Morbidity and Mortality Conference

1. Morbidity and MortalityConference Thomas Wold, D.O. , M.S. July 17, 2002

2. Initial Presentation • 81 y/o white male presents to WRJVA ED with 2 hours of substernal CP • Pain at rest • non-radiating • associated with nausea, diaphoresis and SOB • Patient took aspirin • Reported to WRJVA for evaluation • Pain resolved spontaneously upon arrival at VA

3. Review of Systems • Patient denies previous CP, exertional angina • Denied any h/o palpitations, orthopnea, edema or PND • No history of cardiac events • Poor exercise tolerance secondary to SOB

4. Hypertension Type II DM HbA1C = 8.4 CRI Baseline CR=1.8 Microalbuminuria Hypercholesterolemia TChol 221, HDL 36, LDL 110 COPD No documented PFTs Bell’s Palsy GERD Hypothyroidism TSH = 2.44 Past Medical History

5. Diltiazem SA 300 mg QD Lisinopril 20 mg QD Lovastatin 10 mg HS Glyburide 5 mg QD Quinine Sulfate 325 mg HS Cimetidine 300 mg Q4H prn Levothyroxine 0.125 mg QD Psyllium Powder Lactulose 1-2 tbsp QD Tylenol, prn Outpatient Medications Allergies: PCN

6. Social History Retired plow driver/maintenance worker 80 Pack year smoking history; quit 40 years ago Denies alcohol use Family History Father: h/o cardiac disease; died at 85, unknown CA Mother: DM

7. Physical Exam Vitals: T 96.5 HR 60 BP 146/80 RR 20 Sat 90% RA Gen: Obese, alert & oriented , pleasant, in NAD HEENT: PERLA, EOMI, OP with MMM Neck: no adenopathy, no bruits, JVP difficult to assess Cardiac: Distant, S1 S2, RRR, no gallops/murmurs/rubs Lungs: CTA b/l, Ab: Soft n/t, + BS, no organomegaly Ext: 1+ pulses, no C/C/E Neuro: No focal motor/sensory deficit

8. Labs 15.9 137 98 19 4.4 28 1.6 11.3 234 188 47 Ca 9.7 Trop I <0.03 CPK 132 (35-327) LDH 132 (90-270) CXR: no CHF, no infiltrates AST 17 ALT 18 AlkP 40 Tbili 0.4 PT 12.4 PTT 35.4 INR 1.0

9. EKG

10. Assessment • 81 y/o with story concerning for acute coronary syndrome but negative initial enzymes and EKG w/o acute changes Plan • Admit to telemetry, serial cardiac markers • Add low dose beta-blocker • Continue ASA, ACE inhibitor and statin • Continue glyburide with insulin sliding scale • Follow renal function

11. Hospital Day 2-3 • Chest pain free • Ruled out MI by serial CK and LDH • Persantine Thallium stress test • Asymptomatic bradycardia with HR 45-50 • TSH = 3.99 • Beta-blocker held, restarted on former diltiazem dose

12. EKG

13. Cardiology Consult • EKG consistent with “Wellen’s Pattern” • Concerning for proximal LAD lesion • Recommend: • cardiac catherization to be scheduled at West Roxbury VA • Start anticoagulation with LMWH • D/C diltiazem, start felodipine for BP control • if symptomatic, start nitro drip and GPIIbIIIa inhibitor

14. Hospital Day 5 • At 04:30 intern called to assess patient for epigastric discomfort • “Gas pain” developed into substernal chest pain • rated 8/10, then 3/10 with SL nitro x 2 • BP 177/92, HR 52, O2 sat 97% RA • Cardiac markers drawn • EKG obtained

15. EKG

16. Hospital Day 5 • Patent transferred to VA MICU for acute STEMI • NTG drip initiated, heparin drip continued • Patient started on GPIIbIIIa inhibitor • DHMC contacted for transfer for emergent cardiac catherization • Mobile ICU arrived for transfer at 06:30

17. DHMC Catherization • Pre-catherization medications: IV fluids, N-acetylcysteine • Coronary Angiography: • Right dominance • LAD: mid 1- discrete 90% stenosis mid 2- long segmental 50% stenosis mid Diag 1- 70% discrete stenosis prox Diag 3- 60% discrete stenosis • LCX mod diffuse, mid- 70% stenosis • RCA mod diffuse, mid- 70% stenosis • Intervention • Stent insertion to 90% stenosis in mid LAD, without complication

18. Prevention of Radiographic Contrast-Agent-Induced Reductions in Renal Function by Aceytlcysteine(Tepel et al, NEJM July 20, 2000) • Prospective randomized trial of 83 patients undergoing CT • Mean Creatinine of 2.4 • Randomized to receive aceytlcysteine 600 mg BID x 2 days with 1/2 NS or placebo and 1/2 NS • After 48 hours: • 1/41 (2%) of acetylcysteine group developed RCN • 9/42 (21%) of control group developed RCN (P = 0.01) • Also: • Mean creatinine in acetylcysteine group decreased 2.5 -> 2.1 (p=<0.001) • Increased creatinine observed in control group

19. Transfer to WRJVA • Patient stable and pain free • T 96.4 BP 163/87 P 54 R 18 • Meds: • Plavix 75 mg QD ASA 325 mg QD • Metoprolol 25 mg Q6h L-thyroxine 0.125 mg QD • Lisinopril 20 mg QD Lovastatin 10 mg Qhs • Amlodipine 5 mg QD Rabeprazole 20 mg QD • Labs: 137 99 26 4.7 28 2.1 Plan: Double product control, ECHO, decrease ACE and IV fluids

20. Hospital Day 8 • Patient “feels entirely well”, denies further CP, dyspnea • A.M. labs: BUN/Cr = 28 / 2.6 • ACE inhibitor held • Decreasing urine output • Patient increasingly anxious to go home

21. Discharge AMA • Repeat Creatnine = 2.7 • Patient “feels better than I have in ages...wants to go home” • Team informs patient of risks of leaving • Patient deemed competent • Discharged AMA • Plan for f/u at VA clinic to monitor BUN/Cr

22. VA Emergency Room • Two day h/o dyspnea, orthopnea and wheezing • Vitals: T 97.0 BP 149/68 HR 40 RR 30 O2 sat 80% RA • Exam: bibasilar rales • Labs: 130 92 53 5.2 26 3.4 13.4 268 15.3 186 40.8 CXR- b/l pleural effusions Increased vascular congestion EKG- Sinus brady, No ST  Trop = <0.03 CK= 167 LDH= 201

23. Admission to Medicine • Readmitted to medicine for CHF and ARF • Ruled out for acute coronary event • Echocardiogram: • Mild LV dilation: LVEF = 55% with nl LV size and fx • Anterior wall appears normal • 1+ MR, - AS, -AR • Worsening renal function despite diuresis • Creatnine 3.4  4.0, • Urine lytes: Na 29, K 61, Cl 56, Cr 78.4, FENa 0.96 • Oliguric- 20 cc urine/hour

24. Discussion ofDialysis & Code Status • Patient adamantly refused dialysis • Reports he has a friend on dialysis and “ does not want to live that way” • Understood the consequences of refusing life saving treatment • Judged to have good understanding of situation and “insightful reasoning” • Patient also wished not to be intubated, but clearly wished to pursue all other resuscitation efforts

25. Discharge AMA • With full understanding of poor prognosis, patient chooses discharge AMA • Chaplain consult confirms patients wishes • Home hospice care • Home oxygen

26. VA Emergency Room • “ I decided I wanted dialysis” • Presents with large, supportive family • Dyspnea at baseline, denies CP , orthopnea or PND • Vitals: Afeb BP 119/56 P 55 R 20 O2 sat 87% RA Transfer to DHMC for urgent dialysis 13.1 131 90 99 5.1 24 5.1 22.4 290 138 39.7

27. DHMC Admission • “ They tell me I need dialysis” • Admitted to Medicine team • Plan • emergent hemodialysis for suspected contrast dye nephropathy • r/o other etiologies for ARF • Renal US and UA ordered • Abx held, increased WBC thought secondary to prior steroid use

28. DHMC Hospital Days 2-6 • Patient had good response to dialysis x 3 • Weight: - 11 kg • SOB markedly improved, no complaints CP, orthopnea, or PND • Cr 4.8  2.7 • Renal ultrasound: • R kidney: 7.5 cm, thin cortex • L kidney: 12.9 cm • MRA abdomen • Severe stenosis of proximal R renal artery • HD#3 patient had elevated Troponin T of 0.37 • No EKG changes

29. Cardiology consult - Elevated troponin possibly due to decreased renal excretion of troponin; however, could be new ischemic event • Catherization films reviewed: potential candidate for bypass, but in light of patient’s current medical condition, medical treatment recommended • Recommended restarting beta-blocker, addition of long-acting nitrate, and amlodipine • P-thal recommended as outpatient

30. Outpatient Summary September • HD catheter infected; reinserted but complicated by hematoma • “ I feel like I’m being chopped up!” October • No evidence of recovery of renal function. Patient may not want to continue dialysis if he realizes he will not recover renal function November • tolerating HD well with good hemodynamic stability February • Mounting financial concerns, awaiting Medicaid approval • unable to afford medication co-payments • “can’t squeeze blood from a stone” • Transfers care to Rutland

31. Rutland Hospital ED • lethargic, in acute respiratory distress • T 94.6 BP 181/75 HR 53 RR 30 O2 sat 83% RA • ABG: pH 7.11 pCO2 83 pO2 80 • Assessment: Volume overload, respiratory failure, possible line sepsis • Plan: Intubated, transferred to DHMC ICU 137 99 54 7.6 28 8.3 14.1 21.6 281 43.3

32. DHMC ICUHospital Day 1-5 • Admitted to ICU for emergent dialysis • Treated with empiric antibiotics • Daily hemodialysis • WBC: 21.6 11.5 K: 7.6  5.0 Cr: 8.3  5.2 • Respiratory status markedly improved with daily dialysis • Day 5: extubated and transferred to medicine

33. Hospital Days 5- 9 • Patient remained afebrile, hemodynamically stable • CPK 760  522 with Tropnin 0.23  0.24 • Repeat Echocardiogram: • Multiple wall motion abnormalities • Akinesis of inferior septum, inferior wall and mid posterior wall • LVEF 40% • Patient increasingly agitated • “I’m leaving here and you better get out of my way!” • Patient refuses further dialysis

34. Final Discharge • Family meeting • Given poor prognosis, advanced cardiac disease and difficult hemodialysis, patient and family elect to stop further hemodialysis • Home oxygen therapy • Home hospice care • Comfort measures • Patient discharged to home...