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

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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

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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

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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...