A 60-year-old patient has come to our hospital for
digestive endoscopy.
He was looking in fair general conditions and he was
complaining of epigastric pains.
We have asked him the routine questions about past
medical history and he has not reported anything significant in the past.
We have therefore proceeded with the endoscopic
examination. As we often do, we have injected half ampoule of diazepan and half
ampoule of hyoscine, apart from the lignocaine spray, in order to have a patient
a bit more calm and cooperative.
The gastroscopy went on without much problems and with
good cooperation by the patient.
But, when I was writing the report, the client started
sweating profusely and saying that he could not breathe well.
We have therefore put him in a supine position, and
thinking of a hypoglycaemia secondary to fasting, we have requested for an
urgent blood sugar, which was normal.
Rapidly the patient complicated with apnoea.
We called the anesthetist who was very rapid
intubating the patient and starting assisted respiration with ambu bag.
Meanwhile, thinking of abnormal reaction to
benzodiazepines, we started the infusion of the antagonist anexate;
unfortunately we reached the maximum dose of anexate, without achieving the
reversal of the respiratory arrest.
There was never heart arrest and the heart bit has
been regular throughout.
We have checked the blood pressure and we have got
extremely high levels of BP (260/150).
Our diagnostic hypothesis switched from diazepam
reaction to stroke secondary to previously unknown hypertension. While the
anaesthest was taking care of the breathing we started IV hydralazine, IV lasix
and IV mannitole to reduce the pressure and a possible cerebral oedema
contributing to the deep coma and to the respiratory arrest.
While visiting the patient we noticed a stoma-bag at
the level of the right iliac fossa, in which there was collection of urine.
It was clear that the patient had not told us the
truth about his past medical history.
He was escorted to the hospital only by a small child
and we had to send him home to call the wife of the patient for further medical
information. When the spouse came, she gave us a lot of documents through which
we came to know that for more than 7 years the patient had been diagnosed with
an advanced stage of carcinoma of the bladder.
The malignancy had blocked both ureters and a right
ureterostomy had been performed at Kenyatta National Hospital. In spite of that
the kidney function tests were completely abnormal with a creatinine level of
9g/dl.
The extreme hypertension was secondary to uremia and
probably the patient got a stroke triggered by the nausea and vomiting caused
by the gastroscopy.
We continued the resuscitation for more than 6 hours
and in the end we had to accept that the patient had gone.
There are few learning points from the case above.
1) We cannot rely on the medical history given
by the patients.
2) Although we are to do only a gastroscopy,
we must find time to visit the patient properly before the procedure. If we had
done that we would have seen the urine bag coming from the right iliac fossa.
3) A blood pressure check is compulsory before
all the procedures even though we are very busy.
Dr Giuseppe Gaido
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