This case involves a 53-year-old female who presented to the ED complaining of a 3-4 days history of multiple episodes of daily, non-bilious, non-bloody vomiting along with generalized, diffuse, non-radiating abdominal pain (7/10), and decreased flatus. The patient denied fever, chills, chest pain, and SOB. She was diagnosed with an intestinal obstruction and was taken to the operating room that same day where she was diagnosed with a sigmoidal mass with bowel obstruction. A hemicolectomy with colostomy and mobilization of hepatic flexure was performed. Shortly after surgery, there was some concern that the patient developed an abdominal compartment syndrome and was promptly returned to the operating room. Unfortunately, as her abdomen was opened the patient experienced cardiac arrest. ACLS protocol was followed with return of pulse but the patient remained vent dependent secondary to respiratory failure, with acute renal failure developing and necessitating peritoneal dialysis. The patient eventually underwent tracheostomy and PEG tube placement and never regained consciousness. She was diagnosed with a small subarachnoid bleed in the right posterior parietal lobe and a tiny subarachnoid bleed in the left posterior parietal lobe, and because of a persistent vegetative state with no hope for recovery, the siblings made the decision to withdraw treatment and provide comfort care.
Question(s) For Expert Witness
- 1. Should the abdominal compartment syndrome have been noticed sooner?
- 2. Was there a failure on the part of the physician to properly manage the fluids given during the procedure?
Expert Witness Response E-001353
There are a few more facts I would like to have to gain a greater understanding of what exactly went wrong here such as how much time was there between the diagnosis and the operation? I believe this may be more of a problem of failure to timely diagnose and treat abdominal compartment syndrome. As far as the second question, I’m not sure if failure to properly manage IV fluid administration s/p exploratory laparotomy, extended left hemicolectomy with end colostomy, and mobilization of splenic flexure due to bowel obstruction is negligence in this situation. As a colorectal surgeon, I see patients such as this all the time and many surgical patients have fluid and electrolyte disturbances as a result of surgery but this is considered the norm and is managed on a case by case basis.