Ann Hayes, age 68, initially was admitted

Ann Hayes, age 68, initially was admitted to the hospital for elective surgical repair of an abdominal aortic aneurysm. Her surgery was documented as uneventful. However, complications developed during her fifth postoperative day as a result of small bowel perforation. Postoperative Day 5 VS and Laboratory results were as follows: BP/HR/R/T 170/94 mm Hg / 110 bpm / 30 breaths per min./ 38.6oC (101.4oF) rectal HCT/Hbg 10.1 g/dl / 30% RBC 3.5 x 106/mm3 WBCs 20,000/mm3 Urine tests showed the following: Creatine 0.6 g/24 hr Osmolarity 460 mOsm/L Specific Gravity 1.01 pH 9.0 Na+ 45 mmol/L K+ 15 mmol/L Cl- 48 mmol/L Results of Serum measurements were the following: Na+ 135 mmol/L K+ 4.8 mmol/L Cl- 88 mmol/L Ca++ 6 mg/dl BUN 27 mg/dl Creatine 1.4 mg/dl Uric Acid 9 mg/dl Phosphorus 5.2 mg/dl Alkaline Phosphate 14.8 King-Armstrong units/dl Laboratory results and vital signs were telephoned to her physician. Her physician’s orders included the following: Hydralazine (Apresoline) 10 mg qid Gentamycin sulfate (Garamycin) IV 5 mg/kg tid in divided doses Piperacillin sodium (Pipracil) 3g q 12 h Gastrointestinal Fistula Repair: As a result of an abnormal abdominal x-ray film, Mrs. Hayes was returned to surgery for repair of a small bowel perforation. Four days after Mrs. Hayes’s bowel surgery, she developed a gastrointestinal fistula. She was again taken to surgery for repair of the fistula. Postoperatively her BP drops to 80/52 mm Hg and her urine output was 20 ml/hr, requiring invasive monitoring. Mrs. Hayes’s oxygen saturation and arterial blood gas values dropped significantly. She required intubation and was transferred to the intensive care unit. Intensive Care Unit Admission: After Mrs. Hayes’s admission to the ICU, the staff took a complete history that revealed the following: Mrs. Hayes weighed 76.5 kg, (preoperative weight was 71 kg) and had 2+ pitting edema in her lower extremities. Her skin was pale, shiny, and dry. She complained of nausea and stated that she “felt as if she had no energy left.” Fluid intake for the past 24 hours was 1400 ml and her output was 510 ml. Jugular vein distention was noted, and crackles were auscultated bilaterally in the lung bases. The initial cardiac rhythm was tachycardia with a rate of 110 bpm, a PR interval of 0.18 second, QRS complex of 0.14 second and peaked T waves. What is your differential diagnosis of Mrs. Hayes and how would you treat it?

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