Morbidity

1
Morbidity Mortality Conference

• 7/17/07

2
Morbidity and Mortality

• MT
• 85 y/o F nursing home resident with a PMHx of
  dementia and falls presented to Sinai ER after
  falling from her wheelchair and sustaining a head
  laceration
• Pt noted to be confused unable to clearly define
  the events of her fall
• Along with dementia, had hx of DVTs treated with
  anticoagulation
• INR 3.7 upon arrival to ER

3
Morbidity Mortality

• Vitals
• T- 36 P-68 BP-145/63 O2-100 on 2 L NC
• PE
• HEENT- Forehead laceration 4 cm, PERRL, no
  lymphadenopathy
• CVS- RRR
• Lungs- CTAB
• ABDOMEN- Soft, mild diffuse tenderness,
  nondistended, Bowel sounds-
• Ext- Palpable B/L femoral pulse, doppler PT/DP-
  pulse
• Musculoskeletal- 4/5 x all four extremities,
  sensation-intact
• Neuorological- no focal deficit

4
Morbidity and Mortality

• Labs
• Na-138 K-4.1 Cl-106 CO2-22 BUN-31 Crea-1.3
  Gluc-204
• WBC-14.9 Hgb-8.7 Hct-26.4 Plts-287
• Coags- 33.7/ 3.7/ 31.0
• Radiology
• CT Head
• No acute hemorrhage old infarct in basal ganglia
• CT C-spine
• no acute fracture
• CT Abdomen Pelvis
• Abdominal Aortic Aneurysm, infrarenal 6.2 cm
• US B/L LE
• No evidence of deep venous thrombosis

5
Morbidity and Mortality
6
Morbidity and Mortality

• Assessment
• 85 y/o F s/p fall from wheelchair with head
  laceration and incidental finding of 6cm AAA
• Plan
• Repair of scalp
• Medical management
• Placement into appropriate facility

7
Morbidity and Mortality

• Vascular Surgery
• Agreed with 6.2 cm AAA
• Recommended no elective operative intervention
  due to severe dementia and age of patient
• Family accepted recommendation
• Medical Consult
• HTN control

8
Morbidity and Mortality

• Hospital Course
• Pts confusion slowly improved
• Abdominal pain subsided
• PT/OT continued daily therapy
• Recommended slow paced rehabilitation facility
• HTN controlled
• Lisinopril, HCTZ, and Metoprolol

9
Morbidity and Mortality

• With continued communication with family and
  social work
• plan to move patient to a rehab facility
  confirmed
• HD5 and 6
• Pts becomes more confused

10
Morbidity and Mortality

• HD7
• Scheduled for transfer to rehab facility
• Pt c/o of abominal and back pain
• Vitals
• T-37.0 P-68-80 BP-150-170/62-74 O2-98
• PE
• Gen- Pt confused, no acute distress, mild
  discomfort
• CV-RRR
• Lung-CTAB
• Abdomen- soft, nontender, nondistended, bowel
  sounds- active
• Ext-palpable femoral pulse
• Plan
• Obtain CT AP

11
Morbidity Mortality

• In CT holding
• Pt is given Oral contrast, immediately vomits
• Pt feels sick
• Lethargic, PEA
• ACLS protocol instituted at 1245pm
• Time of Death 1258pm
• Red Surgery contacted by Code Team
• At 104 pm
• Pt found to be in agonal breathing
• Faint Pulse appreciated
• ACLS protocol reinstitued
• Time of Death 112 pm

12
Morbidity and Mortality

• Main Differentials of Complication
• Rupture of AAA
• MI
• PE

13
Morbidity and Mortality
14
Morbidity and Mortality

• Complication
• Death
• Rupture of AAA

15
Morbidity and Mortality

• Abdominal Aortic Aneurysm
• 80,000 operations performed per year
• Comorbid disease include CAD, DM HTN, and PVD
• Therapy indicated when
• Diameter greater than 5 cm
• Expansion rate greater than 0.5 cm / 6 mos.
• Rupture can occur with small AAA, but mostly
  occur with large AAA
• Many authorities preclude operation when pt has
  extreme age, dementia, metastatic cancer, and/or
  severe end stage medical problem

16
Morbidity and Mortality

• - Rupture rates are 25-40 at 5 years for
  aneurysms greater than 5 cm in diameter, 5-7 for
  aneurysms 3.5-5.0 cm in diameter, and approach 0
  for those aneurysms less than 3.5 cm
• Endovascular AAA repair
• Mixed results compared to open AAA repairs
• Endoleak
• CT surveillance
• anatomic factors are used to address three
  essential questions
• Are there suitable upper and lower attachment
  sites?
• Can the aneurysm be excluded completely?
• Can the graft be implanted safely?

17
Morbidity and Mortality

• -Based on literature
• -Most would agree with holding elective repair
  of aneurysm due to severe comorbid condition