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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.

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Morbidity and Mortality February 20 th 2002 Marc Voelkel

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  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

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