Case 5: Death from aspiration pneumonia precipitated by oral bowel preparation General Surgery CASE SUMMARY A woman in her late-70s was admitted to hospital for recurrent SBO on a background of metastatic cancer. She had multiple comorbidities including ischaemic heart disease, congestive cardiac failure, chronic obstructive pulmonary disease and peripheral vascular disease. She had previously been diagnosed with 4 cancers, the predominant one being a gallbladder cancer resected the previous year. She had also undergone a right hemicolectomy for stage 1 caecal cancer and a gastrectomy for a duodenal neuroendocrine tumour. She was considered ASA IV (American Society of Anesthesiologists Physical Status). Goals of patient care were clearly documented: these had become increasingly conservative (not for resuscitation) on successive admissions over 6 months. The patient had been admitted 6 times for similar problems over the preceding 3 months, mostly under different consultants. She had been managed conservatively each time. She was readmitted to hospital with a presumed further sub-acute SBO the day after previous discharge and was correctly managed conservatively. While no radiological reports were provided in the file, reference was made to an abdominal X-ray, which showed dilated small bowel loops and that contrast from the previous Gastrografin™ follow-through had made it into the colon. There was reference to a PET scan 3 months earlier suggesting nodal metastases and possible peritoneal metastases. During the first few days of her admission there was some clinical improvement and she progressed to nourishing fluids. The consultant decided to perform an inpatient colonoscopy, although, interestingly, the day before this, the intern noted on the ward round ‘the patient was not for colonoscopy until the blockage cleared.’ The patient received appropriate bowel preparation, being 2L of ColonLYTELY™. Overnight in ICU; however, she developed aspiration pneumonia with typical clinical findings: right lung consolidation, positive blood cultures and inotropes requirement. She made some improvement over the next few days but remained on inotropes and suddenly passed away.
VOLUME 20 | AUGUST 2021
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