HEMICOLECTOMY WITH DOUBLE HEMICOLECTOMY WITH DOUBLE

BARREL STOMA BARREL STOMA

KAVITHA SATHASIVANKAVITHA SATHASIVAN05/07/201205/07/2012

• 47 yr old female was admitted to 3B on 18/06/12 for

colonoscopy scheduled on 19/06/12 to rule out any

possibilities of cancer after having altered bowel condition

(diarrhea and constipation) a/w vomiting 6 months ago.

• Colonoscopy result - tumours 30 cm from anal verge nearly

obstruct the lumen

• Exploratory Laparatomy with sigmoid colectomy with stoma

and HARTMANN'S procedure on 20/06/12

• Discharged on 27/06/12 with medication and TCA on

24/07/12 for colonoscopy.

• Name : JN• Age : 57 yo• Gender : Female• Race : Malay• Height : 148cm• Weight : 56kg (18/06/12)• BMI : 25.57kg/m2

• Electively admitted for colonoscopy (19/06/2012 )

•Hx of breast abscess -> around 20yrs ago, had

surgery, told not cancer.

•Bronchial asthma

-On prophylaxis (MDI Budesonide & MDI Salbutamol)

-Last attack – last month

•Hypertension- On 3 Antihypertensive (T Perindropil 8mg OD, T Amlodipine 5mg OD, T Hydrochlorothiazide 25mg OD)

• Does not consume Red meat regularly• No family hx of breast / colon/ thyroid ca • Housewife • Has 3 children • Breast fed all her children, youngest is 19yrs • Menopause for 5 years (not on HRT treatment)

• BP : 143/96 mmHg• PR : 86 p/min• RR : 20 b/min• Temp : 37.0°C

•Hemicolectomy with double barrel Stoma

•Tumour at the descending colon

DATE ISSUE WARD MANAGEMENT

RECOMMENDATION OUTCOME

18/06/12 Absence of antiemetic in tx of vomitingPt. been vomiting for the past 3 days

No antiemetic given on admission

Start IV Metoclopramide 10mg TDS

IV Metoclopramide started on 19/06/12-vomiting frequency reduced from x3/d to x1/d

18/06/12 Inappropriate administration time of fleet oralColonoscopy planned on 19/06/12 at 9am

Fleet Oral 45ml at 6pm, 9pm & 12MN

Should be given 12 hours & 2 hours before procedure (9pm on 18/06/12 & 7am on 18/06/12)

DATE ISSUE WARD MANAGEMENT

RECOMMENDATION OUTCOME

19/06/12 Hydrochlorthiazide induced hypokalemiaPt is hypertensive & Potassium level is below range, improper K+ monitoring

T. Amlodipine 5mg, T. Perindropril 8mg, T. Hctz 25mg OD

•Withold HCTZ till hypokalemia is resolved•Monitor the K+ level

T. HCTZ was withheld on the 20/06/12

24/06/12 Inappropriate administration of T. Cefuroxime and T. metronidazole in chemoprophylaxis of surgerysurgery was on 20/06/12, not started with any abx

T. Cefuroxime 500mg BD + T Metronidazole 400 mg TDS started on 24/06/12

IV Cefoperazone 1g BD + IV Metronidazole 500mg TDS on 20/06/12 post-op

DATE ISSUE RECOMMENDATION OUTCOME

27/06/12 Counseling on Fleet Oral as a discharge medication for colonoscopyColonoscope is on 27/7/12

1. Avoid fibre diet 3 days before the procedure: avoid vegetables, fruits with skins/seeds, nuts, whole grain cereal/breads.2.      Only consume soft diets a day before the procedure until 6pm (eg. Soup, porridge)After 6pm, drink only clear liquids and juice. For food, can take plain jelly without added

fruits or toppings.

Pt Understood well

Antihypertensive• Pt had sudden SOB on 24/06/12 night & BP shoot up to

150/89mmhg• pt was on T.perindropril 8mg OD and T.Amlodipine 5mg

OD• The T.amlodipine 5mg OD was converted to T.Felodipinie

5mg and patient tolerated & responded well.• The BP was under control.

1)Manzo BA, Matalka MS, Ravnan SL, Evaluation of a therapeutic conversion from amlodipine to felodipine, 2003 Nov;23(11):1508-12. http://www.ncbi.nlm.nih.gov/pubmed/14620396

2) Parra D, Beckev NP, Korman L , Retrospective evaluation of the conversion of amlodipine to alternative calcium channel blockers, 2000 Sep;20(9):1072-8, http://www.ncbi.nlm.nih.gov/pubmed/10999500

1. Patient discharged on D of admission, with medication :-• T Celecoxib 200mg PRN x 10/7• C. Omeprazole 40mg OD x 2/52• T. Felodipine 5mg BD x 2/12• T. Perindropril 8mg OD x 2/12• T. Metronidazole 400mg TDS x 1/7• T. Prednisolone 40mg OM x 2/7 • T. Prednisolone 40mg ON x 1/7 • T. Cefuroxime 500mg BD x 1/7• Sol. Phospho Soda Oral 45ml BD ( for colonoscopy on 27/7/12)

CT TAP on 9/8/12 at Serdang Hosp

1. Ministry of Health Malaysia. National Antibiotic Guideline. Malaysia: Ministry of Health; 2008. p. 24, 25, 29.

2. Scottish Intercollegiate Guidelines Network (SIGN): Antibiotic prophylaxis in surgery. A National Clinical Guideline. 2008 July. p. 6, 17, 29-31.

3. Kanji S, Devlin JW. Infectious diseases: Antimicrobial prophylaxis in surgery. In: Dipiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM. Pharmacotherapy: a pathophysiologic approach.7 th ed. New York: McGraw Hill; 2008. p. 2030-1, 2036.

4. Thirion DJG, Guglielmo BJ. Infectious disorders: Antimicrobial prophylaxis for surgical infections. In: Koda-Kimble MA, Young LY, Alldredge BK, Corelli RL, Guglielmo BJ, Kradjan WA. Applied therapeutics: The clinical use of drugs.9th ed. US: Lippincott William & Wilkins; 2009. P57 p.1-10.

5. Manzo BA, Matalka MS, Ravnan SL, Evaluation of a therapeutic conversion from amlodipine to felodipine, 2003 Nov;23(11):1508-12. http://www.ncbi.nlm.nih.gov/pubmed/14620396

6. Parra D, Beckev NP, Korman L , Retrospective evaluation of the conversion of amlodipine to alternative calcium channel blockers, 2000 Sep;20(9):1072-8, http://www.ncbi.nlm.nih.gov/pubmed/10999500

7. Dante L. Haw, MD, Swartz principle of surgery 9th edition,benign condition of the colon and rectum/ benign tumors and polyps, september 2010, http://images.xixcalibur19.multiply.multiplycontent.com/attachment/0/TInHeQooCy0AACwxUfY1/surgery%20colon%20and%20rectum.pdf?key=uemed2012b:journal:755&nmid=364634932

8. Klikenberg-KnolEC, Jansen JM, Festen HP, Meiwissen SG, LamersCB, , Double-blind multicentre comparison of omeprazole and ranitidine in the treatment of reflux oesophagitis, Lancet 1987 Feb 14;1(8529):349-51, http://www.ncbi.nlm.nih.gov/pubmed/2880161