The patient was a 64yo female with PMH significant for arthritis, hypertension, hypothyroidism, hepatitis B and tinnitus. She underwent routine screening colonoscopy on 1/22/18, which unfortunately resulted in a colon perforation. The patient was taken to the O.R. for colon resection with end colostomy (i.e., Hartmann’s procedure) that evening. There was transient postoperative sepsis treated w/ IV abx in the ICU. The patient was d/c on oral abx on 1/30/18.
The patient was seen by the surgeon in follow up on 2/7/18. She complained of episodic N&V; no work up was done at that time. Subsequently, the patient experienced persistent N&V that progressively worsened and she returned to the surgeon on 2/21/18. When the patient experienced marked N&V in the surgeon’s office, he arranged to admit her to the hospital.
The patient was sent to the E.D. on 2/21/18 and admitted to the hospital with dx small bowel obstruction (SBO). The patient was followed by the residents x 10 days with reports to the surgeon about her progress. The SBO was treated w/ NG tube and NPO/clears x 10 days w/ a waxing and waning course but ultimately no resolution of the obstruction.
CBC w/ differential showed low HGB on 2/22/18 with elevated Neutrophils and low Lymphocytes but were otherwise normal. CBC w/ differential showed low HGB on 2/23/18 but was otherwise normal. Starting on 2/25/18, CBCs with differentials showed low WBCs with low Neuts and high Lymphs with the same pattern continuing through 3/1/18. BMPs showed low K and BUN but were otherwise normal throughout that same time.
On 3/1/18, the surgeon ordered the patient to be taken to OR for laparoscopic exploration. During surgery, the small bowel (SB) was found to be adherent to and compressing the colostomy. An attempt to separate the adherent SB and colostomy resulted in SB tear and spillage of contents into the abdomen. The operation was converted into an "open" exploratory laparotomy. There were repeated abdominal washouts followed by SB resection; inspection found a serosal laceration at another SB location which was addressed with a primary repair.
The surgical case records indicate that the patient rapidly deteriorated during these events; she became markedly hypotensive and tachycardic. She was placed in Trendelenburg to maintain CBF and she was given vasopressors and fluids to maintain MAP>60. She remained intubated and was transported to the SICU at the end of the case; critical care assumed treatment.
The surgical case record shows the following:
Anesthesia started at 18:22.
Induction at 18:40.
Intubation at 18:44.
Cefazolin (Ancef) at 18:52.
Incision at 19:08.
Vasopressors given at 19:27.
SB tear occurred sometime during 19:08 – 19:27 since that is when vasopressors were started. Surgery converted to exploratory laparotomy. A note reads:
"1944 Quick Note: Surgery converted from laparoscopic to open due to bowel spillage 2/2 perforation. Upon desufflation of abdomen patient became acutely hypotensive and tachycardic. Surgeon notified and patient placed in head-down Trendelenburg position to maintain CBF. Volatile anesthetic turned off and phenylephrine given, patient then started on phenylephrine infusion to maintain MAP >60."
Surgery ended at 21:58.
Patient emerged from anesthesia at 21:59.
IV Piperacillin-Tazobactam was started at 22:02.
Patient remained intubated and transported to SICU at 22:42.
Unsuccessful attempt at ABG at 22:45.
Handoff to SICU staff at 22:47.
The records repeatedly reference sepsis, septic shock and peritonitis over the following 36 hours after surgery. The patient remained intubated during that time. ABGs done starting after arrival in the SICU show the patient was acidotic with elevated lactate among other abnormal readings over the next 36 hours. CBCs with differentials show low WBCs with elevated Neuts and Bands with low Lymphs. IV Piperacillin-tazobactam continued. Her condition markedly deteriorated early in the morning on 3/3/18 and she went into cardiac arrest. Despite extensive resuscitative measures, the patient expired on 3/3/18.
Issues Presented
While the SB tear occurred sometime during 19:08 – 19:27, IV Pip-Tazo was not given until shortly after the surgery ended at 22:02; i.e., at least 2:35(=/+) transpired between the SB tear w/ contents spillage and starting IV Pip-Tazo.
Was the 2:35(=/+) interval between SB contents spillage and the start of IV Piperacillin-Tazobactam a departure from proper medical practice?
Did the 2:35(=/+) minute delay between SB tear and IV Pip-Tazo cause or contribute to the development of overwhelming sepsis in this patient that was ultimately fatal?
What, if anything, is the significance of the patient’s abnormal labs (CBCs w/diff & BMPs) during the 5 days prior to the laparoscopic exploration?
Do the abnormal pre-op labs indicate that there was a failure to diagnose and treat some other condition, e.g., an infection, that contributed to the patient’s rapid post-op deterioration and death?
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No questions yet!
Do you believe there might have been medical error?
Tear of SB may happen during surgery when trying to open up the adhesions. It is a complication of surgery, not a medical error. The antibiotics were given same day even after tear (2h or so) which is reasonable time between ordering the antibiotic and administrating to the patient by the nurse.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The initial injury during colonoscopy is unfortunately a rare complication but occurs. N/V may be secondary to recent surgery and possible adhesions. Patient went to surgery but unfortunately got a tear in small bowel which opened up a severe inflammatory response. Antibiotics were started same day of this problem. Inflammation subsequently was responsible for deterioration of clinical status regardless of critical care care, antibiotics, vasopressors, etc. I do not see causation on this case.
What makes you a good expert for this case?
I am a tenure associate professor of medicine in a tertiary academic medical center and i see these cases quite often in the hospital. I provide consultations for ID complex surgical cases.
How often do you encounter cases similar to this one in your practice?
Once a week or so we see these type of cases.
Do you believe there might have been medical error?
There are many details and decision points presented for this case. In regards to the issue of peri-operative antibiotic timing, I do not think that the time from small bowel perforation to the initiation of Zosyn likely constitutes malpractice. We’re not told of operative or blood culture results, but cefazolin does provide coverage of gram-negative enteric pathogens so it’s possible that cultured bacteria were susceptible to this. Additionally, while the timely initiation of antibiotics is essential in this situation, so is obtaining source control, and presumably this was being performed in the OR. The worsening leukopenia pre-op may have been due to a developing infection, but it seems like the major inciting event was the small bowel perforation in the OR.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As detailed above, I don’t think that there is sufficient evidence to say that an error has occurred
What makes you a good expert for this case?
I frequently care for patients with infectious complications following surgery.
How often do you encounter cases similar to this one in your practice?
I encounter cases like this on a weekly basis.
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