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Morbidity and Mortality Rounds

Morbidity and Mortality Rounds. Dr. Shounak Das July 27, 2007. History. HPI : 53 y.o. Hispanic female admitted through the ER with fever + hypotension h/o diabetes, morbid obesity, CAD 8 years s/p CABG complicated by CVA with residual hemiplegia 1 month PTA admitted with PE

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Morbidity and Mortality Rounds

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  1. Morbidity and Mortality Rounds Dr. Shounak Das July 27, 2007

  2. History HPI: • 53 y.o. Hispanic female admitted through the ER with fever + hypotension • h/o diabetes, morbid obesity, CAD 8 years s/p CABG complicated by CVA with residual hemiplegia • 1 month PTA admitted with PE • PPM placed 3 weeks PTA • 1 day PTA developed chills, nausea, vomiting

  3. History PMH: • diabetes • CAD • CVA • dyslipidemia PSH: • CABG • R knee surgery • lap choly • hypertension • morbid obesity • pulmonary embolus • PPM placement • IVC filter

  4. meds (home): aspirin 81 mg daily lisinopril 10 mg daily actos 45 mg daily 70/30 insulin 20 units bid toprol XL 50 mg daily allergies: NKDA History

  5. History FH: • +ve for diabetes + hypertension SH: • married • non-smoker; no EtOH

  6. History ROS: • denies chest pain or palpitations • no cough • denies abdominal pain or recent change in bowel habits • denies dysuria • weight gain is noted • she complains of slight headache

  7. Vital signs: HR: 88 (reg) RR: 24 BP: 80/51 T°: 103.4 HEENT: PERRLA/EOMI/anicteric/oropharynx normal/no lymphadenopathy Chest: clear to auscultation bilaterally/mild inflammation around pacemaker pocket; no fluctuance/drainage Physical Exam • General: • ill-looking obese patient

  8. CVS: RRR/NL S1 + S2/no extra sounds, rubs, or murmurs Abdo: Nl bowel sounds/ soft, non-tender/no hepatosplenomegaly Neuro: CN II-XII intact/R-sided weakness (U>L) Extremities: +1 bilateral ankle edema Skin: no rashes Physical Exam

  9. Labs 60%N 16%L 12%M 11%B 10.9 132 107 37 194 14.1 106 3.0 16 1.6 32.4 AG = 9 Ca2+: 6.3 7.6corr Mg2+: 0.8 TP: 5.3 Alb: 2.4 INR: 1.3 fibrinogen: 309 CRP: 11 AST: 27 ALT: 13 Alk Phos: 85 T bili: 0.9

  10. Labs • CXR: low volumes; no infiltrate • u/a: 25 WBC/hpf • blood cultures: 2/2 +ve for MSSA • TEE: RA lead – 2-3 mm mobile vegetation/thrombus

  11. Course in Hospital • started on IV vancomycin initially, then switched to nafcillin once sensitivities confirmed • started on pressors • intubated hospital day #2 • started on CVVHD hospital day #8 for ARF • pacemaker removed hospital day #11 • MOF; persistent hypotension despite maximal pressors • withdrawal of care hospital day # 15

  12. Pacemaker Infections • incidence roughly 5% • 90% of these are “pocket infections” • remaining are “deeper infections” i.e. “device –related endocarditis” • risk factors: diabetes, recent manipulation of device, temporary pacers • 90% caused by s. epidermis or s. aureus • 1/3rd “early” (3-6 mos.); 2/3rds “late” (after 3-6 mos.) • lead removal recommended for device-related endocarditis

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