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Morbidity and Mortality Conference

Morbidity and Mortality Conference. Jay V. Dy M.D. Medical Resident. Good Morning!. Learning Objective. To present a case of Severe Leptospirosis and discuss its diagnosis, pathogenesis, complications and mode of treatment. Identifying Data. D.D. 25 year old female Filipino

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Morbidity and Mortality Conference

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  1. Morbidity and Mortality Conference Jay V. Dy M.D. Medical Resident

  2. Good Morning!

  3. Learning Objective • To present a case of Severe Leptospirosis and discuss its diagnosis, pathogenesis, complications and mode of treatment.

  4. Identifying Data • D.D. • 25 year old female • Filipino • single • Chief Complaint: Fever

  5. History of Present Illness • 4 days PTA- undocumented intermittent fever (+) body malaise, (+) dry cough (+) sorethroat, (-) colds, rashes self-medicated with paracetamol affording temporary relief.

  6. History of Present Illness • Few hrs PTA - persistence of symptoms (+) diarrhea, 2x (+) crampy epigastric pain. (+) nausea (-) vomiting Admission

  7. (-) headache (-) dizziness (-) difficulty of breathing (-) orthopnea (-) paroxysmal nocturnal dyspnea (-) palpitations (-) dysuria (-) urinary frequency (-) joint pains Review of systems

  8. Past Medical History • Diagnosed w/ Leptospirosis 7 yrs ago • Unrecalled work up • Admitted St Paul’s Hospital for several days • Given unrecalled IV antibotics • Non hypertensive • Non diabetic • Non asthmatic • No known allergies • No previous operation

  9. Family History • (+) Hypertension- father • (+) DM- mother • (-) Bronchial asthma • (-) PTB • (-) Cancer

  10. Personal/ Social History • Non smoker • Non alcoholic beverage drinker • Works in the office

  11. Physical Examination • General survey: conscious, coherent not in respiratory distress • Vital signs: BP 110/70, HR: 98 RR: 20, T: 38c • Skin: No rashes, no jaundice • HEENT: pinkish palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no tonsillopharyngeal congestion, dry lipsand tongue, no cervical lymphadenopathy, flat neck veins

  12. Physical Examination • Chest/Lungs: equal chest expansion, no retraction, clear breath sounds • Heart: Adynamic precordium, normal rate, regular rhythym, S1 louder than S2 at the apex, S2 louder than S1 at the base, PMI at 5th ICS, LMCL, no murmur • Abdomen: flabby, normoactive bowel sounds, soft, no tenderness, no palpable mass, no hepatosplenomegaly • Extremities: no gross deformities, no edema, no cyanosis, full and equal pulses

  13. Salient features • 25 y.o, F, single • cc: fever x 5 days • body malaise, dry cough, sore throat • (+) 2 episodes of diarrhea • (+) crampy epigastric pain • (+) nausea • P.E. Temp= 38c • Flat neck veins • Dry lips and tongue

  14. At the E.R.

  15. Day of Admission

  16. Initial Impression • Acute gastroenteritis with some signs of dehydration • T/C Dengue fever

  17. Course in the Wards1st hospital day (8/3) • intermittent fever(D6) (Tmax - 39.5 c) • bloatedness • crampy epigastric pain • diarrhea, 8x • vomiting, 1x • Secnidazole 500mg/tab. 4 tabs as single dose • Metoclopramide 10 mg Iv push q8 • Loperamide 2 tabs x 1 dose • IVF rate: increased to 166 cc/hr.

  18. Course in the Wards1st hospital day (8/3) • PTT - 49.6 (n.v. 25.1-33.9 secs) • PT was normal • plt ct 69,000from109,000 > Monitoring of platelet ct q 12 hrs. >Stand by 4 units of FFP

  19. 2nd hospital day (8/4) • on and off fever (D7) (37.0- 39.5 c) • bloatedness • crampy epigastric pain • 7 episodes of LBM • 3 episodes of vomiting • direct epigastric tenderness • Plain film of the abdomen: no localizing signs • hydration/meds were continued • additional dose of Loperamide and Eldicet • started Vamin glucose

  20. 2ND Hosp day

  21. Course in the Wards2nd hospital day (8/4) • Lab test • K - 2.3 • BUN - 23 • creatinine - 3.1

  22. Course in the Wards2nd hospital day (8/4) Problem: (+) Difficulty of breathing • Respiratory rate: 26 • Flat neck veins • Clear breath sounds • ABG: uncompensated metabolic acidosis. pO2=96.9, pH=7.28, Pco2=20.1, HCO3=9.3, O2 sat=96.8, B.E.-14.9, Total CO2=9.9, RR=26, Rm air • given NaHCO3 IV

  23. 2nd hosp day (aug4)

  24. Course in the Wards2nd hospital day (8/4) • CBC: Hgb 8.2, hct 23.6, seg 8,320, seg 77, lym 17 and plt ct 71,000 >Reserved 2 u prbc >repeat CBC w/ plt ct in am >Blood culture done >Referred to Nephrology & Infectious disease service

  25. 3rd hospital day (8/5) • (+) fever (D8) (Tmax39.6 c) • (+) Epigastric tenderness • (+) decreased BM (semi-formed to soft) • (-) vomiting • Rpt CBC: Hgb 8.4, hct 24.4, plt ct 84,000 from71,000 • Transfused 1 of 2 unit Prbc • Increased omeprazole to 1 cap BID

  26. Course in the Wards3rd hospital day (8/5) • PTT- 49.6 • PT: Activity 66.4% INR 1.2 • Vitamin K given • Urinalysis showed proteinuria +2, Blood+3, elev RBC 572.2, elev WBC 14.4 • Urine CS requested

  27. 3rd hospital day • Problem: (+) dyspnea • (+) distended neck veins • (+) bibasal crackles • (+) bipedal edema • Lasix 40mg IV given • IVF rate was decreased to 40cc/hr • Central line inserted (13-14 cmH2O)

  28. 2nd hosp day 3rd hosp day

  29. 3rd hospital day (8/5) • Stat ABG: Po2 52.3, Ph 7.27, Pco232.3, HCO3 14.7, O2 sat 83,B.E. -10.9, TCO2 15.7, RR 28 (O2 2LPM via Nasal cannula). > Nasal cannula was shifted to MVM > stand by intubation > scheduled for stat Hemodialysis

  30. Course in the Wards3rd hospital day (8/5) • Spec (pre HD) • K 2.7, Ca 1.5, total protein 4.6 and Albumin 1.6 • bun 23, crea 3.1, SGOT 336, SGPT 78 and T. Bili 1.4. Given K, Ca, and albumin correction

  31. Course in the Wards3rd hospital day (8/5) • During dialysis: transfused w/ 4 units FFP (150cc/unit/bag)=600cc • 1 unit Prbc (250cc) • 550cc flushing/ meds • Na HCO3 drip @ 40 cc/hr x 4 hrs= 160cc • Ca Gluconate drip @ 80 cc/hr x 4 hrs= 320cc • Kcl drip 10% 40meqs x 4 hrs = 100cc • UF Volume (output)=4,000 cc HD total Input= 1,980 cc

  32. 3RD hosp day (Aug 5)

  33. Course in the Wards3rd hospital day (8/5) > scheduled for another hemodialysis. > Total Input=3,910 cc vs Total output=4,340 cc (urine 340 + HD 4,000cc)

  34. Leptospira antigen test:(+) IgM > Penicillin G 2 million units IV q 4 given.

  35. 4th hospital day (8/6) • Problem: dyspnea • BP: 110/60; CR 120s; RR40s • decreased urine output (7-8 cc/hr) • (+) bloody secretions/sputum. • CVP 15 cmH2O • ABG: Po2 39, ph 7.41, Pco2 32.9, HCO320.6, O2 sat 75.1, B.E. -3.0, TCO2 21.6, RR 60 MVM 0.4 • reffered to a pulmonologist

  36. Course in the Wards4th hospital day (8/6) • immediately intubated • hooked to a mechanical ventilator (settings: AC mode, FiO2 100%, RR 20, TV 300, PEEP 5).

  37. post intubation

  38. ABG 1 hr post intubation still showed hypoxemia (pO2 58, O2 sat 91.7 5%) • Atrovent neb given • PEEP was increased to 7.5 • Patient immediately underwent (2nd)hemodialysis

  39. Course in the Wards4th hospital day (8/6) • Pre HD Labs • decreased serum K (2.4 from 2.7), Ca 1.9, Phosphorus 2.3 and Mg 1.6 (2.5-4.9). • Serum creatininefurther increased (4.6 from 3.1) • Patient was given K, Ca, Mg and phosphorus correction

  40. Course in the Wards4th hospital day (8/6) • During dialysis: • 100cc flushing/ meds • PNSS 40 cc/hr x 4 hrs= 160cc • Vamin glucose 40 cc/hr x 4 hrs= 160cc • Albumin 50cc • HD total Input= 470 cc • UF Volume (output)=3,000 cc

  41. Course in the Wards5th hospital day (8/7) • afebrile • (+) tachycardia (100-118) • (+) decreased urine output (4-5cc/hr) • JVP 13cmH2O • Lasix was continued

  42. Post Intubation 5th Hosp day

  43. Course in the Wards5th hospital day (8/7) • Patient underwent 3rd hemodialysis. • During dialysis: • 50cc flushing/ meds • K Phos 40mmol in PNSS 100ccx 4hrs= 100cc • Ca Gluc 5 g in 450cc pnss x 20cc/hr x 4=80cc • MgSO4 5 g in 500cc PNSS X 20cc/hr x 4=80cc • total Input= 470 cc • UF Volume (output)=2,000 cc

  44. Course in the Wards5th hospital day (8/7) • Pulmonary service was able to bring down FiO2 to 0.6 but had desaturation eventually placed back to 100% FiO2 • More bloody secretions coming out/ suctioned from ET • Frequent/ prn suctioning of secretions. • PEEP was increased to 10.

  45. Course in the Wards5th hospital day (8/7) • CBC: Hgb 12.1, hct 35.1, wbc (15, 760 from 6,850), seg 74, plt ct 135,000 fro 128,000). • Pen G was discontinued • Piperacillin Tazobactam 2.25 IV q8 was started. • Total Input: 2,298cc • Total Output: 2,107cc • (Urine 107 cc+ HD 2,000cc)

  46. Course in the Wards6th hospital day (8/8) • afebrile (D2) • lesser bloody secretions from ET. • Persistent oliguria (4-5 cc/hr) • Lasix was continued • patient had another dialysis (4th)

  47. Course in the Wards6th hospital day (8/8) • During dialysis: • 50cc flushing • 100cc OF • Ca Gluc 5 g in 450cc pnss x 20cc/hr x 4=80cc • Dialysis terminated due to BP 94/63 (3rd hr) • Bp went up 110/70 after • total Input= 230 cc • UF Volume (output)=1,700 cc

  48. Course in the Wards6th hospital day (8/8) • chest xray post HD: clearing of bilateral lung infiltrates. • FiO2 was titrated down to 30%.

  49. S/P 4th dialysis

  50. Course in the Wards6th hospital day (8/8) • Problem: desaturation (02 sat 50%). • Fi0 was increased to 100% • suctioning of secretions • ambubagging • BP noted to be 0, HR 0. • hooked to a cardiac monitor: flat line. • CPR done • Given epinephrine 1 dose

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