Page 44 - Avoiding Surgical Mishaps Part 1

SVMIC Avoiding Surgical Mishaps: Dissecting the Risks

CASE STUDY

continued
The pain continued to be severe into the second night, and
the patient received IV Demerol for relief, as well as Zofran

for nausea and vomiting. When the physician arrived to
check on the patient the next morning, the nurse reported

that the patient had not voided again since 11pm the night
before and that her HCT was now elevated. The physician

ordered a foley catheter, a CT of the abdomen, a CBC, and
Mefoxin.

The CT showed fluid in the abdomen, and the H & H

revealed an elevated hematocrit. These results were called
to the physician at 1pm. No orders were received. The patient

continued to complain of severe pain and was confused,
with clammy, cool skin and an elevated heart rate. The

nurse called the surgeon at 6pm and told him about change
in the patient’s condition; the surgeon increased the pain

medication and ordered additional labs. Within 15 minutes
of that conversation, the patient became short of breath

and was moved urgently to Surgical Intensive Care where
an NG tube was inserted and the patient was intubated.

The surgeon was notified and arrived in the hospital to
assess the patient and aspirate the distended abdomen.

During the procedure, he aspirated frank fecal matter and
immediately called a surgical team to take the patient to the

OR. An exploratory laparotomy identified a perforated bowel
with peritonitis and sepsis. The patient

developed Adult Respiratory Distress
Syndrome and hypotension and remained

on a ventilator, but her condition continued
to deteriorate and she died later that day.

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