Hi, My Wife Was Admitted To Hospital For ERCP 1month

Posted on Sun, 3 Feb 2019

Question: Hi, my wife was admitted to hospital for ERCP 1month back and in the last phase of operation she got air embolism and the second day she got pancreatitis . Now this the fourth week ended and fifth week going on. after the second week of pancreatitis she is getting fever mostly in the evening to night. and again in the morning the fever reduces to normal around 98 and 99.from the past 1 week she is getting high fever, 9jan the fever was 102 and 10 XXXXXXX it reached 104. when the fever the doctor did test and haemoglobin was less around 7 before that in the morning haemoglobin was 6.2 and they transfer blood in morning 7 am of 10 XXXXXXX night 11 the haemoglobin was 8.8 and around 12 the haemoglobin was 10. her wbc count was high for few days around 18, 19 1nd 20. Which is stabilise and on 9th it was 9.5. yesterday 10 XXXXXXX when the fever was high they checked potassium and calcium and found it is low. I am attaching few scan report and hematology report. please suggest what to do. they had found infection in the ET declaration for psedumonas aero...... Which they were treating. her age us 31.
just wanted to correct the on 10 the night 10:30 haemoglobin was 8.8 and after fever it was 7.

Answered by Dr. Ramesh Kumar (39 minutes later)

Brief Answer:
Want some more details.

Detailed Answer:
Hello and thanks for skiing query on this forum,
Have gone through your details,
Hemolysis is the destruction of red blood cells before their normal life span is up.Severe hemolysis is seen in inflammatory conditions like pancreatitis.Secondly toxins released by bacteria can also cause severe hemolysis.As fever is persistent this means that inflammation and infection is still there in body.The basic aim of body to increase temperature is that bacteria's can't tolerate such high temperature.Therefore in high fever state the bacteria dies away but releases large amount of toxins into blood vessels.This may result into increase permeability of blood vessels hence may cause seepage of blood through it.This may be a cause of low hemoglobin despite of transfusion.Was a stool test done for occult blood?
I can't see any reports attached to the query.So please attach all details with follow up.
Are her vitals normal?
Is she maintaining blood pressure and pulse?
What is her blood oxygen saturation?
What was the result of her blood culture and sensitivity?
What antibiotics she is on?
As an attendant what are your observations?Is she improving?
Is she responsive?
Please attach reports of all tests as well as treatment she is on.
All details are required before making any professional comment on her condition.
Waiting
Thanks!

Above answer was peer-reviewed by : Dr. Nagamani Ng

Follow up: Dr. Ramesh Kumar (25 hours later)

Hi Sir, I attached the reports, so reattaching it. still test for occult blood, I am not sure, I will ask today.her vitals are normal, means sometime potassium gets low, not always, she is not in ventilator, she is sense and she talks. blood pressure she was maintainng but from yesterday she got two time slight low blood pressure.blood oxygen saturation was also Ok, but after high fever it was reduced to 85 .and now she is on High Flow oxygen. I will provide the antibiotics details today.blood culture and urine culture are till now negative. I will provide some more details. As per doctors discussion she has fluid behind and below liver, which they say due to pancreatitis. yesterday the put tube through nose and also put a stent to flush out the fluid. they said naturally a opening was made through which fluid are getting passed to duedonium,but some fluids are below,which can,t go to the duedonium easily because of gravity issue. after one episode of flow from yesterday she got one spike of tempreture rise of 100.3 at 11 pm that is after the nose flush setting. after and below that spike she is maintaining tempreture of 98 and 99. seems to be ok. she is complaining of stomach pain. I will put more details after the discussion of doctor today. one antibiotic they started tigicyline after which her tempreture raised to 104 1nd 103, yesterday they stoped the tigicyline. attaching the reports again.

Answered by Dr. Ramesh Kumar (26 minutes later)

Brief Answer:
follow up.

Detailed Answer:
Hello again,
Have seen reports,
Its going to take time sir all these are a result of sepsis(infection due to pancreatitis). This infection is now in her pancreas and in the fluid surrounding it.Till time the bacteria's are fully cleared up from body there would be off and on fever.
Its a clear cut case of sepsis.
Sepsis occurs when chemicals released in the bloodstream to fight an infection trigger inflammation throughout the body. This can cause a cascade of changes that damage multiple organ systems, leading them to fail, sometimes even resulting in death.
Treatment as off now is correct.
Pig tail catheter is there for draining.Antibiotics are main stay of treatment and keeping her vitals stable is the ultimate goal.If pulse blood pressure and oxygen saturation is maintained by patient then all we can do is give her therapy and wait her body to respond.
One request from next time kindly scan the date of tests also.
Frankly speaking this would take time so rest assured till patient is maintaining vitals every thing is ok.Fever pain etc would be there.Her body is in a state of severe infection with inflammatory responses.
Keep me updated.
Hope i was helpful,
Thanks!

Above answer was peer-reviewed by : Dr. Nagamani Ng

Follow up: Dr. Ramesh Kumar (26 hours later)

Hi Sir, they did test of the fluid which they took through endoscopy nd sent to lab and found MDR Klebsiella which is resistive to tigicyline and sensitive to polymixin and fosfomycin. it's a preliminary report. I am still on a way to get the reports, once I get I will attach here. they had contrast scan on 8th XXXXXXX and 12 XXXXXXX from 8th to 12th XXXXXXX there is a increase of air pocket, which seems to be infection. they started the aspiration and flush on 12th XXXXXXX till now they have done it three times.Let me know if they are in right direction or you cn suggest so that the doctor and win the fever and then the patient will be able to fight infection. hoping for a best solution and guidance which can improve and benefit her. Thanking you, XXXXXXX

Answered by Dr. Ramesh Kumar (1 hour later)

Brief Answer:
follow up.

Detailed Answer:
Hello XXXXXXX
Now as doctors have reports of culture and sensitivity the likely hood of fast improvement are high because now they know that to which antibiotic the bacteria is sensitive.Till now it was an instinctive treatment.So its good that culture reports are there.

Very likely cause of increase of air pocket is because till now antibiotic sensitivity and resistance was not known.Now when sensitive antibiotics would be given they would strike the bacterium.
Fever as told earlier is an indicator of infection and her body fluid is infected by klebsiella. Once bacteria is gone fever would settle down by itself.
Solution-
Maintain vitals of patient
Administer high doses of parentral antibiotic and supportive management.

Treatment protocol as off now is administer antibiotics the patient is sensitive to.
Maintain pulse blood pressure and oxygen saturation.
Drain off the fluid (would be quicker now).
Wait and watch.
Hope i was clear and helpful,
Follow up after 24 hours.
Please attach the treatment sheet of patient(if hospital allows).
Thanks.

Above answer was peer-reviewed by : Dr. Vaishalee Punj

Follow up: Dr. Ramesh Kumar (1 hour later)

Hi Sir, attached is the clinical summary

Answered by Dr. Ramesh Kumar (31 minutes later)

Brief Answer:
feeling sorry for her the procedure went wrong.
Detailed Answer:
Hello dear,
Feeling sorry for her after reading the complete summary.
I think you need a easy explaination of what happened and what are they doing now/Whats going on?

See normally ERCP is a non complicated procedure but unfortunately in your case complication occurred (pancreatitis). Now as patient landed up into pancreatitis(in december) she started having sepsis in which the bacteria travels to various other parts of the body and infects it(you can see by yourself that infection spreaded to lungs her chest etc etc) but fortunately at that time infection was controlled but as per her latest scans she is again having a repeat attack of pancreatitis and this time the bacteria involved is klebsiella(I.C.U has its own problems many times patients admitted for long time in hospital gets hospital acquired bacterial infections but we have to deal with that). As of now she is back to square one i mean she is again having pancreatitis and the doctors have started her antibiotics as per her culture sensitivity reports.
As per my experience she would take at least a week more in I.C.U/H.D.U and after that minimum 14 days for recovery.
Blood tests should be done regularly(that they would take care off).
Except that the main procedure got wrong every thing else mentioned in summary is done correctly.

In case you find any thing difficult to understand or the thread closes you could write to me directly at http://doctor.healthcaremagic.com/doctors/dr-ramesh-kumar/72660

Again till patient is maintaining her vitals(pulse,blood pressure and oxygen saturation there is no need to panic).
Hope i was helpful.
In case the thread closes do rate the answers and suggestions to make answers better are welcome.

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Above answer was peer-reviewed by : Dr. Kampana