DATE OF ADMISSION: MM/DD/YYYY
DATE OF DEATH: MM/DD/YYYY
TIME OF DEATH: 07:32 a.m.
HISTORY AND HOSPITAL COURSE: The patient was a (XX)-year-old female who had previously undergone a transduodenal resection of a villous adenoma near her ampulla, who had presented to the outpatient surgical clinic with recurrent jaundice. Workup at that time demonstrated a cystic lesion of the pancreatic uncinate process. An ERCP demonstrated significant mucin from the main pancreatic duct, which was thought to be consistent with a diagnosis of IPMN. At that time, the patient was scheduled for resection of this mass and underwent this procedure on MM/DD/YYYY.
Postoperatively, the patient’s course was complicated by intra-abdominal hemorrhage on postoperative day number one. The patient was taken emergently to the OR at this time and found to have bleeding emanating from the splenic hilum. At this time, a splenectomy was performed, and the patient was returned to the surgical intensive care unit. The patient remained stable for the following 10 postoperative days. She was placed on tube feeds and initially did well. However, on postoperative day number 11, she was noted to decompensate on the floor requiring intubation and a transfer back to the intensive care unit. At that time, she was significantly hypotensive and acidotic. Despite aggressive resuscitation, this did not improve. Her abdominal exam at that time was consistent with acute peritonitis.
For this reason, the patient was returned to the operating room where she was found to have extensive necrosis of her small bowel from the point of the J-tube site extending all the way down to the terminal ileum. It was felt that this necrosis was related to her tube feeds. She underwent extensive small bowel resection at this time and was again returned to the surgical intensive care unit. The patient remained critically ill for the duration of her admission. During this process, she developed multiple intra-abdominal abscesses, which were percutaneously drained. These fluid collections grew multiple microorganisms, including Enterococcus faecalis as well as Enterococcus faecium, which was resistant to both vancomycin and Zyvox as well as non-albicans Candida species. She was treated aggressively with broad spectrum antibiotics, including Synercid and Zosyn.
The patient remained critically ill, however, remained stable. Over the course of the following nine postoperative days, the patient’s white blood cell count was noted to trend up. Multiple CAT scans of the abdomen continued to demonstrate stable fluid collections, and the patient was examined bronchoscopically twice and found to have some plugging but no evidence of pneumonia. The patient was maintained on TPN for nutritional support. Additionally, during this time, the patient developed a line infection, and her central venous lines were changed and cultured demonstrating methicillin resistant Staph. epidermidis.
On postoperative day number 15, following her take back and small bowel resection, the patient underwent a tracheostomy tube placement for a failure to wean from the vent. The patient remained critically ill following this procedure as well, and on postoperative day number seven, following her tracheostomy, was noted to have an acute increase in her white blood cell count. Additionally, the patient became hemodynamically labile. She was placed on IV vasopressor agents. However, at this time, her family declined further aggressive measures.
On postoperative day number seven, following her tracheostomy, the patient’s family requested that ventilatory support be withdrawn along with all active IV medications. This was performed with the family at the bedside, and the patient was noted to become progressively bradycardic and then go asystolic. Time of death was called by the surgical intensive care unit resident at 07:32 a.m. The coroner was notified, but autopsy was declined. The family was present with the patient at the time of death.
