Patient dies from septic shock due to delayed diagnosis of small bowel perforation


male bowelThis case takes place in Oklahoma and involves a sixty-seven year-old male patient who presented to the emergency room via ambulance with severe abdominal pain, hypotension and the appearance of being extremely ill. The patient had a past medical history of prior abdominal surgery eight weeks before the date of the presenting complaint for multiple hernia repairs. The hernia repairs were performed using a Composix Kugel mesh with no reports of complications and the patient was discharged without incident. On arrival at the emergency room a CT scan of the patient’s abdomen was which revealed a large ventral hernia with small and large bowel contained within the hernia sac. On physical examination of the surgical wound there was cellulitis in the anterior abdominal wall and inflammatory changes suggestive of peritonitis. The patient was admitted for dehydration and a suspected small bowel obstruction. The patient was transferred to the medical floors for intravenous fluid resuscitation and pain medication. It was not until more than thirty-six hours after admission that the patient was finally taken to the operating room for an exploratory laparotomy. By this time that patient’s condition had worsened drastically and he was severely unwell. During the procedure a perforation of the cecum was discovered and a colostomy was placed. The patient was started on Imipenem and Diflucan and transferred to the intensive care unit post-operatively. The patient was in a critical state following the surgery. He was not responding to pressor or fluid boluses. A ‘Do Not Resuscitate’ order (DNR) was obtained from the patient’s family and the patient died one day following the exploratory procedure. The cause of death was listed as small bowel perforation leading to septic shock and cardiopulmonary demise.

Question(s) For Expert Witness

  • Was there a timely diagnosis and treatment for this patient’s septic shock? Should this patient have undergone an exploratory laparotomy surgery sooner?

Expert Witness Response E-001188

Cellulitis overlying an incarcerated ventral hernia is extremely worrisome for incarcerated or perforated bowel. Furthermore, the cause of sepsis needs to be treated as soon as possible for older patients who may have further co-morbidities. He would have benefited from earlier surgical intervention. Cellulitis over the hernia and CT suggestive of peritonitis mandates rapid exploration within a time period less than 4-6 hours. A thorough review of the patient’s entire chart would be necessary to be able to figure out if this would have changed the outcome but I presume that it would.

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