalysis, PT / INR Blood grouping and Cross matching Hepatitis B and C, B/S Malaria, Stool Occult Blood, Abdominal scan 3) Management at EMD IV Omeprazole 80mg stat IV D50% 20mls in NS Pass NG tube for feeding IV N/saline 500mls stat – then later, 500ml 08 hrly Management at EMD Cont. . . Allow oral feeds (300mls of semi-solid every 4 Hrly ). Omeprazole 40mg B.D Syrup lactulose 10mls x 8 hrly Consider blood transfusion if Hb < 8g/dl Consider medical r/v on ward Consider GIT endoscopy Rifaxmin 550mg 12 hrly Transfuse with 02 units of fresh frozen plasma Iv Heparmez 04 ampules to be put in N/S 500mls O.D. Consider catheter change on ward

9. Summary of Lab Results RFTs Ranges Urea Blood 52.4 mg/dl 16.6 – 48.5 Creatinine Blood 1.64 mg/dl 0.70 - 1.20 Sodium Blood 52 mmol/ λ 136.00 - 145.00 Potassium Blood 1.94 mmol/ λ 3.50 - 5.10 Chloride Blood 118.2 mmol/ λ 98.0 - 107.0 Prothrombin Blood 22.8 mmol/ λ 10 – 14.7 INR Blood 1.83 mmol/ λ 0.9 – 1.8 FBC Ranges WBC 13.49 10^ 3/ul 4.0 - 11.0 RBC 2.34 10^ 3/ul 3.1 - 5.7 HB 8.4 g/dl 13.0 - 18.0 Haematocrit 21.7 % 40.0 - 54.0 Mean cell volume 92.7 fl 76.0 - 96.0 MCH 30.8 pg 27.0 - 32.0 MCHC 33.2 g/dl 31.0 - 35.0 RDW 26.3 % 11.0 - 16.0 MPV 4.3 ** fl 6.0 - 10.0 Platelets 72 10^ 3/ul 150 - 400 ANC % 10.96 *** % 45.0 - 70.0 Lymphocytes % 24.5 *** % 20.0 - 40.0 Monocytes % 2.3 % 3.0 - 10.0 Eosinophils % 0.3 ** % 1.0 - 5.0

10. Summary of Lab Results LFTs ALP Blood 986 ALT Blood 116.3 AST Blood 548.9 GGT Blood 282 Chloride Blood 118.2 Prothrombin Blood 22.8 INR Blood 1.83 Total Protein Blood 34.5 Total bilirubin Blood 43.125 Direct Bilirubin Blood 32.991 Indirect Bilirubin Blood 10 HB 250 KETONE 150 L.E 100 PH 8.0 Microscopy – Pus cells > 100 Urinalysis

11. FBC Ranges Basophils % 0.6 % 0.0 - 0.5 Neutrophils # 10.33 ** 10^ 3/ul 2.00 - 7.50 Lymphocytes # 3.51 10^ 3/ul 1.50 - 4.00 Monocytes # 0.33 10^ 3/ul 0.20 - 0.80 Eosinophils # 0.05 ** 10^ 3/ul 0.04 - 0.40 Basophils # 0.1 10^ 3/ul 0.20 - 0.10 Blood Group A Rh (D) Positive Haemo Parasites tests Malaria microscopy No malaria parasites seen More than 10 in every HPF Summary of Lab Results Cont. . .

12. 10/05/24 @ 17:30HRS SHO r/v Reviewed and noted the above Hx and findings. of 83/M admitted with back ground hx of HTN > 2Yrs, and had been unwell for 6/12 Who was a transfer from Mt. Elgon Hospital where he had been hospitalized for 1/12. O/E sick looking, obtunded A++ J++ (deep). O++ Vitals – BP = 120/58 mmHg. SPO 2 = 90% Systemic exam : Statusquo Diagnosis A diagnosis made was obstructive jaundice. ? Cause; Hepatic encephalopathy grade I Upper GIT bleeding Hypokalemia. ?? AKI Critical Issues (Priorities) Hydration, Relief of Obstruction Prevent coagulopathy

13. 10 TH /05/2024 @ ??:00HRS SHO r/v Plan – Pt. to be transferred to HDU Medical and Nephrology team Rv IV fluids 3l in 24 hrs. IV ceftriaxone 2g O.D IM vitamin K 10mg O.D Syp Lactulose 10mls tds Tbs Rifoxiclin 550mg BD Transfuse with 2 units of whole blood P.O cholecystamine 4mg BD IV KCL 20mg in 500mls of NS Consider MRCP Note: At 1:10am, pt. was transfused with 150mls of packed cells. Do Electrolytes and RFTs in the evening IV Albumin 20% 100 ml/1g x 2/7 Consider MRCP when patient is stable. IV fluids 20 l in 24 hrs RL:Ds:IV 500 : 500 : 1 ltr 50mls IV Omeprazole 40mg BD

14. 11 TH /05/2024 Morning ward round - SHO r/v Noted 83/M, who is a referral in, and being managed for obstructive jaundice. ? Cause Concerns General body weakness, passed melena stool, no vomiting. O/E sick looking, MOD pallor, deep jaundice. Afebrile to touch with anasarca Vitals: BP = 135/67 mmHg. SPO 2 = 99% Temp. = 36.1C o PR = 69, GCS = 14/15 Eye opening = 4, V = 4, M = 6 R/S – Noted crackles in left mid zone Other systems: Statusquo Dx: 83/M HTN with obstructive jaundice. ?? Ca pancreas. R/O cholangiocarcinoma Hepatic encephalopathy (grade I) Grade I bed sores Hypoalbuminemia Hypokalemia. ? AKI Acute liver injury

15. 11 TH /05/2024 @ ??:00HRS SHO r/v Plan – Continue Rx in addition to IV Kabiven 1448 mls in case NG tube fails to passs , IV Albumin 20% 100 ml/1g x 2/7 Pseudo-cream Consider MRCP when patient is stable. Repeat Electrolytes and RFTs in the evening 11TH/05/2024 @ 10:40HRS SHO r/v – Nephrology review 83/M with above hx, being managed for Hepatic encephalopathy, hypoalbuminemia, anaemia and hypokalemia. Noted the following RFTs: Urea: 52.4 LE: 500 Pus cells >100 pus cells. Plan – IV Levofloxacin 500 mg stat then 250mg O.D. Continue the rest of the management

16. 12 TH /05/2024 @ 09:10HRS SHO r/v R/v and noted the above Hx and concerns of the Pt. Concerns: GBW and general body pain Not feeding. Vitals: BP = 130/59 mmHg, SPO2 = 94% P.R = 72 Bpm, Temp. = 36.1 O C To continue with the above Mgt, but requested for; Urgent decompression Medical review Withhold Cef and instead give Metro IV Transfuse with FFP Nurse on air mattress with 2 hrly turning . 12 TH /05/2024 @ 09:10HRS SHO r/v – Note: CBC was 7.2 WBC = 14.31 ANC = 10.33 Hepatitis B – Negative Hepatitis C – Negative RFTs CR = 1.92 Urea = 63.4 Na = 55 K = 2.23 Cl = 121.7

17. 13 TH /05/2024 @ 01:31am SHO r/v Seen by the surgeon, SHO and Interns Noted the Hx and findings of an 83/M with a working diagnosis of obstructive jaundice. O/E: Sick looking, afebrile to touch, J++, D++, MOD palour with odema +++ Vitals BP = 135 / 67 mmHg, GCS – 13/15 PR = 125 Bpm, SPO 2 = 96% on RA Temp. = 37.3 O C NEWS score - 7 P/A: Moderately distended with ascites, hepatomegaly. DRE: Blood on examining finger, Soft stool No abnormalities noted. R/S – Coarse crackles in the bases.

18. Problem List Obstructive jaundice Hypoalbuminemia. Hypokalemia Renal failure Blood diathesis (coagulation) - c/o thrombocytopenia, ?? D I C Moderate anaemia - ? Portal hypertension Grade 2 HE Grade 2 pressure sores HTN Note: Fluid balance chart not documented well. Plan Plan IM vit K 1mg OD, IV Omeprazole 40mg OD IV Levofloxacin 230mg OD IV heparmez 4ampules in 230mls D5 BD. P.o Rifaximin 550mg BD. P.o Cholestyramine 4mg BD. IV albumin 100mls BD. Protein free diet feeding via NG tube 100mls 3hrly. Lactulose syrup 20mls BD, Air mattress Pseudo cream on sores and cushion Consider bedside PIGTAIL insertion under image guidance.

19. Plan Cont . . . Family conference (prognosis and way forward) Plot fkuid balance chart Do vitals 2 hrly . Dx: 83/M with obstructive jaundice, grade 2 HE possibly 2 O to; Pancreatic tumour Cholangiocarcinoma. 13TH/05/2024 @ 08:30am SHO r/v R/v 83/M HTN referral from mount Elgon hospital with 5/12 h/o general body itching, yellowing of eyes, plus gradual (4/7) development of melena stools. Plan Do CEA, CA19-9 Serum amylase and lipase, PT/INR Do MRCP (tomorrow morning) Nephrology review IV KCL 40meq OD Transfuse with FFP 2 units. Transfuse with PC 2 units (packed cells).

20. Plan Cont . . . Protein free diet feeding via NG tube 100mls 3hrly. Lactulose syrup 20mls BD, Air mattress Pseudo cream on sores and cushion Consider bedside PIGTAIL insertion under image guidance. Family conference (prognosis and way forward) Plot fkuid balance chart Do vitals 2 hrly . Dx: 83/M with obstructive jaundice, grade 2 HE possibly 2 O to; Pancreatic tumour Cholangiocarcinoma. Plan IM vit K 1mg OD, IV Omeprazole 40mg OD IV Levofloxacin 230mg OD IV heparmez 4ampules in 230mls D5 BD. P.O Rifaximin 550mg BD. P.O Cholestyramine 4mg BD. IV albumin 100mls BD.

21. 13TH/05/2024 @ 09:00HRS SHO r/v Nephrology adendum R/v and noted 83/M being managed for the above conditions. O/E: FGC, A+, J++, D++, with clots on the tongue and palate, no active bleeding, severely wasted with generalized edema. Vitals Temp. = 37.3O C SPO2 = 99% on RA BP = 128/63 mmHg, PR = 84 Bpm, RBS – 4.9 mmol/L P/A: Moderately distended with hepatomegaly about 6cm below costal margin, smooth moderately tender, has a positive fluid thrill. Plan Palliative care team to consider initiation of morphine for pain control. Expedite surgical decompression. IV RL 500ml stat over 1hr and then re-assess dehydration KCL infusion with ECG ICCd monitoring 40 mtq to run over 4 hrs , 3 doses ago. Explained to the daughter, Alwenyi Christine about the patient condition and management.

22. 13TH/05/2024 @ ??? HRS - Palliative care Team Patient r/v today, attendant report to have spent on & off sleepless nights, restless in bed. Holistic care management initiated but, stopped in the middle. Reason: they have been called for family conference during the process. Plan Supplied with oral liquid morphine 5mg/5ml 2.5 4 Hrly and 5ml Noct . Ongoing counselling of the patient. Monitor vital observations 2 hrly . 2 hrly turning of position in bed. Note: PT/INR = 40.4 / 3.268 CA199 =591.4 (19 times) CEA = 2.12 At 01:00pm Central Line Inserted

23. 13 TH /05/2024 @ 17:00pm SHO r/v R/v 83/M HTN being managed for obstructive jaundice, grade 2 HE 2O to ? Pancreatic tumor. Cholangiocarcinoma. MRCP not done – needs anesthesiologist review prior to procedure. Inability to communicate. O/E: sick looking, elderly, afebrile A+, O++, D++. Vitals BP = 121/55 mmHg, PR = 112 Bpm, SPO2 = 97% on RA, Temp. = 37.0O C RR – 286bpm, MEWS score – 4 P/A: Distended smiling umbilicus, shiny skin, hepatomegaly ~ 4cm, bowel sounds reduced in pitch, positive fluid thrill. 13 TH /05/2024 @ 17:00pm SHO r/v CNS E – 4 V – 3 M – 5 PEARL No FNDS Other systems – statusquo Plan: Anesthesiologist R/v Follow up blood FFP Continue mgt.

24. 13 TH /05/2024 @ 18:38pm r/v Called in to review patient after cessation of breathing as noted by nursing team. On arrival, patient had no pulse, no respiratory effort, pupils were dilated and fixed with res of 7.4 mmol. CVS Initiated CPR and given adrenaline 7mg, continued with CPR with no return of pulse or spontaneous respiration. Still no pulse And no BP Confirmed dead at 18:30pm Cause of death; Cardiorespiratory arrest 2 O to encephalopathy with cardiopulmonary arrest. Condolence passed on to family.

25. Discussion ( swiss cheese model) Patient factors; Systemic factors; Policies, Check list, Training Personel factors; Education - Communication –Intervention Patient factors Patient was a known HTN with Obstructive Jaundice hence comorbidities. Pts Bps and RBS readings were high signifying poor control. This was a very high risk patient for Neurovascular events and it was wise to have a high index of suspicion.

26. Discussion Cont . . . Systemic factors Policies are in place at emergency Check list is there at emergency. What s the criteria for ICU admission And what was the goal of care ? Is it palliative Factors pertaining to us Diagnosis & intervention was it the right?? Communication; Lack of timely communication for a member of the surgical team to review prior to admission. Primary Doctor at emergency not fully involving the specialty team before admitting. Unclear documentation. No proper recording of patient management notes. No CT results mentioned/recorded, Not quoted the neurosurgeon anywhere yet managed to talk to him.

27. Was the death preventable? Possibly NO. Good Points Doctors on duty including the SHO and nurse team attended to the pt. At least, timely medical interventions were done Take Home Points: Causes can be broken down into pre-hepatic, hepatocellular, and post-hepatic Most cases will warrant initial blood tests and ultrasound imaging, however this should be tailored to the clinical presentation Definitive treatment of jaundice will be dependent on the underlying cause Ensure to monitor for complications, such as coagulopathy, encephalopathy, or infective sequelae Obstructive jaundice is a serious condition requiring prompt diagnosis and treatment Understanding the types, causes, and symptoms is important for effective management Early intervention can help prevent complications and improve patient outcomes

28. Jaundice (Icterus) Jaundice is a symptom that refers to the yellow pigmentation of the skin and eyes as a result of excess bilirubin in the circulation; this usually becomes clinically detectable at plasma levels > 40 µmol/L (normal range is < 22 µmol /L). Types of Jaundice Jaundice can be classified in three ways: Prehepatic (haemolytic) Hepatic (parenchymal) Post-hepatic (cholestatic).

29. Types of jaundice 1) Pre-hepatic jaundice - disruption happens before bilirubin has been transported from the blood to the liver - caused by conditions such as sickle cell anaemia and haemolytic anaemia 2) Intra-hepatic jaundice (hepatocellular jaundice) - disruption happens inside the liver - caused by conditions such as Gilbert's syndrome and liver cirrhosis 3) Post-hepatic jaundice (obstructive jaundice) - disruption prevents the bile (and the bilirubin inside it) from draining out of the gallbladder and into the digestive system - caused by conditions such as cholelithiasis (gallstones) or tumours Pre-hepatic Hepatic Post-hepatic Excessive amount of bilirubin is presented to the liver due to excessive haemolysis Impaired cellular uptake, defective conjugation or abnormal secretion of bilirubin by the liver cell Impaired excretion due to mechanical obstruction to bile flow Elevated unconjugated bilirubin in serum Both conjugated and unconjugated bilirubin may be elevated in serum Elevated conjugated bilirubin in serum

30. Type Pre-hepatic Hepatic Post-hepatic Urine colour Normal Dark Dark Stool colour Normal Normal Acholic (Putty- coloured / greyish-yellow) Pruritus No No Yes Types of Jaundice Pre-hepatic Hepatic Post-hepatic Haemolytic Anaemia , Sickle-cell Anaemia Hepatitis, cirrhosis, hepatocellular diseases etc. Gallstone, malignancy, inflammation

31. Other types of jaundice: Pathologic Jaundice when jaundice presents a health risk in adults / children may be pre-hepatic / hepatic / post-hepatic Gilbert Syndrome harmless hereditary condition results in mild jaundice due to low levels of bilirubin-processing enzymes in their livers does not require further medical treatment Differentiating Types of Jaundice

32. Clinical Features in Obstructive Jaundice Consider: Patients' ages and associated conditions Presence or absence of pain Location and characteristics of the pain Acuteness of the symptoms Presence of systemic symptoms ( eg , fever, weight loss) Symptoms of gastric stasis ( eg , early satiety, vomiting, belching) History of anaemia Previous malignancy Known gallstone disease Gastrointestinal bleeding Hepatitis Previous biliary surgery Diabetes or diarrhoea of recent onset Commonly - pale stools , dark urine , jaundice & pruritus Explore use of any alcohol , drugs, and medications.

33. History Family history of jaundice with anaemia (haemolysis ) - Hereditary spherocytosis Gilbert’s Familial non- hemolytic hyperbilirubinemia Back Pain : 25% of patients with carcinoma pancreas (relieved by sitting Whitish clay- colored stools : suggestive of Obstructive Jaundice Melena : Periampullary carcinoma ( silver paint stool ) Charcot’s triad : Intermittent jaundice, pain, intermittent fever History of infections , drug abuse , tattoos, blood transfusion (Hepatitis B ) Past History of biliary surgery (Post-operative stricture ) History of omphalitis (inflammation of the navel) Infection of Umblicus  incomplete obliterations of umbilical vein  jaundice History of drugs : Chloropromazine , Methyltestosterone

34. Examination Yellow discoloration: sclera , skin , nail bed, posterior part of the hard palate, under surface of the tongue Presence of scratch mark - in the lower limbs, chest and abdomen (accumulation of bile salts) Migratory thrombophlebitis ( Trosseau’s sign seen in carcinoma pancreas) Stigmata of liver disease – spider angioma , ascites, collateral veins on the abdomen and splenomegaly Distended gall bladder Look for supraclavicular nodal enlargement

35. Investigations in Obstructive Jaundice General Full Blood Count – Anaemia , signs of infection, haemoglobulinopathy Serum electrolyte, urea & creatinine Liver function test - Bilirubin (Direct  - obstruction) - Raised serum albumin (  A/G Ratio) Urinalysis – Bilirubin, urobilinogen Faecal occult blood test (Carcinoma of ampulla of pancreas) Coagulation profile – PT, PTT, INR Hepatitis serology ( HbsAg , HCV)

36. Imaging Plain radiographs – little value Abdominal ultrasonography – 1 st -line imaging in jaundice detect liver abnormalities, hepatosplenomegaly and gallstones identify extrahepatic causes of biliary obstruction Identify intrahepatic disease e.g. malignancy

37. Endoscopic ultrasound (EUS) – detailed imaging of pancreas and biliary tree, tissue sampling via fine needle aspiration (EUS-FNA) Computed tomography (CT) scan - more accurate than US to determine specific cause & level of obstruction Magnetic resonance cholangiopancreatography (MRCP) – test of choice in obstructive jaundice

38. Endoscopic retrograde cholangiopancreatography (ERCP) – diagnose benign & extrahepatic obstruction, relieve obstruction Percutaneous transhepatic cholangiography (PTC) – evaluates suspected biliary obstruction when ERCP is unsuccessful.

39. Management of Obstructive Jaundice Medical : Depends on underlying cause Surgical : When indicated Indications for surgery – Resectable * Palliation if unresectable

40. Pre-Operative Management Proper diagnosis and assessment Injection vitamin K IM 10 mg for 5 days Fresh Frozen plasma ‐ 6 bottles or more Blood transfusion (if anaemic) Oral neomycin, lactulose IV Mannitol 100‐200 ml BD to prevent hepatorenal syndrome Adequate hydration Repeated monitoring by doing prothrombin time, serum electrolytes Antibiotics e.g. 3 rd generation cephalosporins Calcium supplements e.g. IV Calcium chloride

41. Surgical Management Modalities Triple Bypass Whipple Procedure ERCP / Stenting CBD exploration (CBDE) + Choledochojejunostomy (CDJ) CBDE + T Tube Percutaneous transhepatic biliary drainage + Palliative Hepatojejunostomy

42. Percutaneous transhepatic biliary drainage

43. Choledocholithiasis / cholecystolithiasis – Cholecystectomy (Open / Laparoscopic) Carcinoma of head of pancreas Early: Whipple procedure, Pancreaticoduodenectomy + Pancreaticojejunostomy + Gastrojejunostomy + Cholecystojejunostomy Late: Triple bypass surgery Cholangiocarcinoma - Hepaticojejunostomy Carcinoma of ampulla of Vater – Whipples procedure Chronic pancreatitis – Subduodenal exploration, sphincterectomy , stent insertion Liver transplantation

44. Whipple Procedure Pylorus-Preserving Pancreaticoduodenectomy (PPPD)

45. Triple Bypass Consisting choledochojejunostomy ( cholecystojejunostomy ), gastrojejunostomy , and pancreaticojejunostomy

46. Cholecystectomy

47. Post-Operative Care Monitoring with prothrombin time, bilirubin, albumin,creatinine , electrolyte estimation FFP or blood transfusion Antibiotics Observe for septicaemia, haemorrhage, pneumonia, pleural effusion, bile leak Care of T-tube and drains T‐tube cholangiography in 10‐14 days TPN, CVP line, nasogastric tube, urinary catheter

48. T Tube –drainage of bile leaks post-operatively

49. Conclusion The treatment of Obstructive Jaundice depends on the underlying cause, and as such, it is crucial to identify the cause of the obstruction to provide appropriate treatment. Currently, surgical intervention remains the primary approach for treating Obstructive Jaundice. However, perioperative complications associated with Obstructive Jaundice also require comprehensive treatment.

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