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Washington University Experience | VASCULAR | Infarct, watershed | 14A0 Case 14 History
Case 14 History ---- The decedent was a 71yo male with a history of nephrolithiasis, traumatic amputations of the left lower extremity and bilateral upper extremities, cataracts, and a recent history of laparoscopic converted to open cholecystectomy. The surgery was complicated by intra-operative blood loss, post-operative hypotension, and PEA arrest on September 26 which lasted about 9 minutes. After CPR and two rounds of epinephrine, calcium chloride, and sodium bicarbonate, return of systemic circulation was achieved. Following the PEA arrest, the decedent developed multi-organ dysfunction. He was transferred to BJH on October 2 with poor neurologic status. Off sedation, he was not responsive to sternal rub and had sluggishly reactive pupils. Renal ultrasound showed concern for acute tubular necrosis, and he was started on hemodialysis. Nasogastric tube placement returned 750 ml of coffee ground gastric contents, concerning for a gastrointestinal bleed. Endoscopy showed concern for ischemic gastritis. Troponins were initially elevated then down-trended; the elevation was thought to be secondary to shock and demand ischemia rather than acute coronary syndrome. The decedent's white blood cell count was elevated and he was treated with antibiotics for suspected sepsis. On October 2 the decedent was transferred from an OSH to BJH for a suspected bile leak. On arrival, he was neurologically unresponsive with only intact brainstem reflexes. A non-contrast head CT was obtained and showed multiple subacute ischemic infarcts. MRI of the brain and magnetic resonance angiography of the head without contrast re-demonstrated multiple subacute watershed infarcts, compatible with severe hypoxic/anoxic and hypovolemic injury. Emergent EEG showed moderate generalized slowing. The family was informed of the poor neurologic prognosis. The decedent was terminally extubated and expired on October 5.
