Sunday, September 25, 2011

A case of Perforative Peritonitis with MCA infarct

A 37 year old male patient, admitted to our hospital, with 3 days history of abdominal pain, in severe shock...BP not recordable, Carotids present, HR=140/min. Resuscitated as per EGDT guidelines... Detected to have Perforation... Operated after optimization within 6 hours of admission. Intra-op hemodynamically maintained...found to have a Pre-pyloric perforation...repaired. Inv: TLC =18000/cmm, Platelets = 4 lacs/cmm, Creat= 2.6mg/dl, Coag normal, CXR=clear, CD Echo= normal.
Day2 - Improved hemodynamically, Ionotropes tapering, Urine output good, Creat decreased from 2.6 to 1.7 mg/dl. RS - Clear. Leucocyte count decreasing, Platelets decreased from 4 lacs to 2 lacs/cmm
CNS- Drowsy, momentarily opens eyes to pain, not following any commands, attempts to localise pain with right upper limb, Pupils bilaterally equal, reacting to light.
Same midnight, has repeated episodes of hypoglycemia ( least sugar level = 63mg/dl).
Day 3 - early morning - Right pupil dilated as compared to left. BP decreasing again, Increased ionotropic requirement, Platelets decreased to 70000/cmm. TLC=9000/cmm.
CT Brain plain done...showing a huge right MCA infarct, with midline shift n early herniation.
What could be the reason for the infarct???
Please post your comments.... N your experiences....