UNASSUMING ABDOMINAL PAIN

UNASSUMING ABDOMINAL PAIN

As I walk through the intensive care unit (ICU) I am greeted by machine after machine, one in almost every patient's room. I make my rounds at a leisurely pace, introducing myself to the patients while reviewing their charts.

Free Air under the Right Hemi-Diaphragm

In order to make room for tomorrow's cases, patients who are stable and meet criteria are transferred to the floor. As I wander, I overhear the sign out of a patient leaving the ICU"... post op patient with mild complaints of abdominal pain..." I glance inside the room and see the patient lying comfortably in bed. It is not long before transport arrives and the patient is wheeled upstairs to the 5th floor. 

Early that morning I get a call from the floor. A hypotensive patient with low oxygen levels! Taking the staff elevators, I run through plans and scenarios as I ascend to the 10th floor. A small crowd greets me in front of the patient's room. Inside, the patient from earlier in the night,  whose sign out I'd overheard, is sitting upright and working hard to breathe. He tires quickly and it is not long before we need to intubate. 

We order a chest x-ray (CXR) to check placement of the breathing tube and crowd around the screen to analyze the image. Air under the right hemi-diaphragm.. a potentially sinister omen... free air in the abdomen stemming from a hole in the stomach or intestines 

Femoral Nerve, Artery, Vein (Left to Right)

The blood pressure cuff squeezes and then relaxes on his arm. The alarm bells ring on the monitor. BP is 40/20. We all scratch our heads. The number is so low its hard to believe and certainly not compatible with life if sustained. An arterial line is needed for more accurate measurements. Due to the urgency of the situation I decide to place one in the femoral artery. I identify the artery lateral to the vein on the ultrasound and enter it sharply with a needle. Bright red blood streams out. Im in. I quickly thread a wire through the needle before threading a catheter over the wire. Satisfied with the placement I remove the wire. The nurse hands me the pressure transducer and I hook it up to the catheter. All heads turn towards the monitor. Dang. 50/30. Push 1mg Epinephrine, now! The blood pressure responds temporarily and we use the respite to draw labs, blood cultures and start broad spectrum antibiotics.  

His blood pressure remains low despite numerous pushes of epinephrine. We start him on an epinephrine and norepinephrine drips and race downstairs. 

Despite our interventions, by the time we reach the ICU his blood pressure is still low, his oxygen levels are dropping again and his pH is 6.9 (normal 7.35-7.45)! We add phenylephrine and vasopressin in a desperate attempt to raise the blood pressure and turn the oxygen delivery to maximum on the ventilatory. Sodium bicarbonate is given to increase the pH. The next set of labs bring more bad news. His CO2 levels in the blood (pCO2) is 90! We start the patient on continuous albuterol, hoping to open up the constricted airway. Suddenly the patient flips into a deadly rhythm. V-fib!!(Ventricular Fibrillation). In this rhythm the ventricles of the heart quiver instead of contracting disabling the hearts ability to pump blood to the body

By this time we are maxed on four pressors. I hear someone yell for another mg of epinephrine, amiodarone and calcium. I grab AED (shock) pads and place them on the patient. The room is alive with action, everyone moving swiftly in tandem but our current efforts are to no avail, we have no choice but to go for the Hail Mary. VA ECMO (Venoarterial Extracorporeal Membrane Oxygneation). Similar to the heart-lung machine used in the operating room it siphons blood from the body removes the carbon dioxide and other impurities before enriching it with oxygen and returning it to the patient, doing the work of both the heart and lungs.

ECMO 

We swiftly dilate the vessels in order to make room for the ECMO cannulas. Inevitably, the erratic beeping of the monitor is replaced by a long continuous sound. ASYSTOLE. We have to start the ECMO machine NOW! The tubing is connected to the ECMO cannulas and we ensure there are no air bubbles in the system. "Clamps off, go on !" We all breathe a collective sigh of relief as the ECMO machine takes over the function of his ailing heart and lungs, supplying oxygenated blood to the body. 

We then rush the patient to the CAT scan to obtain chest abdomen and pelvis imaging, eager to reveal the identity of what precipitated the nights events. The culprit, a perforated peptic ulcer! I recall the conversation I had overheard earlier in the night, regarding his unassuming abdominal pain. A vague symptom that foreshadowed the events of the night and something to ponder as we race to the operating and prepare for an exploratory laparotomy.

H. pylori is a gram-negative, helically-shaped bacterium usually found in the stomach. Like major surgical interventions, it is a significant risk factor for the development of mucosal ulceration of the digestive tract.  H Pylori testing represents a way to risk stratify post-operative patients and determine who would most benefit from prophylaxis. H. Pylori fecal antigen test is the most sensitive and specific for active infection. Most common chemoprophylaxis includes H2 blockers and Proton pump inhibitors. A non-pharmaceutical intervention is early enteral nutrition. The mechanism is not fully understood but it is thought that by initiating a PO diet mucosal blood flow is increased and gastric acid is buffered. 

Major open surgical interventions have increased risk of clinically significant peptic ulceration. H. pylori testing provides the means to risk stratify patients. Combined with chemoprophylaxis and early enteral nutrition it may be possible to reduce post-operative complications.

Perforated Peptic Ulcer