Occasions at the most recent time in the year he developed a chronic fistula from his pancreatic bed he had a defuncturing loop ileostomy on friday and were basically just quite a bit of everything that could just keep happening he was really well before this he was fully have a really really good baseline he's been around me once almost 3 he's been icu for a long time yeah 5 pounds and he's now scoring an 8 so this happened yesterday when he went off a little bit and we sent cultures from everything but he was lying because we still we still need to keep that in use he was on iv mirabegron started yesterday he put up a bolus of blood his blood pressure's dropped that's what's triggered this day ercp disturbance like horrendously now we're put the nystagmus up yeah this is from the pancreatic duct the kernel yeah defunctioning defunctioning was the friday friday friday so yeah all 8 pills yeah he's deteriorated with low blood pressure low blood pressure he's also had him he's in positive fluid balance as well so he's got bilateral pleural effusion we did have him on 25 o d and I only breathe yesterday obviously he's probably going up and he's on tpn or mj for the idea that's our surgical red shoes and the peep scrubs great so we're all here it's just obviously protocol is to get some extra hands yeah we're so I'm back on to his story but do you wanna go in and put the gown on and go and see if he's happy to see if there's certain questions you have made you know you're on the side I'm gonna keep blood pressure a little bit yeah that is quite complicated oh I'm to make sure that I just oh I just need to oh he's the guy he's the guy yeah yeah he didn't he's trying to keep blood pressure a little bit I know I I I I don't know okay but he's a little longer yeah he's on a meridian yeah and well now is that involved a little bit more with the issues that we can see a little way I just got off there you what when you're part of your age is it appropriate no I'm still doing a lot of work alright hello hi thank you for coming pleasure thanks I'm tina I'm the incubator yeah it's quite common to meet you yeah I'm talking about that yeah we're 10 20 rcp in 2020 I'm trying to help you it's a dangerous it is a dangerous procedure as you all well know yeah so it's all been a secretly for my life yeah okay he had a ct a ct yesterday okay yeah yeah still has persistent headaches are they taking a migraine infection yes we have done that yes that's right he had to do a functioning ayostomy with his hip bone defect see had to not yet have prolonged fistula yeah but typically is it unusual could this be an early complication of the operation laparoscopic complication with this hypertension and kidney headache I'll actually after that not because around the stoma's fine the stoma's working as well he's not feeling sick but just feels quite washed out yeah it's been it's a symptom sensation yeah there is a suggestion that there's another collection for me absolutely I don't if splenic infarct but mister briggs was going to have a look at the scans because then we've got another patient on well as well so it's been it's been chaotic so right now I guess we're we're trying to get the hypertension correct physiology we know what's driving it yeah distributive shock from intradominium that's it it's gonna be the intravascular he's yeah overloaded 0.4 yesterday so so did he do other chipping stuff at georgia I heard they did I think proton culture they just did a line sal's gonna do a cathodectomy this afternoon he hasn't yet had a buzz today because again they have to be on his line because he's been drinking oh okay yeah / but he's been made of in cushing's supply of course I guess of course but we should make sure that he hasn't gone to the lyme sepsis lyme sepsis yeah so some worry yeah I think the issue yesterday was that they called you online and you were to do it so using access yeah yeah the lungs at the same time annually he got it in somewhere in the dfa no impact going to manage to get 1 yeah so without the yeah the bones coming back right so we have alternative access so we should be able help you but that means no tpn anything along with the pop up with the ngt now that we've confirmed the tumor's in the right place is it fine so it's a need for going to secondary to having a septic shock yeah yeah it's but it's under duodenum and that's the thing so so the the dietitian or is it there's not it's a girl yeah yeah he has been trained phyliotomy he is good to go through enteral physics fine no his ct this morning was walled on the top of the pancreas yeah a pancreatic colonic fistula which is known bilateral profusion pine free gas soft heels which may reflect on the official legal surgery within the last few days it's happened so nothing's really changed so you've got an enteral double collection instead of his pancreatic duct he's got nothing else he's got no collections with 2 drains in between okay so that's great so we are we have a restoration yeah there there's still a drain 2 drains in in situ at night but he's got a new retroperitoneal 1 there which may be communicating with him my breast makes sense so it's all very bad but I was gonna talk to mister briggs about it anyway until he's happy so I guess it's more extravascular how how we can it's just blood pressure yeah I mean is he spiking your temperature along with this he's 8 9 he's yeah the cultures were all taken at 5 so 60 yeah so yeah it's and what did he do in the last hour did he use the line he the only thing he sat out he sat out he sat he'd been back in like quite a while like a half hour at least nothing happened no no it was all up he was all nice yeah lying down everything yeah okay so what how do we proceed then just continue vomiting and see if it's if you're taking any I've started tim's got an expert review I think he's had recent imaging you know there's no intraventricular fashion or anything I think looking for line surfaces is really sensible yeah and putting nutrition on the back burner for a moment to make sure that that's not drying in more so of course with the line basically you're scheduled for and then should we get him a chest x-ray make sure he hasn't got another postoperative complication that's coming about 1am yesterday great or this morning 1am the ct did show he's got bilateral pleural effusions as well so he's which is why I couldn't hear any actual excellent excellent should we do we'll have a look at his heart rate 2 weeks later I guess yeah yeah preparation we've got the ecg for her infusion test just to weigh it yeah yeah I don't know if he's blood sugar pops about just I've just done it covid wise 11.9 that we just keep giving bonuses each unfortunately think you have to put it in the transplant don't you if we don't it's gonna be narrow but yeah we need put it somewhere yeah from without I guess the alternative is a good option you just take that opportunity and work with your health this from the like hot shampoo I can go harder with the inhaler give him lots of 2 50 doses to make sure the blood pressure is normal until he can and then once you fill him up in his box to require him to go off then you just need be to write to him that's possible well he's dry so I I just out of yeah but I think all the evidence shows that it just washes out very quickly it doesn't affect exercise again in the long term yeah yeah okay I would think that I would think that sepsis probably drive a lot of leakage there as opposed to a low outflow yep yeah mhmm you can do it if you can you'll probably give it some bites out then and you have blood pancreas now for sure right yeah so what do think about thyroid cancer so you just get a good gastric and gastrin you just get I'm just not worried but you're looking at it to try and get something to do with x-ray and then we'll take them there okay michelle put up the batting to the consultants mister briggs was let's just say not pleased that he's definitely as a cosoptotic call was not going well so that'll be fun times to to talk to him again not personally am very thankful for you yeah terrific so much you so know maybe enough but yeah it would be outside no so where are the phones in d bay yeah very bottom of the cabinet in d bay okay cool okay 011 oh y f a okay there are not fixed steps now so what do you think that's been kind of rewrapped the same time well I think was like the same thing every time yeah the same thing in the same like in the way sorry yeah well secondary to intradermal infection secondary to necrotizing pancreatitis yeah of loss of myelosuppressive yeah yeah easy fluid responsive hypotension significant spacing is limited but I'll I'll move means I have to I I was trying to move what's yeah I mean I've tried adjust the blood pressure yeah by definition it's hypertensive yeah you can measure your glucose 10 people that are going to see the material yeah pretty much not us yeah I think it's just it's fully integrated physiologically proud it's been a long time it's been a a terrible time they're getting compelling enough because that's what we can do but you're not fixing the actual problem that's driving his hypotension think his guess is a leak he needs to swab and you know he's got a huge amount of cervical vasoactive compounds leaking out of intrabundal inflection which is gonna make more than less of skip and that's what's driving this hypoception so you can pour fluid in but the vessels do not clot the more fluid that you pour in will just leak out into the space then he'll worsen his oxygenation she's got actually and like probably like and sneeze so you'll see his pectoritis but if you manage that or if you need to decide to see him again then come back go back and see him hi yeah that's not good so the plan is venous blood gas blood for chest x-ray ecg we can take that off if done it then strict it out for monitoring bolus of fluid to titrate blood pressure within range discuss rate of an echo so it's you've got a big collection now obviously it's gonna drive sepsis you wanna take it out but you need to I mean I think the I'm sure that you've heard the rules of surgery which is essentially never let the sun set on an abscess and no crack with the pancreas size and stuff and we have done exactly all of this so so they just don't like the fact that they've been entirely resourceful when you look at the outcome and they're terrible for an open necrosectomy because they're like necrosectomy they are exactly here we do endoscopic necrospectomy at 1 of the gastroenterologists doctor suarez has their own history so they're like a stent in an axial stent hot through the stomach wall into the flexion and then put a wire in through the stent endoscopically and fluoroscopically and then you can drain the collection like that it has sorry sam you're alright do you wanna have no I'll just clean that 1 so it can come out think you're fine okay thank you for coming they've actually changed so it's tested for kind of to yeah it's growing in day yeah look horrible we've got bacteria they they're open they're open you know it's easy I mean nice 1 see you guys later bye cheers guys bye