The Real-World Boards: Question #43
The hernia repair went well, but then ...
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A 58-year-old man with atrial fibrillation underwent an abdominal wall hernia repair three weeks ago. Two weeks ago, he presented to the E.D. with abdominal pain, nausea, and vomiting, and was admitted to the medical unit after a CT of the abdomen showed dilated loops of bowel consistent with a small bowel obstruction. His original surgeon was consulted and recommended conservative management with gastric decompression by NG tube to suction.
One week ago, he was admitted to the ICU for intermittent hypotension that responded to volume resuscitation and a brief infusion of vasopressors. He was given seven days of piperacillin-tazobactam. A CT without contrast at that time showed colonic thickening and persistent (improved?) dilation of the small bowel, which along with the stomach was fluid-filled. Blood cultures were negative.
Today, he has worsening hypotension and tachycardia, now requiring two vasopressors, afebrile and without new localizing symptoms. Abdominal exam is unchanged: significant distension with mild diffuse tenderness, no rebound. He denies any change in his symptoms, but has been receiving regular opioids for pain. Meropenem is started, and blood and urine cultures are obtained.
The surgeon’s note describes an unchanged abdominal exam and recommends a CT abdomen with oral contrast if the abdominal exam worsens. Creatinine was 1.5 mg/dL on admission and is now 3.1 mg/dL with low-normal urine output. The nephrologist’s note advises “avoid nephrotoxins, including contrast”.
