Detailed Treatment Process
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Male, 29 years old Admitted to the emergency department on April 12 and died on August 30. The medical damage appraisal committee’s expert report describes the course of care as follows: Four. Treatment course: On April 12, the patient was urgently transferred to the hospital because of “sudden coma with convulsions for 5 hours.” Head CT showed right frontal lobe intracerebral hemorrhage with intraventricular extension. He was admitted immediately. Admission physical examination (general condition) recorded: temperature 37.0°C, pulse not palpable, respirations shallow and irregular, blood pressure barely measurable. Neurologic findings: 1. unconscious, GCS 5; 2. both pupils 8 mm in diameter with sluggish light reflex; 3. limb muscle power not assessable, increased tone; 4. sensory examination not assessable; 5. bilateral Babinski sign positive. Admission diagnosis: spontaneous right frontal hemorrhage with intraventricular extension and fourth ventricular casting. Suspected etiology: cerebral arteriovenous malformation likely. The same day, under general anesthesia, bilateral external ventricular drainage was performed. The operative record states: “…small arcuate incision in the frontal region, burr holes drilled 2 cm anterior to the coronal suture and 2 cm lateral to the midline on each side, dura coagulated and opened, F2 drainage tube placed on the right and Ommaya reservoir on the left, both inserted smoothly. Thick, old bloody cerebrospinal fluid was drained under very high pressure…” After surgery the patient returned to the ICU for anti-infective, antispasmodic, and dehydrating treatment. On April 13, the progress note recorded that the patient had regained consciousness in the early morning; the endotracheal tube was removed, but he was agitated. Chlorpromazine was given for symptom control. Both drainage tubes were patent and draining old bloody CSF. On April 17, the progress note stated that the patient had developed high fever the previous day. Cefepime had been changed but the temperature continued to rise. Because of the presence of drainage tubes, he was considered at high risk for intracranial infection, so the antibiotic was switched to meropenem for stronger coverage. CSF analysis: light red and turbid, white blood cells 90 × 10⁹/L, neutrophils 60%, Pandy’s test 1+, glucose 3.5 mmol/L, protein 879 mg/L (reference 150-600 mg/L), chloride 123 mmol/L (reference 120-132 mmol/L). On April 19, the progress note recorded a temperature of 39°C in the morning and CSF white blood cells of 1,440 × 10⁹/L. Vancomycin was added to prevent worsening intracranial infection, and the family was informed of the possibility of intracranial infection and re-bleeding. On May 4 the patient’s temperature returned to normal with no headache. The Ommaya reservoir was removed, and vancomycin and meropenem were discontinued on May 6 and 7, respectively. At 6:30 on May 9, the patient suddenly developed severe headache followed by coma. Head CT showed new right frontal and corpus callosum hemorrhage with intraventricular extension (significantly increased compared with prior scan) and subarachnoid hemorrhage. He was declared critically ill. Under general anesthesia, right external ventricular drainage with placement of an Ommaya reservoir was performed, and vancomycin plus meropenem was continued. On May 10, under general anesthesia, cerebral DSA and embolization of a left anterior communicating artery aneurysm were performed. The operative record states: “…the microcatheter tip was shaped, and under real-time DSA roadmap guidance the microcatheter was carefully advanced over a microwire into the left anterior communicating artery aneurysm. First, an Axium 3D (3 × 8 mm) coil was deployed to form a basket, followed by four additional coils (Axium 2 × 6 mm, 2 × 4 mm, 2 × 4 mm, and 1.5 × 2 mm). Dense packing was achieved. Post-embolization angiography showed patency of the parent artery and good filling of the bilateral anterior cerebral arteries and left middle cerebral artery.” On May 19 the patient remained comatose. Head CT showed right frontal and corpus callosum hemorrhage with intraventricular extension and drainage in place, a small right frontoparietal subdural hematoma, and a large left temporoparietal ischemic infarct. Under general anesthesia, right frontotemporal decompressive craniectomy and evacuation of the frontal hematoma were performed. Postoperative treatment included anti-infective agents, antispasmodics, volume expansion, and dehydration. On May 24 the patient’s GCS score was 6. CSF analysis: orange-red and turbid, white blood cells 50 × 10⁹/L, neutrophils 80%, Pandy’s test weakly positive, glucose 3.3 mmol/L, protein 1,595 mg/L, chloride 112 mmol/L. After consultation with the antibiotic research institute, the regimen was changed to fosfomycin plus amikacin. From June 10 onward the patient again developed high fever, with axillary temperature reaching 39.2°C. CSF showed clots and white blood cells too numerous to count. Puncture confirmed Ommaya reservoir obstruction. Lumbar drainage was instituted and antibiotics were changed to meropenem plus amikacin. On June 11, Gram stain of CSF showed Gram-negative rods 3+. Chest radiograph showed increased lung markings bilaterally. On June 14, CSF culture grew extensively drug-resistant Pseudomonas aeruginosa. On June 16, after consultation with the antibiotic research institute, the regimen was changed to meropenem plus fosfomycin plus isepamicin. On June 28, CSF white blood cells were 130 × 10⁹/L. Throat swab culture grew extensively drug-resistant Pseudomonas aeruginosa 3+. On June 30, sputum culture grew extensively drug-resistant Pseudomonas aeruginosa 4+. On July 5, after consultation, the regimen was changed to fosfomycin plus ceftazidime plus gentamicin. On July 9, chest radiograph suggested left middle and lower lobe pneumonia. On July 10, oxygen saturation declined. The patient underwent endotracheal intubation followed by tracheostomy and was placed on mechanical ventilation. On July 11, sputum culture grew Stenotrophomonas maltophilia, sensitive to some agents. On July 23, the patient’s heart rate and blood pressure dropped and intracranial pressure rose. Lumbar CSF contained abundant flocculent material. Under local anesthesia the Ommaya reservoir was replaced. On July 24, after consultation, antibiotics were changed to fosfomycin plus meropenem. On August 6, the patient’s temperature reached 38.2°C and vancomycin was added. On August 19, the Ommaya reservoir was found to be completely obstructed. Under intravenous anesthesia, exploration and external drainage were performed. The operative record states: “…the ventricular catheter was carefully withdrawn. The side holes at the tip were blocked by yellow flocculent material. The catheter was flushed with concentrated gentamicin saline until fully patent, then reinserted. Patency of the ventricular end was confirmed…” On August 22, because of high pressure at the bone window and slow Ommaya drainage, exploration and external ventricular drainage were again performed under intravenous anesthesia with placement of an F3 ventricular drain. The operative record states: “a large amount of yellow coagulated material was found obstructing the ventricular end of the tube. The tube was repeatedly flushed with sterile gentamicin saline until the ventricular end was patent…” On August 25, the patient developed hypotension requiring vasopressors at progressively higher doses while remaining on mechanical ventilation. On August 29, sputum culture again grew extensively drug-resistant Pseudomonas aeruginosa 4+. On August 30 at 11:00, the patient’s heart rate slowed and blood pressure became unmeasurable. Epinephrine, atropine, and other drugs were given by intravenous push and external cardiac compression was performed. He was pronounced dead at 11:37. Cause of death: multiple ruptures of intracranial aneurysm after interventional treatment; intracranial infection; pulmonary infection; circulatory and respiratory failure.