Postoperative hypoxia in a woman with Down's syndrome: case presentati
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《英国医生杂志》
1 Northern General Hospital, Sheffield, S5 7AU, 2 Ninewells Hospital, Dundee, 3 Rotherham District General Hospital, Rotherham, S60 2UD
Correspondence to: A K Siotia Anjan.Siotia@sth.nhs.uk
Miss Webb, a 24 year old woman with Down's syndrome, was referred by her general practitioner to the gynaecology outpatient clinic. She gave a one year history of heavy and irregular periods, general lethargy, and a painful abdominal lump, which examination showed to be an umbilical hernia. She had no serious medical history (including congenital heart disease) and she was not taking any regular medicine. She lived with her mother, who was her main carer.
Attempts at insertion of a levonorgestrel intrauterine system (Mirena) under general anaesthesia to treat her menorrhagia were unsuccessful. She subsequently had a dual operation to repair a painful umbilical hernia and a total abdominal hysterectomy under general anaesthesia. Preoperative blood tests including full blood count, urea and electrolytes concentrations, liver function tests, and coagulation profile all gave normal results.
Questions
What are the ethical considerations around obtaining Miss Webb's consent for a hysterectomy and what would be best practice here?
What are the differential diagnoses for the sudden postoperative deterioration in Miss Webb's condition?
What further investigations would you do?
What earlier intervention may have prevented this deterioration?
Please respond through bmj.com, remembering that Miss Webb is a real patient and that she and her carers will read your response
Immediately after the operation, she was slow to recover from the anaesthetic. She was hypoxic with poor respiratory effort. She was given intravenous naloxone for suspected opiate induced hypoventilation, but her condition was unchanged. She required respiratory support in the intensive therapy unit. She was taken off the ventilator after 24 hours, but had slow respiratory effort, and despite high flow oxygen her oxygen saturation was only 93%. On examination she was alert with a Glasgow coma score of 15, respiratory rate of 10 breaths/minute, heart rate of 70 beats/minute, regular rhythm, systolic blood pressure of 98 mm Hg, and temperature of 37°C. Examination of the cardiovascular system, chest, abdomen, and nervous system showed no abnormality. The table shows the results of the blood tests. Portable chest radiography (AP view) showed normal lung fields with possibly increased cardiothoracic ratio.
Results of patient's preoperative blood tests
This is the first of a three part case report where we invite readers to take part in considering the diagnosis and management of a case using the rapid response feature on bmj.com. Next week we will report the case progression and in four weeks' time we will report the outcome and summarise the responses
Competing interests: None declared.(A K Siotia, research fellow in cardiolog)
Correspondence to: A K Siotia Anjan.Siotia@sth.nhs.uk
Miss Webb, a 24 year old woman with Down's syndrome, was referred by her general practitioner to the gynaecology outpatient clinic. She gave a one year history of heavy and irregular periods, general lethargy, and a painful abdominal lump, which examination showed to be an umbilical hernia. She had no serious medical history (including congenital heart disease) and she was not taking any regular medicine. She lived with her mother, who was her main carer.
Attempts at insertion of a levonorgestrel intrauterine system (Mirena) under general anaesthesia to treat her menorrhagia were unsuccessful. She subsequently had a dual operation to repair a painful umbilical hernia and a total abdominal hysterectomy under general anaesthesia. Preoperative blood tests including full blood count, urea and electrolytes concentrations, liver function tests, and coagulation profile all gave normal results.
Questions
What are the ethical considerations around obtaining Miss Webb's consent for a hysterectomy and what would be best practice here?
What are the differential diagnoses for the sudden postoperative deterioration in Miss Webb's condition?
What further investigations would you do?
What earlier intervention may have prevented this deterioration?
Please respond through bmj.com, remembering that Miss Webb is a real patient and that she and her carers will read your response
Immediately after the operation, she was slow to recover from the anaesthetic. She was hypoxic with poor respiratory effort. She was given intravenous naloxone for suspected opiate induced hypoventilation, but her condition was unchanged. She required respiratory support in the intensive therapy unit. She was taken off the ventilator after 24 hours, but had slow respiratory effort, and despite high flow oxygen her oxygen saturation was only 93%. On examination she was alert with a Glasgow coma score of 15, respiratory rate of 10 breaths/minute, heart rate of 70 beats/minute, regular rhythm, systolic blood pressure of 98 mm Hg, and temperature of 37°C. Examination of the cardiovascular system, chest, abdomen, and nervous system showed no abnormality. The table shows the results of the blood tests. Portable chest radiography (AP view) showed normal lung fields with possibly increased cardiothoracic ratio.
Results of patient's preoperative blood tests
This is the first of a three part case report where we invite readers to take part in considering the diagnosis and management of a case using the rapid response feature on bmj.com. Next week we will report the case progression and in four weeks' time we will report the outcome and summarise the responses
Competing interests: None declared.(A K Siotia, research fellow in cardiolog)