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Mortality and Morbidity Conference

Mortality and Morbidity Conference. Iandine Hans Paras, MD William Rodriguez, MD. General Data. J.H. 60 year old, male American Residing in Makati CC: vomiting. Medical Background. Compression wedge fracture, T11; Retrolisthesis, L5 Tramadol On physical rehab (+) DM Type 2

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Mortality and Morbidity Conference

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  1. Mortality and Morbidity Conference Iandine Hans Paras, MD William Rodriguez, MD

  2. General Data • J.H. • 60 year old, male • American • Residing in Makati • CC: vomiting

  3. Medical Background • Compression wedge fracture, T11; Retrolisthesis, L5 • Tramadol • On physical rehab • (+) DM Type 2 • (+) HPN Retrolisthesis- posterior displacement of one vertebral body on the subjacent vertebral body; mostly found in the lumbosacral spine and may be caused by degenerative changes or trauma.

  4. History of Present Illness 1 day PTA nausea vomiting (-) diarrhea (-) constipation (-) abdominal pain (-) fever Admission

  5. Review of Systems • No headache, blurring of vision • No cough, colds, dyspnea • No chest pain, palpitations • No weight loss • No polyuria, polydipsia, polyphagia • Intermittent low back pain

  6. Personal and Social History • Smoker (76 pack years) • Previous alcoholic (stopped 28 years ago)

  7. Past Medical History • (+) HPN on Lisinopril • (+) DM on Metformin/Glipizide • (+) Dyslipidemia on Rosuvastatin

  8. Past Medical History • Compression wedge fracture, T11; Retrolisthesis, L5 • Post cholecystectomy (1979) • Post bilateral hip surgery (R-2003, L-2005) • Elevated PSA

  9. Family History • (-) HPN • (-) DM • (-) Asthma • (-) Cancer

  10. Physical Examination • Conscious, coherent, not in distress • BP : 150/80 CR: 70, reg RR: 18 T: 36.8oC BMI: 30.4 • No neck vein distention, thyroid not enlarged • Clear breath sounds • Adynamic precordium; apex beat at 5th ICS left MCL; no heaves, thrills, murmurs

  11. Physical Examination • Abdomen: normoactive bowel sounds, soft, non tender • No pedal edema, pulses full and equal • Limited ROM on the hip region

  12. Salient Features • 60 y/o, male • DM Type 2 • Compression wedge fracture, T11; Retrolisthesis, L5 • Tramadol • Nausea and vomiting • Unremarkable abdominal exam

  13. Admitting Impressions • Adverse Drug Reaction • r/o DKA • Hypertension Stage 1 • Diabetes Mellitus Type 2 • Obese Class II • Dyslipidemia

  14. Admitting Impressions • Compression wedge fracture, T11; Retrolisthesis, L5 • Post Cholecystectomy • Post bilateral hip surgery • r/o Prostate malignancy

  15. At the ER • Random blood sugar: 160 • 12-L ECG: Normal • CXR: Normal • Rx: Metoclopramide, Ranitidine

  16. At the ER • Endocrine referral • DM diet • Rx: Lisinopril, Rosuvastatin, Glipizide

  17. On Admission • Rehab Med referral • Urology Referral • Scheduled for prostate biopsy • Started on IV Ciprofloxacin pre op

  18. Course in the Ward • Underwent prostate biopsy (2nd HD) under local anesthesia • Stable perioperatively

  19. Problem: Fever(3rd hospital day/Day 1 post biopsy)

  20. Problem: Fever • Unremarkble PE • CBC: hgb 12.7 hct 36.5 WBC 6,100 seg 89 lymph 10 stabs 1 plt 213,000 • Urinalysis: CHON 3+ RBC 37.5 WBC 525.1 Bact 13, 333

  21. Complicated UTI • Blood and urine C/S: E. coli • Dx: Complicated UTI • Rx: Ciprofloxacin  Meropenem

  22. Complications of Prostate Biopsy • Urosepsis- feared complication of prostate biopsy • Fever develop in about 23% of patients who do not receive prophylactic antibiotics Gustaffson O, Norming U, Nyman CR, Öhström M. Complications following combined transrectal aspiration and core biopsy of the prostate. Scand J Urol Nephrol 1990;24:249-51.

  23. General recommendations for the management of complicated UTI • Urine sample for GS and C/S testing must always be obtained prior to the initiation of any therapy (Grade C) • Mild to moderate illness- oral fluoroquinolones • Severe illness- parenteral antibiotics with adequately broad coverage should be used (Grade C) The Philippine Clinical Practice Guideline on the Diagnosis and Management of Urinary Tract Infections: A Quick Reference Guide for Clinicians Report of the Task Force on Urinary Tract Infections, 1998

  24. General recommendations for the management of complicated UTI • Antibiotics are modified according to the results of the urine culture and sensitivity test • Patients started with parenteral regimen may eventually be switched to oral therapy after clinical improvement has been noted • At least 14 days of therapy is recommended (Grade C) The Philippine Clinical Practice Guideline on the Diagnosis and Management of Urinary Tract Infections: A Quick Reference Guide for Clinicians Report of the Task Force on Urinary Tract Infections, 1998

  25. Oral Regimen Ciprofloxacin 250 mg po q 12 hrs x 14 days Norfloxacin 400 mg BID po x 14 days Ofloxacin 200 mg q 12hrs po x 14 days Trimethoprim-sulfamethoxazole 160/800 q 12hrs po x 10 days Parenteral Regimen Ampicillin 1 gm q 6hrs IV + gentamicin 3 mg/kg/day OD IV Ceftazidime 1-2 gm q 8hrs IV Ceftriaxone 1-2 gm OD IV Ciprofloxacin 200-400 mg q 12hrs IV Imipenem-cilastatin 250-500 mg q 6-8 hrs IV Ofloxacin 200-400 mg q 12hrs IV Empiric therapy for Complicated UTI Chest pain

  26. Problem: Chest pain(4th hospital day/2nd day post biopsy) Heaviness, non radiating, 8, persistent

  27. Problem: Chest pain • BP: 150/90 CR: 94, reg RR: 22 Temp: 37.4oC • ECG: Sinus tachycardia • CPK-MB: 29.3 Trop I: 5.55

  28. NSTEMI • Anginal chest pain • Elevated cardiac enzymes • ECG: Sinus tachycardia

  29. NSTEMI • NPO • Complete bed rest • ASA • Clopidogrel • Metoprolol • LMWH (Enoxaparine) • Oral hypoglycemics  Insulin

  30. Other labs • CBC- hgb: 12 hct: 35.6 WBC: 24, 880 seg: 89 lym: 10 Baso: 1 stabs: 2 myelo: 1 Metamyel: 1 plt: 174T • Na: 126 K: 4.7 • BUN: 11 crea: 3.5

  31. Diagnosis • NSTEMI • Urosepsis • Acute Renal Failure, pre renal

  32. Problem: Hypotension

  33. Problem: Hypotension • BP: 80/50 CR: 110’s RR: 25 Temp: 37.5oC • JVP: 7 cm at 30o • Clear breath sounds, no murmurs, no gallops

  34. Chest pain Elevated cardiac enzymes Fever Tachycardia Tachypnea Leukocytosis Complicated UTI Cardiogenic vs Septic Shock?

  35. Cardiogenic vs Septic Shock? • Clear breath sounds • No murmurs, gallops • Normal JVP • No pedal edema • 2D Echo: normal • CBC: Leukocytosis w/ segmenter predominance

  36. Management of Septic Shock • IV fluid resucitation • CVP line insertion (initial 10-11cmH2O) • Vasopressors: Dopamine Dobutamine Noradrenaline

  37. Management of Septic Shock Antibiotics • 4th HD • Ciprofloxacin Meropenem • 7th HD • Meropenem Piperacillin-Tazobactam • 9th HD • Piperacillin-Tazobactam Ertapenem IM

  38. General recommendations for the management of septic shock • Early management • Stabilize respiration - secure airway and correct hypoxemia - ABG, CXR

  39. General recommendations for the management of septic shock • Early management 2. Restore perfusion - central venous catheter insertion - intravenous fluids - vasopressors

  40. Resuscitation goals • Central venous pressure: 8-12 mm Hg • Mean arterial pressure ≥ 65 mm Hg • Urine output ≥ 0.5 mL.kg-1.hr-1 • Central venous or mixed venous oxygen saturation ≥ 70%

  41. General recommendations for the management of septic shock • Identification of the septic focus • Eradication of infection • Remove/drain possible source • Antimicrobials

  42. General recommendations for the management of septic shock • Antimicrobials (UptoDate) If Pseudomonas is an unlikely pathogen, we favor combining vancomycin with one of the following: • Cephalosporin, 3rd or 4th generation (eg, ceftriaxone, cefotaxime, or cefepime), or • Beta-lactam/beta-lactamase inhibitor (eg, piperacillin-tazobactam, ticarcillin-clavulanate, or ampicillin-sulbactam), or • Carbapenem (eg, imipenem or meropenem)

  43. General recommendations for the management of septic shock • Antimicrobials (UptoDate) If Pseudomonas is a possible pathogen, we combine vancomycin with two of the following: • Antipseudomonal cephalosporin (eg, cefepime, ceftazidime, or cefoperazone), or • Antipseudomonal carbapenem (eg, imipenem, meropenem), or • Antipseudomonal beta-lactam/beta-lactamase inhibitor (eg, piperacillin-tazobactam,ticarcillin-clavulanate), or • Fluoroquinolone with good anti-pseudomonal activity (eg, ciprofloxacin), or • Aminoglycoside (eg, gentamicin, amikacin), or • Monobactam (eg, aztreonam)

  44. Problem: Acute Renal Failure • Treatment of underlying cause (sepsis) • IV hydration (CVP 8-12) • Accurate measurement of fluid balance • Serial monitoring of electrolytes and creatinine

  45. Problem: Acute Renal Failure

  46. Course in the Ward • Coronary angiogram was recommended - not done • Discharged stable and improved

  47. Final Diagnosis • Septic shock sec. to complicated UTI • Non ST elevation myocardial infarction • HASCAD • DM type 2 • Compression wedge fracture, T11; Retrolisthesis, L5

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