Intra-operatively there was significant blood loss of 5.5L, and he received seven units of packed red cells, two units of pooled platelets and six units of fresh frozen plasma. He underwent a second exploratory laparotomy with tube diversion and primary repair of the wound dehiscence pedicled omentoplasty.Īfter significant improvement, he had definitive surgery consisting of primary exclusion and roux loop gastrojejunostomy, his third operation, five days after the second operation, on post-admission day forty. A duodeno-jejunal anastomotic leak was diagnosed on post-admission day thirty-five, post-operative day nine. This was managed medically with paralysis and renal replacement therapy. On post-admission day twenty-eight, post-operative day two, it was noted that the patient had a high intra-abdominal pressure of 26mmHg, complicated by oliguric acute kidney impairment from abdominal compartment syndrome. Post-operatively, he was transferred to the surgical intensive care unit (ICU) for ventilatory and haemodynamic support. A computed-tomography abdominal and pelvis investigation revealed a perforated duodenal ulcer, and subsequently, he went for an exploratory laparotomy with a roux loop mucosal patch, his first operation. Unfortunately, he developed acute severe abdominal pain twenty-six days post-admission. He was initially treated with antibiotics and ascitic drainage for culture-negative neutrocystic ascites. He had a history of extensive smoking, hypertension, chronic kidney disease and Child C liver disease complicated by portal hypertension, ascites, oesophageal varies and gastropathy. We suggest that earlier and more routine use of bronchoscopy should be employed in an intensive care unit, especially as a definitive way to rule out endotracheal obstruction.Ī 63-year-old male, 170cm tall, weighing 69kg, was admitted to the Singapore General Hospital, Singapore, presenting with epigastric bloating and discomfort. It resulted in various treatments being trialed whilst the patient continued to deteriorate from the evasive offending culprit. Due to the absence of classical signs, the delayed identification of the obstructing mucus plug exacerbated diagnostic confusion. The mucus plug was not identified until a bronchoscopic assessment of the airway was performed. A case is described of endotracheal tube obstruction from a mucus plug that compounded severe respiratory acidosis and hypotension in a patient who simultaneously had abdominal compartment syndrome. The inability to pass a suction catheter through the endotracheal tube with high peak and plateau pressure differences are classical features of an endotracheal tube obstruction. Endotracheal tube obstruction by a mucus plug causing a ball-valve effect is a rare but significant complication.
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