Case 8: Delayed laparotomy in deteriorating cardiothoracic patient Cardiothoracic surgery CASE SUMMARY A male patient aged 70 was transferred to a tertiary hospital after an unconscious collapse assessed as being secondary to severe aortic stenosis. His aortic valve was replaced on day 11 of his hospital admission, the delay being due to lack of operating theatre time. The procedure and initial recovery were satisfactory. On the second postoperative day the patient’s oxygen saturation levels began to deteriorate. This was initially ascribed to hypoventilation secondary to pain and a history of asbestosis. On the fourth postoperative day, after two MET calls for tachypnoea, the patient was transferred to ICU. His abdomen had become distended. The surgical team was called, and the possibility of ischaemic bowel was raised. The patient’s condition declined steadily. He was assessed by the surgical team several times but not considered in need of intervention. A CT scan was initially thought to show ileus only, however a subsequent report mentions pneumatosis coli—a sign of ischaemic colitis. By the fifth postoperative day, the patient was tachycardic, febrile and on a low dose of noradrenaline to maintain BP, with worsening respiratory failure and evidence of acute kidney injury. Laparotomy was still not considered to be indicated. On the sixth postoperative day, the patient underwent a laparotomy. The findings were underwhelming (no evidence of full thickness infarction) given the gravity of his condition at this time, possibly because he had either colonic mucosal ischaemia or venous ischaemia of the small and large bowel (or both). He underwent a right hemicolectomy and ileostomy. The patient deteriorated rapidly after this procedure, requiring increased inotropes and dialysis. He died of multiorgan failure the following day, one week after his aortic valve replacement.
DISCUSSION Ischaemic bowel can be notoriously difficult to diagnose, particularly in a postoperative patient when the main symptom—pain—can be masked by
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