1 / 32

Morbidity and Mortality February 20 th 2002 Marc Voelkel

Morbidity and Mortality February 20 th 2002 Marc Voelkel. History of Present Illness. 63 year old woman with a chief complaint of chest pain. 6/10 with radiation to her jaw and arms. Awoke her from sleep with associated diaphoresis and nausea.

havard
Download Presentation

Morbidity and Mortality February 20 th 2002 Marc Voelkel

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Morbidity and MortalityFebruary 20th 2002Marc Voelkel

  2. History of Present Illness 63 year old woman with a chief complaint of chest pain. • 6/10 with radiation to her jaw and arms. • Awoke her from sleep with associated diaphoresis and nausea. • Relieved after 4 SLNTG, but recurred 1 hour later. • No relief with 3 more SLNTG. • Presented to outside Emergency Room. • 3 day history of URI symptoms.

  3. Past Medical History 1. 25 years of atypical chest pain/ASCVD: Cardiac Cath in 98: normal LM, mild diffuse LCX, mild diffuse LAD, normal RCA, LVEF = 55%. Stress thallium 98 negative. 2. Asthma/COPD: Last ICU admission to DHMC with exacerbation 3/99. Resting O2 saturation 88%, home O2 dependent. 3. DM Type II. 4. History of congestive heart failure in 1997: Echo 8/97 with normal wall motion, and EF =70%, normal valves. Similar echo in 3/99. 5. Rheumatoid Arthritis – steroid dependent.

  4. Social History: • Recently Widowed. • Disabled with severe arthritis. Bed to Chair Existence. • No children, lives with niece – who is DPOA. • Tobacco : 21 pack years, quit 2 years PTA. Family History: • Father died age 52 with cancer of the throat, and CAD. • Mother died 67 from a MI. • Brother died age 57 from a MI, had hx of a CVA. • One sister with a hx of strokes . One brother living healthy.

  5. Medications: Diltiazem CD 240mg po qd Celecoxib 200mg po BID Monteleukast 10mg po qd Albuterol/Atrovent Inhaler 2puffs qid Salmeterol 2 puffs qd Prednisone 10mg po qd Furosemide 40mg po BID Metolazone 2.5mg po qd Calcitonin Spray 1 puff each nostril alternating Loratadine 10mg po qd Pantoprazole 40mg po qd Oxygen 2 liters by nasal canula

  6. Physical Exam: Vitals: T:99.9F HR:110 BP:143/84 RR:32 O2 Sat 96% on 4 liters via NC. General: A/OX3, obese, anxious, dyspneic, in distress HEENT: Mouth moist, neck supple, JVD + fused to breathing. CV: Distant S1 S2. Lungs: Coarse rales bilaterally 1/3 up, with L> R. Abd: Round, NT ND. LE: Bilateral pitting edema. Skin: Dry, and friable.

  7. Labs 195 138 | 92 | 16 / 3.9 | 30 | 0.7 \ Calcium 8.7, Magnesium 3.9 Troponin 0.16 (Normal 0.00 –0.04) CK 20

  8. ECG 1- 1998, pre-admission comparison

  9. ECG#2: At Admission to OSH 1/13/02 405am

  10. Events At Outside Hospital • Chest Pain Continued, and given SL nitroglycerin. MSO4, lorazepam -> CP = 1-2/10, nitropaste placed, to bring patient to chest pain free. • Stable for 5 hours in ED, then became acutely SOB & requested nebulizer. • VF/VT arrest, resuscitated with CPR, 2 shocks, intubated. • Repeat ECG was done - show. • CK 20 266, CK MB 81.3 Troponin T 0.16 2.70. • Transferred to DHMC.

  11. ECG# 3 Post Event 1/13/02 905am

  12. TheNew England Journal of Medicine February 21, 2002 MILD THERAPEUTIC HYPOTHERMIA TO IMPROVE THE NEUROLOGIC OUTCOME AFTER CARDIAC ARREST • Multicenter trial, 275 patients randomly assigned to 24 hrs of hypothermia vs. standard treatment • Favorable neurologic outcome • Risk Ratio 1.40 (1.08-1.81) • p=0.009 • Death • Risk Ratio 0.74 (0.58-0.95) • p=0.02

  13. Taken Directly to Cardiac Catheterization • Normal LM, normal LAD, and RCA, 99% proximal LCX occlusion, and stented. • Started on Eptifibatide, and Clopidegrel, and brought to the CCU.

  14. Physical Exam at DHMC Admission Gen: Morbidly obese woman, unable to speak, still intubated, and sedated. T = 37.1 P 114 BP 76/51 93% on AC rate 14, PS 10, PEEP 5, TV 600, FIO2 = 0.7 S/G Catheter: CVP: 20 PA:36/28 Wedge:31 CO/CI: 2.3/1.3 SVR: 2111 Neck: Supple. FROM. No bruits or LAD, JVP difficult to assess Lungs: CTA anteriorly and laterally CV: Distant heart sounds, RRR, nl S1/S2, no m/r/g Abd: Soft, obese, ND. Organs not palpable. NABS no r/g. Extr: Extensive UE echymosis bilaterally. No c/c/e. Pulses 1+ UE/LE bilaterally. Neuro: Responsive to pain, PLR- normal, DTR 2+ bilateral LE and UE

  15. Labs: CBC: 11.9 Coags: PT 14.4 / INR 1.2/PTT >130 28.0 406 Thrombin Time: 18 Fibrinogen:418 33.4 D-dimer: 3570 SMA7: 137 95 18 Ca 8.2 Mg 0.52 2.7 26 0.5 Trop T: 0.55 CPK 804 ABG: 7.49/ 40/ 356/ 29.8 on 70% O2, Ventilated, AC 194

  16. Next: • Placed on Dopamine and Neosynephrine for Hypotension • ABG: 7.43/37/100/24.7 on 70% • Hgb 12 fell to 8.0, 2 Units of PRBC’s transfused • Stat Abdominal CT performed

  17. Active Medications: Dopamine gtt (40mcg/min) Phenylephrine (40mcg/min) Norepinephrine gtt ( 5mcg/min) Propofol gtt Omeprazole 20mg po/per tube qd Hydrocortisone 50mg iv q8hr Albuterol neb prn Atorvastatin 40mg po/per tube qd Sliding Scale Insulin sq Cefuroxime 750 mg iv q8 Azithromycin 500mg iv qd

  18. Overnight: • Retroperitoneal Bleed • Vascular Surgery Consult: • No emergent surgery, watch. • CV and hemoglobin remained stable: • Hgb from 11.0 to 13.2 with 2nd Unit PRBC. • PA= 40/22, PCWP 12/CVP:14/CO=3/CI= 2. • Neosynephrine/norepinephrine changed to dobutamine/dopamine. • Serial Cardiac Enzymes followed. • Started on Hydrocortisone

  19. Day 2: • Pulmonary consult: • Asked to help with vent management, wean, and etiology of poor pulmonary status. • Ventilator changed to SIMV, 12/15 PEEP 5 TV as tolerated, and FIO2 to 0.4 • Improved cardiac dynamics: • With improvement of CO/CI to 4.6/2.7. CVP 14, PAP 42/20, Wedge 13, and SVR 1150. BP increased from 87/56 to 102/60, and dopa/dobutamine were weaned off. • Echo: • Inferior/ posterior and lateral wma EF 35-40%, RV hypokinesis trivial MR.

  20. Hemodynamic Effects of Positive Pressure Ventilation • Decrease in cardiac output (CO) & systemic hypotension • Accentuated by PEEP & auto-PEEP • Hypotension more likely with associated hypovolemia • Even low levels of PEEP can be deleterious for CO if the mean intrathoracic pressure is high • PCWP artificially elevated with positive pressure ventilation Marino, The ICU Book. 1990.

  21. Day3-4: • NGT placed, and patient started on tube feeds • Remained Stable, began Vent Weans: SIMV rate=12, TV 600, PS=15 PEEP =5 FIO2 =40% • Pressors completely weaned • She started to have diarrhea Tm 37.9 HR 100-110 BP 90-100/5-60 O2 sats = 92%, IMV 12 TV 600 PSV 15 PEEP 5 9.3 7.42/45/139/28/98.4% 15.4 121 28.2 145 | 109 | 14 2.4 |26 | 0.3 202

  22. Day 5: • K+ replaced: • Etiology felt secondary to diarrhea, as well as effects of mineralocorticoid and furosemide. • Patient began to spike fevers to 39.6 C. Pan cultured, WBC to 8.4. • ID consult requested. • Central line changed, arterial line changed, foley replaced, CXR done, and nasal culture, ETT sputum culture, urine culture. • Hgb stable 11.4, and she was placed back on clopidogrel. • Weaning off vent still difficult: • 6 hours on PSV, 15/5, 40%, returned to SIMV.

  23. Day 6: • ID Consult: • Blood Cultures Negative • Check urine legionella antigen • Sputum Culture – Pseudomonas aeruginosa • Nasal Aspiratory Culture – Staph. aureus

  24. Day 6: • ID Consult: • Blood Cultures Negative • Check urine legionella antigen • Sputum Culture – Pseudomonas aeruginosa • Nasal Aspiratory Culture – Staph. aureus • Treatment : Recommended and started on levofloxacin, ceftazidime, vancomycin. • Double cover Pseudomonas • Staph. aureus potentially MRSA. • Hemodynamics- Continued to improve: BP 130/70, Started auto diuresis – minimal furosemide. CVP 11 PA 40/25 PCWP 10 CI =3.1

  25. Day 7: Febrile and hypotensive • Tm = 40.5 Newly hypotensive 80’s/40’s • WBC climbed to 10.9. • Metronidazole was added for continued diarrhea and stool was recultured for C.difficile • Fluid resuscitation started to keep blood pressure up, 1-2 doses of albumin tried to help pressure, and spare the use of pressors. • CXR remained unchanged. • Patient continued on ventilator weans • (PS 18, PEEP 5, 40% FIO2, failed to get to PS 10)

  26. Colloid versus Crystalloid • Rationale: Colloid provides rapid volume expansion with a decreased risk of pulmonary edema • Colloid therapy slows progression of tissue injury in sepsis1 • No evidence for either improved outcome or increased mortality in patients given albumin2 • No evidence from RCTs that resuscitation with colloids reduces the risk of death compared to crystalloids3 • Morisaki H, et al. Compared with crystalloid, colloid therapy slows progression of extrapulmonary tissue injury in septic sheep. Journal of Applied Physiology. 1994;77:1507-1518. • Wilkes MM, Navickis RJ. Patient Survival after human albumin administration. A meta-analysis of randomized, controlled trials. Annals of Internal Medicine. 2001;135:149-164. • Alderson P, Schierhout G, Roberts I, Bunn F. Colloids versus crystalloids for fluid resuscitation in critically ill patients (Cochrane Review). In: The Cochrane Library, Issue 2, 2001. Oxford: Update Software.

  27. Day 8-9: Remained Stable, but… • WBC climbed to 19.0. • No new cultures positive, because of ongoing fevers – patient cultured daily for all sites. • Tube feeds stopped, and diarrhea resolved. C.difficile negative X3. • TPN started. Evaluation for PEG and tracheostomy requested, as patient was difficult to wean.

  28. Day 10-12: • Stable, hemodynamically, but continued to gain weight/ fluid • WBC continued to climb (19,000), Fevers continued (38.4 C). • Peg and trach deferred. • Continued slow ventilator wean. • Family discussions started on long term prognosis. • Niece was DPOA • Patient never wished to be on long term ventilator support.

  29. Day 13: Events: • Candida Albicans : • Blood cultures, Swan Cx, Pulmonary Artery Cath Cx, Arterial line Cx. • Sputum cx: Positive with rare yeast and pseudohyphae. • Blood Pressure fell to 80’s/40’s and Dopamine restarted • Fever spikes to 39.6, and WBC still at 21.4. • Started on Fluconazole per ID recommendations • Family Discussion Continued, Niece wished to talk with patient’s sister and brother before making a decision.

  30. Day 14: • Resolution of fevers, WBC began to come down • BP stable at 100/60’s • PSV 16 PEEP 5 FIO2 0.4 • Family Meeting : Niece and Sister discuss near hopeless situation with team, and recapitulate patient’s wishes - that she would not want to remain vent dependent this long. This level of support would be against her wishes. • Patient was extubated, and expired with her family surrounding her at 4:10 p.m. No post-mortem exam.

  31. Issues Addressed: Acute MI management Hemodynamics of Positive Pressure Ventilation Identification of Retroperitoneal Bleeding Auto-PEEP in COPD Hospital Acquired Infections Use of Colloids in Sepsis End of Life Decision Making

More Related