Clinically Unstable Patient Undergoes Elective Surgery and Dies

Case Overview

This case involves a 59-year-old woman who had a past medical history that was significant for hypertension, hypothyroidism, and liver cirrhosis. The patient was scheduled for an elective total knee replacement for osteoarthritis and underwent pre-admissions testing in preparation for her surgery. At this time, the medical records demonstrated that the patient had a poor overall medical status and was on several medications including lactulose, levothyroxine, spironolactone, furosemide, and propranolol. The patient was cleared for surgery despite abnormal coagulation values and a deteriorating clinical picture. The knee replacement surgery went ahead without any complication, however, in the immediate postoperative period, the patient became severely hypotensive and experienced persistent tachycardia. Fluid resuscitation with normal saline was administered and orders for blood products were entered. Subsequently, a transfusion was initiated and transfer of the patient to a critical care setting with vasopressor support was suggested. Throughout the evening the patient’s blood pressure remained low, her urine output was poor, and she was given additional blood products. Renal failure quickly developed and was attributed to the bleeding and hypotension. Over the next few days, there were consults from a variety of physicians, including a gastroenterologist, who diagnosed the patient with Disseminated Intravascular Coagulation and a severe gastrointestinal bleed. Despite continued medical treatment that included transfusions, hemodialysis, and other lifesaving measures, the patient expired.