A 40 years old woman presented to the emergency department (ED) complaining of 5 days of developed nausea and vomiting, and 1 day of epigastric abdominal pain, she underwent cesarean section 1 month ago, and had no known predisposing factor for peptic ulcer disease. She had been to a local hospital for symptomatic treatment, and the time the pain did not improve, so she sought medical attention. On examination, the out-patient computed tomography (CT) scan of the chest and abdomen showed patchy shadow on the lower right lung and pneumoperitoneum. Laboratory studies are significant for elevated inflammatory indicators. The patient experienced syncope during the outpatient visit, and recovered after intravenous fluid replacement, and her vital signs were still unstable. Possibility of septic shock with a diagnosis of intestinal perforation was considered, and the patient underwent emergency laparotomy after reporting to the hospital management department under strict protection 4–7.
During the preoperative preparation in the operating room, the patient experienced a loss of consciousness again, accompanied by a decrease in pulse oxygen saturation to 70% and blood pressure to 80/60 mmHg. And the anesthesiologist immediately gave tracheal intubation, mechanical ventilation to assist breathing, and fluid resuscitation, vasoactive drugs to maintain blood pressure. Intra-operatively, there were about 1.6 liters of yellow-green purulent fluid in the peritoneal cavity. The omentum adhered to the stomach and duodenum, with white pus mosses on the surface. And 3 cm long perforation was found at the posterior wall of the duodenum, with gastric juice and bile flowing out. Rest of the gut was normal. During the operation, patients needed vasoactive drugs (norepinephrine 1ug/kg · min) to maintain blood pressure, and returned to Medical Intensive Care Unit (MICU) with tracheal catheter for isolation and monitoring.
On the day after surgery, the patient's bedside chest radiograph indicated: 1. Right pneumothorax (approximately 50% compression of the right lung); 2. Pneumonia; 3. Subcutaneous gas accumulation at the base of the bilateral neck and the right armpit. Then closed drainage of the right thoracic cavity was performed. Anti-infection, ventilator-assisted ventilation, fluid resuscitation and vascular active drug maintenance circulation, continuous gastrointestinal decompression, proton pump inhibitors for acid suppression and stomach protection, intravenous high nutrition support treatment, low molecular weight heparin prevents venous thrombosis.
On the third postoperative day, the patient's breathing and circulation were stable, and the tracheal tube was removed. And the 2019-nCoV nucleic acid test showed positive, she was continued to be isolated in the single room, reported in time according to the COVID-19 reporting process, and interferon antiviral treatment was added. On the 4th day after surgery, the patient's CT review showed: Multiple ground-glass opacities and patchy shadows of both lungs, combined with medical history, consider viral pneumonia; A small amount of pneumothorax on the right side, subcutaneous gas accumulation in both neck and chest wall, gas accumulation in mediastinum; A small amount of pleural effusion; Combined with medical history, consistent with abdominal postoperative changes, pelvic effusion. On the 5th postoperative day, her 2019-nCoV nucleic acid test showed a positive again. Her vital signs were stable and she was transferred to a designated hospital for treatment of COVID-19.