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Morbidity and Mortality Conference

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Lisinopril 20 mg QD. Lovastatin 10 mg HS. Glyburide 5 mg QD ... Lisinopril 20 mg QD Lovastatin 10 mg Qhs. Amlodipine 5 mg QD Rabeprazole 20 mg QD. Labs: ... – PowerPoint PPT presentation

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Title: Morbidity and Mortality Conference


1
Morbidity and MortalityConference
  • Thomas Wold, D.O. , M.S.
  • July 17, 2002

2
Initial Presentation
  • 81 y/o white male presents to WRJVA ED with 2
    hours of substernal CP
  • Pain at rest
  • non-radiating
  • associated with nausea, diaphoresis and SOB
  • Patient took aspirin
  • Reported to WRJVA for evaluation
  • Pain resolved spontaneously upon arrival at VA

3
Review of Systems
  • Patient denies previous CP, exertional angina
  • Denied any h/o palpitations, orthopnea, edema or
    PND
  • No history of cardiac events
  • Poor exercise tolerance secondary to SOB

4
Past Medical History
  • Hypertension
  • Type II DM
  • HbA1C 8.4
  • CRI
  • Baseline CR1.8
  • Microalbuminuria
  • Hypercholesterolemia
  • TChol 221, HDL 36,
  • LDL 110
  • COPD
  • No documented PFTs
  • Bells Palsy
  • GERD
  • Hypothyroidism
  • TSH 2.44

5
Outpatient Medications
  • Diltiazem SA 300 mg QD
  • Lisinopril 20 mg QD
  • Lovastatin 10 mg HS
  • Glyburide 5 mg QD
  • Quinine Sulfate 325 mg HS
  • Cimetidine 300 mg Q4H prn
  • Levothyroxine 0.125 mg QD
  • Psyllium Powder
  • Lactulose 1-2 tbsp QD
  • Tylenol, prn

Allergies PCN
6
Social History
Retired plow driver/maintenance worker 80 Pack
year smoking history quit 40 years ago Denies
alcohol use
Family History
Father h/o cardiac disease died at 85, unknown
CA Mother DM
7
Physical Exam
Vitals T 96.5 HR 60 BP 146/80 RR 20
Sat 90 RA Gen Obese, alert oriented ,
pleasant, in NAD HEENT PERLA, EOMI, OP with
MMM Neck no adenopathy, no bruits, JVP
difficult to assess Cardiac Distant, S1 S2,
RRR, no gallops/murmurs/rubs Lungs CTA b/l,
Ab Soft n/t, BS, no organomegaly Ext 1
pulses, no C/C/E Neuro No focal motor/sensory
deficit
8
Labs
15.9
137 98 19 4.4 28 1.6
11.3
234
188
47
Ca 9.7 Trop I lt0.03 CPK 132 (35-327) LDH 132 (90
-270) CXR no CHF, no infiltrates
AST 17 ALT 18 AlkP 40 Tbili 0.4 PT 12.4 PTT 35.4 I
NR 1.0
9
EKG
10
Assessment
  • 81 y/o with story concerning for acute coronary
    syndrome but negative initial enzymes and EKG w/o
    acute changes
  • Plan
  • Admit to telemetry, serial cardiac markers
  • Add low dose beta-blocker
  • Continue ASA, ACE inhibitor and statin
  • Continue glyburide with insulin sliding scale
  • Follow renal function

11
Hospital Day 2-3
  • Chest pain free
  • Ruled out MI by serial CK and LDH
  • Persantine Thallium stress test
  • Asymptomatic bradycardia with HR 45-50
  • TSH 3.99
  • Beta-blocker held, restarted on former diltiazem
    dose

12
EKG
13
Cardiology Consult
  • EKG consistent with Wellens Pattern
  • Concerning for proximal LAD lesion
  • Recommend
  • cardiac catherization to be scheduled at West
    Roxbury VA
  • Start anticoagulation with LMWH
  • D/C diltiazem, start felodipine for BP control
  • if symptomatic, start nitro drip and GPIIbIIIa
    inhibitor

14
Hospital Day 5
  • At 0430 intern called to assess patient for
    epigastric discomfort
  • Gas pain developed into substernal chest pain
  • rated 8/10, then 3/10 with SL nitro x 2
  • BP 177/92, HR 52, O2 sat 97 RA
  • Cardiac markers drawn
  • EKG obtained

15
EKG
16
Hospital Day 5
  • Patent transferred to VA MICU for acute STEMI
  • NTG drip initiated, heparin drip continued
  • Patient started on GPIIbIIIa inhibitor
  • DHMC contacted for transfer for emergent cardiac
    catherization
  • Mobile ICU arrived for transfer at 0630

17
DHMC Catherization
  • Pre-catherization medications IV fluids,
    N-acetylcysteine
  • Coronary Angiography
  • Right dominance
  • LAD mid 1- discrete 90 stenosis mid 2-
    long segmental 50 stenosis mid Diag 1- 70
    discrete stenosis prox Diag 3- 60
    discrete stenosis
  • LCX mod diffuse, mid- 70 stenosis
  • RCA mod diffuse, mid- 70 stenosis
  • Intervention
  • Stent insertion to 90 stenosis in mid LAD,
    without complication

18
Prevention of Radiographic Contrast-Agent-Induced
Reductions in Renal Function by
Aceytlcysteine(Tepel et al, NEJM July 20, 2000)
  • Prospective randomized trial of 83 patients
    undergoing CT
  • Mean Creatinine of 2.4
  • Randomized to receive aceytlcysteine 600 mg BID x
    2 days with 1/2 NS or placebo and 1/2 NS
  • After 48 hours
  • 1/41 (2) of acetylcysteine group developed RCN
  • 9/42 (21) of control group developed RCN (P
    0.01)
  • Also
  • Mean creatinine in acetylcysteine group decreased
    2.5 -gt 2.1 (plt0.001)
  • Increased creatinine observed in control group

19
Transfer to WRJVA
  • Patient stable and pain free
  • T 96.4 BP 163/87 P 54 R 18
  • Meds
  • Plavix 75 mg QD ASA 325 mg QD
  • Metoprolol 25 mg Q6h L-thyroxine 0.125 mg QD
  • Lisinopril 20 mg QD Lovastatin 10 mg Qhs
  • Amlodipine 5 mg QD Rabeprazole 20 mg QD
  • Labs

137 99 26 4.7 28 2.1
Plan Double product control, ECHO, decrease ACE
and IV fluids
20
Hospital Day 8
  • Patient feels entirely well, denies further CP,
    dyspnea
  • A.M. labs BUN/Cr 28 / 2.6
  • ACE inhibitor held
  • Decreasing urine output
  • Patient increasingly anxious to go home

21
Discharge AMA
  • Repeat Creatnine 2.7
  • Patient feels better than I have in ages...wants
    to go home
  • Team informs patient of risks of leaving
  • Patient deemed competent
  • Discharged AMA
  • Plan for f/u at VA clinic to monitor BUN/Cr

22
VA Emergency Room
  • Two day h/o dyspnea, orthopnea and wheezing
  • Vitals T 97.0 BP 149/68 HR 40 RR 30
    O2 sat 80 RA
  • Exam bibasilar rales
  • Labs

130 92 53 5.2 26 3.4
13.4
268
15.3
186
40.8
CXR- b/l pleural effusions Increased vascular
congestion EKG- Sinus brady, No ST ?
Trop lt0.03 CK 167 LDH 201
23
Admission to Medicine
  • Readmitted to medicine for CHF and ARF
  • Ruled out for acute coronary event
  • Echocardiogram
  • Mild LV dilation LVEF 55 with nl LV size and
    fx
  • Anterior wall appears normal
  • 1 MR, - AS, -AR
  • Worsening renal function despite diuresis
  • Creatnine 3.4 ? 4.0,
  • Urine lytes Na 29, K 61, Cl 56, Cr 78.4,
    FENa 0.96
  • Oliguric- 20 cc urine/hour

24
Discussion ofDialysis Code Status
  • Patient adamantly refused dialysis
  • Reports he has a friend on dialysis and does
    not want to live that way
  • Understood the consequences of refusing life
    saving treatment
  • Judged to have good understanding of situation
    and insightful reasoning
  • Patient also wished not to be intubated, but
    clearly wished to pursue all other resuscitation
    efforts

25
Discharge AMA
  • With full understanding of poor prognosis,
    patient chooses discharge AMA
  • Chaplain consult confirms patients wishes
  • Home hospice care
  • Home oxygen

26
VA Emergency Room
  • I decided I wanted dialysis
  • Presents with large, supportive family
  • Dyspnea at baseline, denies CP , orthopnea or
    PND
  • Vitals Afeb BP 119/56 P 55 R 20 O2 sat
    87 RA
  • Transfer to DHMC for urgent dialysis

13.1
131 90 99 5.1 24 5.1
22.4
290
138
39.7
27
DHMC Admission
  • They tell me I need dialysis
  • Admitted to Medicine team
  • Plan
  • emergent hemodialysis for suspected contrast dye
    nephropathy
  • r/o other etiologies for ARF
  • Renal US and UA ordered
  • Abx held, increased WBC thought secondary to
    prior steroid use

28
DHMC Hospital Days 2-6
  • Patient had good response to dialysis x 3
  • Weight - 11 kg
  • SOB markedly improved, no complaints CP,
    orthopnea, or PND
  • Cr 4.8 ? 2.7
  • Renal ultrasound
  • R kidney 7.5 cm, thin cortex
  • L kidney 12.9 cm
  • MRA abdomen
  • Severe stenosis of proximal R renal artery
  • HD3 patient had elevated Troponin T of 0.37
  • No EKG changes

29
Cardiology consult
  • - Elevated troponin possibly due to decreased
    renal excretion of troponin however, could be
    new ischemic event
  • Catherization films reviewed potential candidate
    for bypass, but in light of patients current
    medical condition, medical treatment recommended
  • Recommended restarting beta-blocker, addition of
    long-acting nitrate, and ?amlodipine
  • P-thal recommended as outpatient

30
Outpatient Summary
  • September
  • HD catheter infected reinserted but complicated
    by hematoma
  • I feel like Im being chopped up!
  • October
  • No evidence of recovery of renal function.
    Patient may not want to continue dialysis if he
    realizes he will not recover renal function
  • November
  • tolerating HD well with good hemodynamic
    stability
  • February
  • Mounting financial concerns, awaiting Medicaid
    approval
  • unable to afford medication co-payments
  • cant squeeze blood from a stone
  • Transfers care to Rutland

31
Rutland Hospital ED
  • lethargic, in acute respiratory distress
  • T 94.6 BP 181/75 HR 53 RR 30 O2 sat 83
    RA
  • ABG pH 7.11 pCO2 83 pO2 80
  • Assessment Volume overload, respiratory failure,
    possible line sepsis
  • Plan Intubated, transferred to DHMC ICU

137 99 54 7.6 28 8.3
14.1
21.6
281
43.3
32
DHMC ICUHospital Day 1-5
  • Admitted to ICU for emergent dialysis
  • Treated with empiric antibiotics
  • Daily hemodialysis
  • WBC 21.6 ?11.5 K 7.6 ? 5.0 Cr 8.3 ? 5.2
  • Respiratory status markedly improved with daily
    dialysis
  • Day 5 extubated and transferred to medicine

33
Hospital Days 5- 9
  • Patient remained afebrile, hemodynamically stable
  • CPK 760 ? 522 with Tropnin 0.23 ? 0.24
  • Repeat Echocardiogram
  • Multiple wall motion abnormalities
  • Akinesis of inferior septum, inferior wall and
    mid posterior wall
  • LVEF 40
  • Patient increasingly agitated
  • Im leaving here and you better get out of my
    way!
  • Patient refuses further dialysis

34
Final Discharge
  • Family meeting
  • Given poor prognosis, advanced cardiac disease
    and difficult hemodialysis, patient and family
    elect to stop further hemodialysis
  • Home oxygen therapy
  • Home hospice care
  • Comfort measures
  • Patient discharged to home...
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