Mortality Meet new outline of presentation.pptx

Mortality meet new outline

1. Surgery Unit 2- Mortality Meet April 2025

2. Statistics (Unit 2) JAN FEB MARCH APRIL ADMISSIONS 170 169 160 111 DISCHARGES 160 165 158 106 MORTALITY 2 2 4 2 ELECTIVE OT 56 58 41 57 EMERGENCY OT 16 18 15 15 LOCAL OT 15 17 17 20

3. MORTALITY- 1 Age/ Sex - 70 years/ Male Diagnosis - Perforation peritonitis DOA - 10.04.2025 DOM - 26.04.2025 (SICU)

4. On Presentation Time - 10.04.25 01:15 am ℅ diffuse abdomen pain and gradual distension for 7 days Ass/w fever+ non-bilious vomiting - 2 episodes for 5 days Not passing stool and flatus for 1 day Known PTB patient 6 months back, defaulter. No past surgical history/ addiction

5. Contd … Diagnosed case of PTB patient 6 months back, defaulter. No past surgical history. Chronic smoker as addiction.

6. On Examination GCS:- 15/15, Dehydration++ VITALS: PR - 90 bpm, BP - 80/52 mm Hg, RR - 30/ min, SpO2 - 94% in RA & 99% with 4L O2. ABG:- pH: 7.2, pO2: 125, pCO2: 25.5, Lac: 3.3, HCO3: 18,

7. On Examination Per Abdomen: – Diffuse tenderness, guarding, rigidity, BS absent. DRE:- collapsed, fecal staining+ Chest:- (on Auscultation) B/L coarse crepts ++ with mild productive cough

8. 9/4/25- CECT Whole abdomen+ pelvis + thorax (outside): – Large intra abdominal collection with Pneumoperitoneum- suspicion for perforation. Mediastinal lymph nodes enlarged with centrilobular nodules likely TB.

9. What was done? IV Fluid resuscitation Ryles tube decompression, NPO + RTA. Foley was inserted. Was started on Piperacillin Tazobactam 4.5 gm iv stat dose. Hb-8, TLC-13k, Creat - 0.54, Alb-1.5, Na- 136, K-3.4 Plan for Laparotomy & shifted to emergency ot .

10. Emergency OT

11. POST OPERATIVE COU R SE (1-5): Patient shifted to ward extubated. On POD 1- Cough+ with raised TLC. On POD 2- Stoma functional, gradually oral diet allowed On POD 3- patient developed SSI. Re-feeding was started via stoma. On POD 5- productive cough with bilateral crepts +, raised TLC.

12. What was done? Review CECT was done retrospectively which showed:

13. Contd … Pulmonology Consultation was done i /v/o Old Pulmonary Tb- defaulter: Was diagnosed as COPD & work up to rule out Tuberculosis. Sputum for AFB & MTB was sent. Ct was reviewed: Showed signs suggestive of Infective etilology of lungs-?TB. Pt was started on Nebulization and was planned for BAL and CBNAAT assessment.

14. Contd … Midline wound SSI was present & pus was sent for culture and sensitivity. Initially was started on Inj Piperacillin Tazobactum with Inj Metronidazole post operatively. However, on Day 5 antibiotics was changed to Inj Tigecycline based on wound pus culture sensitivity report and because of persisting high TLC counts with few intermittent spikes of Fever(101 degree).

15. Contd … Post Operatively: Stoma was functional with output of about 700-1.1 L/day. Pt was shifted to SHDU in view of respiratory issues of desaturations( 94% at room air). On POD 8 : Sputum, BAL sample was sent for CBNAAT, AFB and MTB.

16. INVESTIGATIONS: 10/4 14/4 16/4 20/4 Hb 8.4 8.2 8.6 8.8 Tlc 10.5 11.5 12.5 15.5 Na/ K 134/ 4.2 132/ 4.3 133/ 4.1 130/ 4.6 Ur/ Cr 116/ 0.9 110/ 0.6 96/ 0.7 66/ 0.6 TB 0.64 0.66 0.54 0.44 ALT/ ALP 60/ 111 55/ 120 50/ 89 82/ 106 Alb/ Globulin 1.4/ 3.66 1.5/ 4 1.6/ 4.2 1.8/ 3.96

17. POST OPERATIVE COURSE (10-14):-

18. HISTOPATHOLOGY REPORT

19. Article Review:

20. Key Highlights: Intestinal TB occurs mainly in the ileocecal region, with perforation commonly involving the ileal mucosa. Can occur at single or multiple sites and may be associated with the formation of intestinal strictures or ulceration. As most perforations are stricture-related, small-intestinal perforations are more common than large-intestinal perforations. Risk factors for increased morbidity and mortality include delayed surgical treatment, multiple sites of perforation, concomitant corticosteroid therapy, anastomotic leaks, advanced age, and primary closure of the perforation. Perforation may occur before or after starting antitubercular therapy. Intestinal perforation occurring during or after completion of antitubercular therapy can be a paradoxical reaction to treatment. Paradoxical reactions have been observed in patients with TB affecting the nervous system, respiratory system, skin/soft tissue, lymph nodes, and the abdomen, in decreasing order of frequency.

21. Contd … (A) Abdominal computed tomography (CT) scan showing multisegmental wall thickening and luminal narrowing of the terminal and distal ileum with partial small bowel obstruction, peritonitis, and complicated ascites. (B) Repeat abdominal CT scan showing multiple, extraluminal air-filled spaces in the pelvic cavity, indicating intestinal perforation (arrow).

22. Contd … (A) An image of the initial chest X-ray showing increased opacity of the right upper lobe. (B) Chest computed tomography, scan performed 4 weeks after starting antitubercular therapy, showing findings typical of active pulmonary tuberculosis, including infiltration and ill-defined centrilobular nodules with patchy opacity and bilateral multifocal tree-in-bud patterns in the upper lobes.

23. Contd … Paradoxical Reaction in Tuberculosis? D efined by a clinical or radiological worsening of pre-existing tuberculous lesions or the development of new lesions, in patients receiving anti-tuberculous medication who initially improved on treatment. Major cause of mortality & morbidity in patients especially in those with immunocompromised state or poor general health conditions and associated comorbidities. Although the exact mechanisms are not understood it is most likely due to an abnormal immune response or reconstitution of the immune system.  Increased exposure to mycobacterial antigens released from the bacilli, killed due to effective antitubercular therapy, strengthens delayed hypersensitivity of the host.

24. Contd … Risk factors for paradoxical reactions include extrapulmonary tuberculous lesions, a relatively low basal lymphocyte level in peripheral blood, and a sudden rise in the lymphocyte count during treatment. DDs include diagnostic errors, inadequate response due to drug resistance, and poor adherence to therapy. Therefore, it is important to culture the affected tissue specimen at the time of the initial diagnosis to confirm the diagnosis and to determine the baseline level of drug resistance. Hence, when paradoxical reaction is suspected, continuing treatment is necessary.

25. MORTALITY- 2 Age/ Sex:- 20 years/ Female. Diagnosis – Sub-acute intestinal obstruction(resolved) with acute liver failure. DOA - 12.04.2025 DOM - 15.04.2025 (SICU)

26. On P resentation: Referred from General Medicine to Casualty: With c/o: Gradual abdominal distension with multiple episodes of bilious vomiting on and off for past 4 months. H/o chronic constipation + Currently not passed stools for 3 days but passing flatus. k/c/o CLD x 1 year and endometrial sarcoma underwent TAH+BSO at Jan 24 f/b adjuvant CRT 6 cycles given.

27. On Examination GCS-15, Dehydration+, pallor+, B/L pitting pedal edema +. PR - 110 bpm, BP - 94/61 mmHg, RR - 20/ min, SpO2 - 97% in RA. P/A - mild distension+, no guarding/rigidity, BS sluggish. DRE – normal anal tone, no stool staining, no collapsed/dilated rectum.

28. INVESTIGATIONS: ABG - pH 7.4, HCO3 24, pCO2 34, Lac 1.3, K-3.4 Abdomen X Ray erect- few air fluid level present (2 nos ). 12/4 14/4 Hb 8.4 8.6 Tlc 4.1 3.1 Na/ K 134/ 3.0 132/ 3.2 Ur/ Cr 116/ 0.9 110/ 0.6 TB 4 4.5 ALT/ ALP/ INR 821/ 190/ 1.4 990/ 200/ 1.5 Alb/ Globulin 1.4/ 3.66 1.5/ 4

29. INVESTIGATIONS: USG whole abdomen and pelvis- B/L gross pleural effusion, chronic liver disease changes, moderate ascites likely paralytic ileus. (12/4/25) CECT Whole abdomen+ pelvis + thorax (o/s) – clumping of distal ileal loops in RIF with upstream dilatation of jejunal and ileal loop – likely paralytic ileus. DD: Adhesive bowel obstruction.

30. What was done? IV Fluid resuscitation with IV Antibiotics. Inj Ceftriaxone with Inj Metronidazole was started. Ryles tube decompression, NPO + RTA. Foley was inserted. Plan of admission in ward and conservative management.

31. In hospital course: Potassium correction was started. (KCL infusion of 120 meq /day.) Patient passed stools and flatus after day 1 of admission, distension settled. General medicine and Gastroenterology call was given i /v/o acute liver failure, planned to transfer once bed is available. On 15/4/25, 7am- patient developed tachycardia with hypotension+ low u/o and shifted to SICU, started on inotropes. On 15/4/25, 12 pm, declared deceased. CAUSE OF DEATH – Acute on chronic liver failure.

32. Thank you.