Childhood Appendectomy Causes Severe Third Spacing of Fluid and Shock

Case Overview

This case involves a 44-year-old male with a past medical history of bi-polar disorder, type II diabetes, sciatica, chronic back pain, insomnia, and obesity. He was on a myriad of medications, including Onglyza. Major surgical history includes a plate placed in his right leg following a motorcycle crash in the late 1980’s, right elbow surgery in 1996, a lumbar laminectomy for L5 in 1996, and an appendectomy in 2001. Patient has a significant family history of chronic back issues. The patient was aggressively treated with medical management for his chronic back pain but responded poorly to treatment and surgery was recommended as the only remedy. Minimally invasive left-sided transforaminal inter-body fusion, L5-S1, with radical discectomy, placement of biomechanical spacer (CD Horizon Legacy Spinal System), and arthrodesis with allograft and bone morphogenetic protein, pedicle screw placement and segmental instrumentation, L5-S1, and posterolateral fusion with local autograft and allograft. Immediately following the surgery, the patient began to feel a burning sensation down his left leg. The surgeon did not seem to consider this to be a problem and the patient was discharged home on with prescriptions for Carisoprodol, Gabapentin, Hydrocodone, Oxycodone, Tramadol, and Zolpidem. A follow-up MRI showed no problems but further EMG testing displayed, electro-diagnostic evidence of severe, advanced sensorimotor polyneuropathy evidenced in both lower extremities, as well as superimposed left L5 radiculopathy with extensive denervation changes. The patient now experiences foot drop, chronic pain, and a significant reduction in his mobility after undergoing this procedure.

Questions to the Pediatrics expert and their responses

What are some of the signs that indicate mismanaged care post-operatively?

From the case summary that you shared with me, it seems as if the patient may have been mismanaged postoperatively given that the surgery went without complication. But what is most troubling to me is the third spacing of fluids. This may be an ominous sign of a surgery that went longer than expected or one that was not properly replaced with IV fluids. Cases like this need close monitoring of the patients fluid status throughout the procedure and afterwards in a critical care setting. If the patient did have an insidious infection this would complicate the problem even further.

About the expert

This expert is a board certified Pediatrician with additional fellowship training in pediatric intensive care and anesthesia critical care. He was trained at Loyola University Medical Center during residency and Johns Hopkins University for his Fellowship. He has extensive experience in dealing with the complicated pediatric patient that requires critical care post operatively. He was the Director of a pediatric intensive care unit at a Major Medical Center in California. He currently is the Chief Medical Coordinator for a Pediatric Medical Consulting Program at a Children's Hospital in California.

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Specialties:

Pediatrics

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