1) A 50-year-old female with a history of metastatic colon cancer presented with abdominal distension and vomiting. 2) During an attempt to place an IV line for a CT scan, the patient became unresponsive. Resuscitation was required. 3) A CT scan showed an intraventricular hemorrhage. The patient's condition deteriorated and she eventually passed away despite recommendations for surgical decompression. 4) There were several delays in care including protecting the patient's airway, obtaining the CT scan, communicating the critical results, following up on results, and initiating treatments for brain edema.

1. MORTALITY AUDIT

2.  A 50 years old female presented to ER at 9 PM on
01/07/21.
 Chief complaints:
1) Obstipation and abdominal distension for 4 days
2) Multiple episodes of vomiting for 1 day
CASE:

3. PAST HISTORY:
 Patient is known case of metastatic signet cell
adenocarcinoma of sigmoid colon, received 3 cycles of
chemotherapy (CAPEOX regimen) and was planned for 4th
cycle of chemotherapy on 08/07/2021.
 Patient received 3rd cycle of chemotherapy on 16/06/2021.
 Patient had a history of similar complaints 3 days back, in
case of which patient was advised admission for further
management, but had got discharged against medical
advice citing personal reasons.
 No other known comorbidities.

4.  PR:110/min
 RR:20/min
 BP:110/60 mm of Hg
 Spo2 : 98% ON ROOM AIR
 GCS :15/15
 Temp – 98.6 F
 No palor/icterus/cyanosis/clubbing/lymphadenopathy
/edema.
VITALS AT PRESENTATION:

5.  ABDOMEN: Distended with diffuse tenderness, free
fluid present, bowel sounds present.
 RS : B/L air entry +; clear.
 CVS: S1 ,S2 heard.
 CNS – Normal
SYSTEMIC EXAMINATION

6. INVESTIGATIONS:
Hb 9.9
TLC 5100 ( 49+ 40)
Platelets 1,31,000
Na+, k+
creatinine
138, 3.4
0.9
XRAY OF ABDOMEN
CECT ABDOMEN
AND PELVIS
?
CXR, ECG NORMAL

7.  Metastatic signet cell adenocarcinoma of the
sigmoid colon in sub acute intestinal obstruction.
DIAGNOSIS :
PLAN :
 Conservative management with IV fluids, NG insertion
and analgesics.

8. Course in hospital:
DAY 1 OF ADMISSION:
• Medical oncologist opinion was sought on 01/07/2021 and on
discussion with surgical consultant decision to do CECT abdomen
and pelvis after ascitic tapping was taken to look for tumor burden
after 3 cycles of chemotherapy and also to rule complete luminal
obstruction of sigmoid colon.
• Under strict aseptic precautions and by using USG guidance 2
liters of straw colored ascitic fluid was drained.
• Patient was shifted to CECT abdomen and pelvis, but due to
absence of 18G IV cannula patient was shifted back to ward.

9. • In view of past chemotherapy peripheral vein cannulation
was difficult and for injection of IV contrast during CT scan
required a 18G cannula, hence EJV access was tried.
• During which patient had abnormal moments and became
unresponsive following which code blue was called.
• At 4:30PM patient vitals:
BP – Not recordable, Pulse – absent, GCS – 3/15.

10. • After 8 cycles of CPR patient was revived, and during
intubation it was observed that their was fresh blood pooled in
oral cavity( approximately – 200ml) and hence MTP was
called and 1 unit of PRBC and 2 units of RDP was transfused.
•Patient developed VT hence cardioverted with 200J and was
started on Inj Amiodarone.
• After counselling the family patient was shifted to HICU.
• Vitals at the time of shifting the patient to HICU:
BP – Not recordable, Pulse – 144/min

11. • In HICU arterial and central line was secured and was
started on inotropic supports which was gradually increased to
triple inotropic support.

12. DIFFERENTIAL DIAGNOSIS
- Erosive gastritis
- Oesophageal varices
Patient admitted to HDU @ 5:30 PM
Kept NPO , Continued on IV Fluids NS 100 ml / hour
and started on Omeprazole infusion .

13. In HDU
In HDU patient seen by ward on call at 5:45 PM
From 5:30 pm – 11:30 PM
- Vitally stable
- Symptomatically better
- GCS – 15/15
@11:30 PM resident was informed that patient had increased work of
breathing .
Patient seen by resident at 11:40 PM and found to have decreased
response ( GCS – E2V1M3 ) 7/15
BP – 150/90 mm Hg , PR – 64/min , RR – 18/min
Shifted to ICU

14. In ICU
Received in ICU @ 12:00 AM
In ICU
GCS – 6/15
Pupils – equal and reacting
BP – 140/70 , PR – 76/min , RR – 19/min , SPO2 – 89% in room air .
In ICU
Intubated @ 12:30 AM ( midaz , fentanyl , scoline )
Comtiued on same treartment .
I/v/o sudden drop in GCS CT Brain was done @ 2:00 AM
CT report ( Critical alert ) informed to “Dr KYNSHEW “ at 3:20 AM
IVH in 3rd and 4th ventrincel , aqueduct and loccipital horns and lateral
ventricle with moderate hydrocephalus .

15. @ 8 :00 AM
Vitally unstable
BP – 80/40 mm Hg , PR – 46/min , GCS – 2T/10T
Started on ionotropes at 9:00 AM
@ 10:00 AM
BP - not recordable on ionotropes
Patient was started on antiedema measures
Neurosurgery consult was sought and case seen by surgery resident and
advised SURGICAL DECOMPRESSION
S/b Neurosurgeon @ 11:00 AM and advised surgical decompression
Patient attenders opted palliative care ( no consent for palliative care ).
Cardiac arrest @ 2:07 PM – death declared .

16. WHAT COULD HAVE BEEN AVOIDED –
Delay in protecting airway after sudden drop in GCS ( patient shifted to ICU
and intubated there )
Delay in shifting patient for CT Brain after drop in GCS ( 2hrs )
Error in communicating critical report
Delay in following up of CT report
Delay in initiating antiedema measures

17. THANK YOU 