A 55yrs.lady having normal preop investigations underwent cholecystectomy under spinal anaesthesia . After about 20hrs. she became drowsy & disoriented. Vitals were normal.Pt. has passed only 75ml. urine in last 4 hrs.investigation: tlc-16000,BL urea -32,s.creatinine-1.2,BL.sugar-408(preop-102,no h/0 DM).ECG enclosed.Comments for management invited



looks like she is landing into multi organ failure.now patient is in altered sensorium. Renal tests are normal at present , repeat it again as urine output gas reduced. there is hyperglycemia also it can also cause altered mental status.you have not mentioned electrolytes , pls look for hypercalcarmia,hypo/hypernatraemia.do one ABG , for hypoxia/hypercapnia.TLC raised indicating sepsis.ECG showing STD in precordial & inferior leads.do cardiac enzymes. see if hyperkalaemia is there. All routine investigation including RFT,LFT,thyroid profile,echo. if possible CT brain to r/o any brain pathology. Treat with higher antibiotics , control Sugar with insulin(~180). correct hypoxia/hypercapnia if there.any serum electrolyte imbalance, thyroid abnormality(unlikely).depending upon the investigations ,determine further course of management.if cardiac enzymes positive start on iv heparin or LMWH( will also take care of DVT/PTE risk).

ST depression in V1-6 with T inversion...suggestive of myocardial ischemia...urine output is ~18.75ml/hr for 4 hours...which is I think less than 0.5ml /kg/hr for 4 hours...s.creatinine is 1.2(baseline u have not mentioned)...which is suggestive of renal injury...TLC >12000 and altered sensorium..all suggestive of MODS...kindly do trop t and echo to rule out NSTEMI...iv insulin -r for control of hyperglycemia...keep a vigil over vitals including JVP and urine output...use iv fluid judiciously... procalcitonin level for sepsis detection...manage accordingly

No ST depression now, T-wave inversion persisting in V1-6.RFT wnl.Trip t negative, cpk-mb raised .Urine out put normal. ABG at the time of problem show respiratory acidosis. Insulin being given.Pt fully conscious. Please suggest role of LMWH in this post surgery case

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Widespread st depression with St elevation in avr, v1 Demand supply mismatch check lytes , KETOAN BODIES treat as insulin glucose drip Serch for the cause why such things happen? ?

electrolytes wnl.No ketone bodies

pt is landing in multiorgan failure, with hyperglycemia, u have to find out the cause of the ,case cvp to r/o hypovolumia ,see electrolyte imbalance ,and hypoxia event , definitely ecg changes r their, if we have to maintain vitals, such maintain hgt control put on HAI INFUSION, PUT CVP LINE MAINTAIN CVP TO 8CM OF H20, PUT ON HIGHER ANTIBIOTICS,

There is ST depression in infr leads and lateral leads,do trop I

k level....then respective sr.soduim level needs to be chased....that's not the question here.... I am really interested in how much bupivacaine volume u have given for doing cholecystectomy? was any supplemental sedation was provided? duration of surgery? what were preop level of TLC?

s.electrolytes ,rft are normal. 2.5ml of bupivacaine was given. Surgery lasted half hr.Midajolam 1mg. was given as premedication. Preop TLC was 7800.Problem occurred 20 hr.after surgery

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looking at ecg it appers she had succumbed to myocardial damage(nstemi) myocardial damage wud have resulted in decreased output n low output can be explained or it cud be hypovolemia.how much fluid was infused in 20hra?. TLC 16000 suggest of SIRS or sepsis.... sugars can be controlled by insulin but keep a watch on sr.K

Is intraop urine output was normal and intra operative sepsis was maintain and also look for intraop surgical problem

Intraop every thing fine.Preop she had cough, but no spasm,so anti biotics & nebulization given

kindly repeat ECG if ST elevation in avr alongwith ST depression in V1-6 with T inversion... this shows LMCA stenosis....

No ST changes now,only T- wave inversion in V1-6 persisting

or it cud be manifestation of incipient cholangitis

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