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1. MORTALITY REVIEW By ho shiva ram SUPERVISOR : Dr AMZAR

2. Demographics Madam K 79 years old Date of admission : 10/07/2022 Date of death : 11/07/2022 Duration of stay : 2 days Cause of death : Septic shock secondary to intrabdominal sepsis Underlying medical illness Hypertension Diabetes mellitus Dyslipidemia

3. HISTORY (ED 10/07/2022 14:14H) Presented to ED with complaint of Right hypochondriac pain today since 9am Colicky in nature Non radiating Sudden onset Had belching past 2 days -PS 7/10 Otherwise, No AGE sx No fever No change in skin color No skin itchiness No tea colored urine No pale stool No sob/chest pain No dizziness Denied hx fall/trauma O/E BP : 173/75 P : 68 T 36.5 SPo2 : 97% under RA Lungs : Clear CVS : DRNM P/A : Soft and tender RHC No mass palpable Bedside scan Gallbladder wall not thickened,no calculi No gross hydronephrosis Bilateral renal punch : negative Investigations : Hb/TWC/ Plt 13.2/ 12.1/ 232 Na/K/Cl/Urea/ Creat 141/4.5/107/6.9/100 TP/Alb/TB/ALT/ALP 69/ 33/ 7.9/ 8/ 48 PT/INR/APTT Not taken Amylase 80 ECG : SR /T inversion lead III IMP (ED ) – TRO Acute Cholecystitis

4. Plan : Refer surgical IV Tramal 50mg TDS IV Maxolon 10mg STAT IV Pantoprazole 40mg STAT Syrup MMT 30ml STAT

5. CXR and AXR upon admission in ED

6. Surgery review (ED 10/07/2022 15:38H) Currently Patient still having right hypochondriac pain Radiating to shoulder tip PS: 7/10 No vomiting No fever O/E Alert conscious Not tachypneic Pink ,not jaundiced BP : 173/75 P : 68 T 36.5 SPo2 : 97% under RA P/A : Soft and tender right hy pochondriac No mass palpable Plan Admit K2 KBNM IVD maintenance 4 pint NS /24h Start IV cefobid and IV flagyl Start IV tramadol 50mg TDS Start IV pantoprazole 40mg OD Trace and start old medication To get US Abdomen IMP – Acute Cholecystitis

7. Ward round (K2 10/07/2022 20:58H) Currently Still having abdominal pain Vomitting x 1 No fever No altered bowel habits O/E Alert conscious Not jaundice BP 147/76 P 104 T 37 Spo2 : 95% under RA P/a Soft and tender over RHC N o mass palpable Plan For s/c morphine 2.5g STAT KBNM 2am with IVD 4 pint NS/24h Cont IV cefobid and IV flagyl Cont IV tramadol 50mg TDS Cont IV pantoprazole 40mg OD To request US Abdomen cm KIV CT AP after US abdomen REV IMP – Acute Cholecystitis TRO gallbladder empyema

8. Summary nursing report At 9pm , patient was put on Npo2 3L/min At 11pm ,BP 95/56 ,P 140 ,Spo2 86% under FMO2  changed to HFMO2 15L/min At 11.40pm,Bp 157/104 ,P 140,Spo2 93 % under HFMO2  run 1 pint HM At 3am,noted nil urine output since 1am ,warm compression given At 6.40am ,noted patient gasping BP 58/17 P 109 Spo2 87% run another 1 pint HM intubation done started IVI noradrenaline 8cc/h vitals post intubation : BP 123/85 P 87 Spo2 100%

9. AM review (K2 11/07/2022 06:50H) Currently Still complains of right hypochondriac pain No vomiting No fever No diarrhea O/E Tachypneic BP 139/71 PR 120 --  run fast 1 pint HM T 37 Spo2 97% under HFMO2 DXT 2.5 ---IV D50 50ml Ix ABG under HFMO2 pH/ pO2/ pCO2/ HCO3/ BE/ S02 7.35 / 134 / 27 / 14.9 /-9.1 / 94% Plan Vital signs monitoring Strict I/O charting Keep spo2 >95% Cont IV cefobid and IV flagyl Cont IV tramadol 50mg TDS Cont IV pantoprazole 40mg OD To request US Abdomen cm KIV CT AP after US abdomen IMP – Acute Cholecystitis TRO gallbladder empyema

10. < Entry > (K2 11/07/2022 07:15H) Noted patient gasping and Spo2 not picking up after HFMO2 Upon r/v Patient gasping Unable to answer question GCS E4V4M4 Pupils bilateral reactive Lungs clear BP 58/17—ongoing 1 pint HM PR 109 T 37 Spo2 76-89 % under HFMO2 15L -Spo2 fluctuating DXT 13 Decided for manual bagging IV midazolam and fenta nyl given Proceed with crash intubation Successful single attempt Plan Trace baseline ix sent CXR post intubation To refer anes th IMP – Acute Cholecystitis TRO gallbladder empyema

11. Anesth review (K2 11/07/2022 08:08H) In ward pt tachypneic and desaturated under RA Upgrade to HFMO2 However respiratory distress worsening Repeated ABG under HFMO2 pH/ pO2/ pCO2/ HCO3/ BE/ S02 7.24 / 112 / 24 / 10.3 /-15.3/ 97% ABG post intubation Still pending O/E Intubated GCS 2T Pupils 2/2 reactive Sedated with IVI midamorphine 3cc/H Hemodynamically supported with IVI Noradrenaline 20cc/h (double strength ) BP 11 3/93 PR 101 Spo2 100 under manual bagging Lung equal air entry CVS DRNM IMP – Acute Cholecystitis TRO gallbladder empyema Investigations : Hb/TWC/ Plt 13.2/12.1/232 Na/ K/ Cl/ Urea / Creat 141/4.5/107/6.9/100 TP/Alb/TB/ALT/ALP 56/ 26/19.3/6/34

12. Plan : Start ventilation SIMV VC Fio2 0.8 ,PEEP 8,VT 450 R 16 PS 15 ABG post intubation Repeat CXR post intubation Continue sedation Cont IV noradrenaline 20cc ,to titrate accordingly Keep MAP >65 To ventilate in ward i /v/o no ICU bed available Suggest to insert CVL i /v/o of high inotropic support Primary team to explore family exploration

13. Ward round (K2 11/07/2022 08:52H) Currently Intubated Sedated Hemodynamically supported with IVI noradrenaline 15cc/h O/E Intubated GCS 2T Sedated with IVI midamorphine 3cc/H BP 175/104 P 112 SPO2 95% under SIMV VC Fio2 0.8,PEEP 8,VT 450 ,R16,PS 15 CXR : No air under diaphragm ( pre intubation ) Plan KIV for CT abdomen once more stable Cont IV cefobid and IV flagyl REV IMP – Acute Cholecystitis TRO gallbladder empyema

14. ABG post intubation under SIMV VC Fio2 0.8,PEEP 8,VT 450 ,R16,PS 15 Ph 6.92 Po2 106 Pco2 21 Hco3 4.3 Lac 14.3 BE -26.5 SO2 93% CXR Post Intubation

15. Ward round (K2 11/07/2022 14:27H) DIL & DNR issued Currently Intubated Sedated with IVI midamorphine 3cc/h Hemodynamically supported O/E Intubated Sedated BP 120/71  IVI noradrenaline 20cc/h P 90 T 37 Spo2 99% under SIMV VC Fio2 0.8,PEEP 8,VT 450 ,R16,PS 15 Coagulation profile PT 23.3 INR 1.83 APTT >180 sec Plan KNBM IVD 4 pint NS + 1pint NS/24H DXT QID To refer medical for severe metabolic acidosis and AKI Transfuse 2 unit FFP Start T vit K 10mg OD x 3/7 Start IV meropenem 1g BD KIV CT AP cm once pt more stable IMP – Acute Cholecystitis TRO gallbladder empyema

16. < Entry > (K2 11/07/2022 17:05H) Informed by SN patient asystole BP HR SpO2 unrecordable Pupil fixed dilated bilaterally No spontaneous breathing No pulse palpable DIL & DNR issued on 11/7/22 @ 11am Cause of death :Septic shock secondary to intrabdominal sepsis Time of death : 11/7/22 @1650 H IMP – :Septic shock secondary to intrabdominal sepsis

17. 10/07/2022 11/07/2022 TCW 12.1 HB 13.2 PLT 232 TCW 4.61 HB 11.6 PLT 184 Na 141 K 4.5 Cl 107 Urea 6.9 Creat 100 Na 151 K 5.5 Cl 102 Urea 9.2 Creat 247 PO4 2.06 Mg 0.92 Ca 2.01 TP 69 Albumin 33 Globulin 36 ALT 8 ALP 48 TB 22.5 TP 49 Albumin 22 Globulin 27 ALT 411 ALP 37 TB 10.9 CK 644 AST 682 LDH 1314 Amylase 80 PT 23.3 INR 1.83 APTT >180 sec Summary of Blood Investigation 10/7/22 –11/07/22

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