245. Nepal Day 12

Surgery today uneventful, but in the evening a patient from the first day returned after not feeling well for several days. Low blood pressure, no significant urine output, rapid heart rate, and rapid respiratory rate. No fever. Appeared in considerable distress.

Severe dehydration? Internal bleeding? Septic shock (systemic infection; see post #)?  

A "stock" image showing healthy pink bowel
and necotic dark bowel segment

Deteriorating vitals signs prompted surgery which showed a necrotic bowel. The necrotic areas of the bowel were removed, and the patient transported to the nearest hospital with an ICU, about two hours away, where several hours later she was reported as stable. 

Which came first, an infected bowel (say from accidental surgical injury) or necrosis from inadequate blood supply which then led to infection? The surgeons “ran the bowel” (that is, inspected the bowel from top to bottom) and found no evidence of perforation.  

Regarding the latter, at her age (71 it appears now though in the clinic she said she was 60, perhaps translation error or concern that she would be rejected because of age), there could be poor bowel vascularity—not enough blood going to bowels means not enough oxygen which increases risk of tissue death and widespread necrosis.

A final possibility is the antibiotic that a Nepalese doctor gave her at discharge (we would not routinely give antibiotics for a postop patient).  A not uncommon bowel bacteria call
clostridium is not covered by these drugs and could take advantage of the open field provided as normal bacteria were eliminated by the antibiotics. But clostridium infection
is usually associated with severe diarrhea. 

Lesson learned? Better attempts at screening for age or age-related conditions--easer said than done. Longer post-op stays: 2-3 nights after surgery instead of 1-2. Low threshold for use of metronidazole, the one antibiotic that covers clostridium. And a tweak of the method used to clean the vaginal wall.