Intraoperative period

• Patient was received in the EmOT as E1VtM1, BP not recordable and

Central pulse not palpable B/L.
• CPR started immediately as par ACLS protocol.
• ROSC achieved and patient was put on high dose vasopressor support.
• Surgery was started under general anesthesia and gradually vasopressor
dose was decreased.
• Total intraoperative fluid was 3 Liters RL and 500 ml of 4% Gelatin
(Colloid) and 1 unit PRBC.
• 5H-5T evaluation showed severe lactic acidosis.
Shifting to ICU
• Patient was shifted to ICU with GCS E1VtM1, Pupils are sluggishly reactive to
light, BP 120/80 on high vasopressor support (Noradrenaline @0.35
mic/kg/min), HR 170/min.
• Patient was febrile with 103 degree F.
• Patient was put on MV (P-SIMV mode).
• All cultures were sent and Baseline serum PCT was established, which was 1.4
ng/ml.
• Patient was put on Broad spectrum antibiotic coverage (Meropenem and
Clindamycin)
• POCUS findings suggested adequate volume resuscitation and no gross
pulmonary pathology.
ICU Stay
• Patient continued to be mechanically ventilated and on high vasopressor
support, despite which, shock could not be controlled, as evident by
lactate.
• Hypoalbuminemia was managed with 20% Human Albumin.
• Hyperkalemia was managed with Salbutamol nebulization, Insulin-
Dextrose solution and Calcium Gluconate.
• Frequent hypoglycemia was countered and managed with 25% dextrose
infusion.
• Patient became oliguric, and then anuric. Sodabicarb was started.
• To control refractory hyperkalemia with anuria, one cycle SLEDD was done.
ICU Scores
After 24 hours of ICU stay:
1. SOFA score: 17
2. APACHE II score: 36
3. NUTRIC score: 6
Trend in ABG parameters and Vasopressors
Chart Title
18

16

14

12

10

0
9:00 AM 12:00 PM 7:00 PM 2:00 AM 5:00 PM 11:00 PM 6:00 AM 11:00 AM

pH Lactate VasoP K+ Norad

Cause of Death
• 1. Immediate: Metabolic acidosis and Hyperkalemia
• 2. From: Billiary peritonitis and AKI
• 3. From: Duodenal Perforation