Description of Event or Problem · 1
IT IS EXPLAINED THAT IT COULD HAPPEN DUE TO CSD -CALCIUM SULFATE DIHYDRATE- OCCURS THROMBO-EMBOLISM DURING INJECTION AND RESULTS IN DEATH DUE TO BLOOD CLOTTING IN VESSELS, ESPECIALLY IN BRAIN. SUMMARY OF HISTORY: PATIENT IS (B)(6) FEMALE. SHE WENT TO HOSPITAL DUE TO SUFFERING FROM SEVERE LOW BACK PAIN AFTER FALLING DOWN FROM HORIZONTAL BAR (B)(6). AFTER RADIOLOGICAL EXAM AND ALL RELATED LAB AND PHYSICAL EXAMS, THERE WAS REPORT OF A COMPRESSION FRACTURE OF T11. THUS, WE WERE SUGGESTED THAT THE BEST WAY TO TREAT A WAS RECEIVING THE TREATMENT OF POSTEROLATERAL FIXATION WITH TPS FROM T10 TO T12 AND VERTEBROPLASTY ON T11 WITH MIIG. DURING SURGERY, A WAS SUDDENLY SHOCK WHEN THE DOCTOR WAS SEALING THE WOUND -ABOUT TO THE END OF SURGERY-. AFTER INJECTION OF EPHEDRINE 8MG FOR 4 TIMES, BOSMINE 0.1MG FOR 2 TIMES AND HUGE AMOUNT OF FLUID AND HAES GIVEN-FLUID 2000ML+HAES 500ML-, A GAINED THE BLOOD PRESSURE BACK TO NORMAL OF 10 MINS. HOWEVER, IN ONE HOUR AFTER FIRST AID, HEMIPLEGIA AT RIGHT PART OF THE BODY. A WAS URGENTLY SENT TO CT SCAN AND FIND BILATERAL PLEURAL EFFUSIONS, SUBSEGMENTAL ATELECTASIS, THROMBO-EMBOLISM, INTRACRANIAL CALCIFICATIONS PRESENT AT LEFT PUTAMEN. THEN A WAS SENT BACK TO OPERATING ROOM AGAIN TO FIND WHAT OCCURS HEMORRHAGE. FROM BACK WOUND, THE DOCTOR FILLED IN LOTS OF HEMOSTATIC COTTON INSIDE AND GAVE PRESSURE ON THE WOUND. DURING SEVEN HOURS IN THE OPERATING ROOM, THE TOTAL BLOOD LOST WAS 2000CC, MOST BLOOD WAS FOUND DURING THE PROCESS OF A SENDING TO CT SCAN AND BACK TO OPERATING ROOM. THEREFORE, DOCTORS KEPT GIVING A FLUID, HAES AND BLOOD AGAIN -ANOTHER FLUID 3500ML+HAES 1000ML +BLOOD 1500CC-. AND THEN SENT A TO ICU DUE TO UNSTABLE AND POOR DEVELOPMENT. IN NINE HOURS AFTER SPINE SURGERY, FROM MRI OF BRAIN, INCLUDING MRA, DOCTORS FOUND ACUTE CEREBRAL ISCHEMIC INFARCT AT LEFT MCA, AND WATERSHED AREA OF RIGHT CEREBRUM. NARROW AT M1 SEGMENT -LEFT MCA- WAS SUSPECTED, BUT THAT WAS ODD SINCE MOST VESSELS WERE PATENCY AT THAT TIME. DOCTORS SUGGESTED THERE WAS CEREBRAL ISCHEMIC INFARCT AT LEFT MCA. ON DAY 2, 12 HOURS AFTER SPINE SURGERY, THEIR LEFT PUPIL SIZE DILATED WAS ALSO FOUND AND DOCTORS SEND A TO CT SCAN AGAIN AND FOUND MIDDLE SHIFT WITH CEREBRAL ISCHEMIC INFARCT AT LEFT MCA. DOCTORS ARRANGED EMERGENCY SURGERY FOR LEFT DECOMPRESSIVE CRANIECTOMY. FOLLOWING SIX DAYS UNSTABLE VITAL SIGNS, WAS JUDGED AS BRAIN DEAD IN EARLY MORNING OF DAY 7. WAS DEAD AT DAY 17 DUE TO CARDIOPULMONARY FAILURE. TIME TABLE: DAY 1 AM 8:00: START TO UNDER ANESTHESIA PROCESS AM:30: INDICATE HYPOTENSIVE ANESTHESIA AM 9:00: START TO OPEN AM 10:50: SHOCK AM 11:00:PRESSURE BACK TO NORMAL AM 12:00:FIND HEMIPLEGIA AT RIGHT PART OF THE BODY AM 12:30: CT SCAN PM 13:30:BACK TO OPERATING ROOM AND HEMOSTASIA DEBRIDEMENT PM14:55:SENT TO ICU PM 21:33:MULTIPLANAR MRI OF BRAIN, INCLUDING MRA, WITHOUT GD ENHANCEMENT DAY 2 AM 02:20: CT SCAN AM 3:40: LEFT DECOMPRESSIVE CRANIECTOMY AM 6:17: SENT TO ICU DAY 7 AM 10:00: BRAIN DEAD DAY 17 AM 7:00:CARDIOPULMONARY FAILURE. DEATH. DOSE OR AMOUNT: 5CC. DATES OF USE: (B)(6) 2007 -- (B)(6) 2007. DIAGNOSIS OR REASON FOR USE: COMPRESSION FRACTURE OF T11.