A mortality case who had SMA chimney EVAR revision developed bowel ischemia...

1. Morbidity & Mortality ConferenceMorbidity & Mortality Conference
Bowel Ischemia after Abdominal
Aortic Aneurysm Stent-grafting
心臟血管外科 陳勁辰 醫師
台北慈濟醫院
02/24/2016

2.  Sex: MaleSex: Male
 Age: 72 yearsAge: 72 years
 Date of admission: 11/07/2015Date of admission: 11/07/2015
 Dates of surgery/procedure:Dates of surgery/procedure:
11/07/2015, 12/07/2015, 12/14/201511/07/2015, 12/07/2015, 12/14/2015
 Date of death: 12/14/2015Date of death: 12/14/2015
Patient data

3.  CC: Abd pain for 3 daysCC: Abd pain for 3 days
 PH: CRI=6+ but UO++; Gout; CAD s/p POBASPH: CRI=6+ but UO++; Gout; CAD s/p POBAS
 Course:Course:
 11/07/2015: EVAR11/07/2015: EVAR
 11/25/2015: HD11/25/2015: HD
 12/02/2015: ICU-> Ward12/02/2015: ICU-> Ward
 12/05/2015: CTA: supra-EVAR Ao rupture12/05/2015: CTA: supra-EVAR Ao rupture
 12/07/2015: Chimney & TEVAR12/07/2015: Chimney & TEVAR
 12/14/2015: Rescue Chimney (SMA); Mortality12/14/2015: Rescue Chimney (SMA); Mortality
Brief summary

4.  Cons: alertCons: alert
 VS: BP=177/89, HR=70, BT=35.9C, RR=20VS: BP=177/89, HR=70, BT=35.9C, RR=20
 Abdomen: soft, midline pulsatile massAbdomen: soft, midline pulsatile mass
 EKG: sinus, 74/min, no ST changeEKG: sinus, 74/min, no ST change
 Lab: Hb=9.6, WBC=10.3k, Cre=6.3 (no HD)Lab: Hb=9.6, WBC=10.3k, Cre=6.3 (no HD)
ER (4am, 11/07/2015)

5. CTA (11/07/2015)

6. CTA (11/07/2015)

7. EVAREVAR
 Endovascular aortic repairEndovascular aortic repair

8. Operation: EVAR (11/07/2015)

9. Operation: EVAR (11/07/2015)

10. Postop CoursePostop Course
 PneumoniaPneumonia
 Progressive deliriumProgressive delirium
 Strong Abx useStrong Abx use
 Diuretic-responsive UO=2000 kcal/dayDiuretic-responsive UO=2000 kcal/day
 BUN/Cre =200/7BUN/Cre =200/7
 NG pump feeding 1500 kcal/dayNG pump feeding 1500 kcal/day

11. CXR (11/16/2015)

12. Postop CoursePostop Course
 11/07: EVAR11/07: EVAR
 11/25: Hemodialysis; improving11/25: Hemodialysis; improving
 12/01: MV extubation12/01: MV extubation
 12/02: ICU -> ward; NG & oral12/02: ICU -> ward; NG & oral
 12/05: Pre-MBD CTA12/05: Pre-MBD CTA
!!! Supra-renal artery Ao rupture!!!! Supra-renal artery Ao rupture!

13. CXR (12/05/2015)

14. CTA (12/04/2015)

15. CTA (12/04/2015)

16. Chimney TechniqueChimney Technique

17. Op2: ChTEVAR (12/07/2015)

18. Postop2 CoursePostop2 Course
 12/07: Chimney SMA & TEVAR, sacrificing bil12/07: Chimney SMA & TEVAR, sacrificing bil
renal arteries; PermCathrenal arteries; PermCath
 12/08: NG pump 800kcal/day, abd soft, bowel12/08: NG pump 800kcal/day, abd soft, bowel
sounds activesounds active
 12/09: HD; GCS: M6; MV extubation12/09: HD; GCS: M6; MV extubation
 12/10: NG 1500 kcal/day, Abx: Tapi, Vanco,12/10: NG 1500 kcal/day, Abx: Tapi, Vanco,
Diflucan; WBC=13k, CRP=27, CK=554,Diflucan; WBC=13k, CRP=27, CK=554,
lipase=93, Lac=1.4lipase=93, Lac=1.4

19. CXR (12/11/2015)

20. Postop2 CoursePostop2 Course
 12/11: Diarrhea 2335 g/day, WBC=8.4k,12/11: Diarrhea 2335 g/day, WBC=8.4k,
ABG=7.32/157/34/19/-9, NIPPV useABG=7.32/157/34/19/-9, NIPPV use
 12/12: NG 1500 kcal/day, abd soft & flat,12/12: NG 1500 kcal/day, abd soft & flat,
diarrheadiarrhea
 12/13: NG 1500 kcal/day, diarrhea stopped12/13: NG 1500 kcal/day, diarrhea stopped
after Imodium, CRP=34, PCT=47, WBC=8.4kafter Imodium, CRP=34, PCT=47, WBC=8.4k

21. Postop2 CoursePostop2 Course
 12/14: Shock, re-ETT, Lac=3.4, WBC=7.2,12/14: Shock, re-ETT, Lac=3.4, WBC=7.2,
CK=21, CRP=18, lipase=137CK=21, CRP=18, lipase=137
 CT workup: ischemia bowel! SMA chimneyCT workup: ischemia bowel! SMA chimney
kinkingkinking
 Cath rescue: SMA re-chimneyCath rescue: SMA re-chimney
 12/14: Treatment futility; support withdrawal;12/14: Treatment futility; support withdrawal;
MortalityMortality

22. CXR (12/14/2015)

23. CTA (12/14/2015)

24. CTA (12/14/2015)

25. CTA (12/14/2015)

26. Rescue (12/14/2015)

27. Rescue (12/14/2015)

28. Rescue (12/14/2015)

29. Possible Causes of Mortality
Shock
Bowel ischemia
Kinked chimney to SMA
Delayed diagnosis & treatment
Hesitated hemodialysis (Prolonged toxinemia)

32. 手術適應症 (2nd) 是否恰當 --> Yes
手術前評估是否完整 --> Yes
手術中麻醉是否洽當 --> Yes
加護病房之照護洽當否 --> Yes?
死亡原因之根本分析 ?
Bowel ischemia
整體而言 , 本案例可以改進之處為何 ?
Alertness; Technique
本案例學到什麼 ?
Timely management!
How to do better?

33. Thank you!Thank you!

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