We describe the case of a 73-year-old woman with a high body mass index and a virgin abdomen who presented with a 5-day history of abdominal pain, emesis and confusion on admission. Inflammatory markers and renal function were significantly deranged. CT of the abdomen and pelvis demonstrated a clear transition point and faecalisation of the small bowel proximal to the obstruction. It was suggested that the patient may have ingested a foreign object. A collateral history was obtained, making this less likely and confirmed an acute cognitive impairment. She was optimised following multidisciplinary discussion preoperatively. Thereafter, the patient underwent a laparotomy, where a hard, mobile mass was identified in the jejunum. This was diagnosed as an enterolith of dimensions 62×38×32 mm secondary to a duodenal diverticulum. She improved postoperatively with complete resolution of her confusion and renal function. She was discharged on day 14 of admission.
Aims Surgical patients in the intensive care unit (ICU) are frequently critically unwell with varied abnormal physiology1. The use of haemodynamic monitors in such cases is invaluable in permitting early intervention of complications such as multi-organ failure (MOF), yet is often overlooked1. A Trust-wide study was performed utilising guidelines outlining criteria for haemodynamic monitor instigation2. Methods We retrospectively reviewed the records of 20 surgical patients to determine whether standards were achieved. Concurrently, we conducted a survey of junior doctors in order to establish knowledge and identify areas for improvement. Results 20% of patients were new admissions with sepsis and MOF. 10% had inotropic requirements in accordance to Trust guidance. 35% required fluid bolus >2l within 12 hours of ICU stay; 40% did not and there was no documentation for 25% of patients. 85% were within the 1st 48 hours post-operatively. Only 4 patients received haemodynamic monitoring, LiDCO and PiCCO monitors being used equally. 12 responses were received from our survey of junior doctors. 66.7% were familiar with different haemodynamic monitor types. 58.3% stated they would be confident knowing when to initiate usage. 83.3% added they would be able to use these monitors independently. Only 2 individuals had read the Trust guidelines on haemodynamic monitoring. All participants stated they would benefit from teaching on this subject. Conclusions Our study showed Trust guidance for haemodynamic monitor instigation was not being adhered to optimally. Increased awareness via education programmes would be beneficial, ensuring more favourable outcomes for patients- surgical or otherwise.
A 4 year-old child suffered catastrophic 60% total body surface area burn injuries affecting head and neck, trunk and limbs following sulphuric acid burns. He underwent limited treatment in his country consisting of first aid and debridement and grafting in upper and lower limbs and trunk, but no treatment to the facial and ocular areas. He was referred for assessment and reconstruction in the United Kingdom. Even though there were widespread burn scar contractures, his most severe injuries involved both eyes and adnexal structures with evidence of severe bilateral cicatricial ectropion and threat to vision. He required multidisciplinary plastic surgery and ophthalmic complex bilateral eyelid reconstruction in two separate procedures to restore anatomical and cosmetic integrity to both eyes. The initial procedure involved examination under anaesthesia of both eyes, release of the left upper and lower eyelids burns scar ectropion and resurfacing of the resulting defect with full thickness grafts from the left clavicular area. The grafts had full take with no evidence of infection and excellent cosmesis. A similar procedure was performed to reconstruct the right eyelids 6 weeks later. The vision of this eye was beyond salvage but the need for cosmetic eyelid symmetry was considered as an appropriate indication to proceed to reconstruction. This was found to be successful with excellent graft take and parental satisfaction. This case required coordination, expert holistic approach, complex surgery and extra efforts from the team to ensure compliance, communication and positive outcomes and highlights the importance of multidisciplinary team effort.
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