Morbidity and Mortality Conference

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Morbidity and Mortality Conference

• Stephen K. Liu, M.D.
• February 27, 2002

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Initial Presentation - Feb 2001

• A 76 y/o male presented to his physicians
  assistant at the VA Medical Center in WRJ with a
  chief complaint of a dry cough for several months

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Initial Presentation

• The pt believed that the cough improved after
  getting a course of amoxicillin for a dental
  infection
• ROS negative for fever, chills, night sweats,
  shortness of breath, or weight loss
• PE decreased breath sounds at the right base
• CXR bilateral (RgtL) pleural effusions
• Followup was difficult

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History

• Two months later-
• CT scan (without contrast) large left
  mediastinal mass encasing the aorta
• Over the ensuing months, the pt canceled multiple
  follow-up appointments, an enhanced CT scan, and
  a planned diagnostic thoracentesis.
• It was difficult to reach him by phone
• Letters were sent regarding his results

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History

• Pt had avoided further work-up and treatment of
  his pleural effusions for the past nine months
  due to anxiety, denial, the recent death of his
  ex-wife, and a desire to try herbal remedies
  first.

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Presentation to the Drop-In Clinic - November 2001

• On presentation, the patient was significantly
  SOB with minimal effort, including talking
• The patient agreed to admission for a diagnostic
  and therapeutic thoracentesis
• Advance directives full-code

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History

• Past Medical History
• HTN
• Basal Cell Carcinoma
• DJD
• Medications
• None
• ALL Erythromycin

• SocHx
• Quit smoking over 50 yrs ago, no alcohol misuse
• Six children
• Retired insurance agent
• Previously enjoyed racquetball and rowing.
• FHx
• father - lung CA
• brother - prostate CA

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Physical Exam
Gen Somnolent but arousable, ill appearing,
cachectic VS T 97.5 BP 150/84 HR 86
RR 30 SpO2 85 RA 96 4L NC HEENT PERRL,
EOMI, OP-dry MM, no erythema Neck Supple, no
LAD, JVP lt 5 cm CV RRR, no S3 or
S4 Resp Decreased BS LgtR, dull to percussion 2/3
up lung fields, minimal air movement in apices
, decreased tactile fremitus at both bases Abd
ND, BS, Soft, NT, no palpable masses or HSM, no
palpable inguinal LN Ext No edema, no
palpable axillary adenopathy Neuro Arousable
with some difficulty, oriented to date but not to
place
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Laboratory Data
14.4 8.5
252 41.8 89Gran 7lymphs
3monos 0.1eos 0.1 baso
130 90 23
119 4.5 32 0.7

• Ca- 9.7
• T.Bili - 0.7
• Alk Phos - 52
• AST - 34
• ALT - 30
• GGT - 38

ABG 7.255/84/82.5 PT - 12.8 INR - 1.0 PTT -
49.2
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11/7
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Admission to WRJ VAMC

• Thoracentesis performed
• Pleural Fluid Analysis
• pH 7.350
• Glucose 120
• LDH 131
• Protein 3.8
• RBC 5800
• Nucleated Cells 450
• 10 segs
• 22 macrophages
• 5 mesothelial
• 63 lymphs

Gram Stain 1 WBC No orgs
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Hospital Day 3

• Patient awoke with dyspnea and tachypnea
• Increased O2 requirements
• ABG 7.18/104/79/29
• CXR showed an increased effusion on the left
  without a pneumothorax and the persistent
  effusion on the right
• Transfer to the MICU
• Therapeutic left thoracentesis performed at the
  bedside

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Hospital Day 3

• Increased somnolence, then became unarousable
• Emergently intubated
• Propofol gtt begun
• Chest tube inserted on the right
• 2-3L of pleural fluid filled the Pleura-Vac in
  minutes before the chest tube was clamped
• Pt became hypotensive and tachycardic requiring a
  dopamine gtt to maintain pressures

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11/9
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Hospital Day 4

• Pt remained hypotensive and on dopamine
• The blood pressure was extremely sensitive to
  propofol
• Additional labs returned
• LDH 170
• uric acid 2.5
• albumin 1.9
• Swan placed
• RA 25/16 RV 49/15 PA 44/17 PAOP 20
• CO 4.4 CI 2.3 SVR 1417
• Dopamine gtt - 6

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Hospital Days 5-7

• Pt continued to require numerous fluid boluses in
  addition to maintenance IVF to maintain Urine OP
  and BP
• Left sided pigtail catheter placed
• CT of the chest/abd/pelvis obtained
• Platelets begin trending down to 70 - all
  non-essential meds including heparin flushes
  discontinued

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Hospital Day 8

• A CT guided biopsy of the mediastinal mass was
  performed by interventional radiology
• A trans-thoracic echo was performed

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Homogeneous population of lymphocytes with a
scant to moderate amount of vacuolated cytoplasm.
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Poorly cohesive small lymphocytes with irreg.
hyperchromatic nuclei, some with eosinophilic
cytoplasm rare plasma cells.
By flow cytometry Monoclonal kappa light chain,
CD19, CD20, slight CD23, CD10-, CD5-. C/w
B-cell lymphoprolif. disorder. Diagnosis B-cell
lymphoma
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Hospital Days 9 - 14

• Extubated, then re-intubated after only two hours
  for respiratory failure
• Extubated again two days later
• Both chest tubes drained a liter of fluid/day
• Massive anasarca
• Platelets began to rise
• First round of CHOP given at 67

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Hospital Days 15-19

• Pt developed rigors
• Pleural fluid sent for culture
• Initial Gram stain showed GPC/GNR
• Started on pip/tazo
• Culture grew out coag neg Staph and Providencia
  rettgeri
• Pt re-intubated for worsening respiratory status
• Etiology thought to be due to failure of the left
  chest tube
• Platelets fell to a low of 36

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Platelet count
11/13 - heparin flushes and allopurinol
d/cd 11/20 - first dose of CHOP
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Hospital Days 20-29

• Extubated, given platelet transfusions, and
  pressors weaned off
• Repeat echo showed improved hemodynamics
• s/p one cycle of CHOP
• Chest tubes continued to drain a liter of fluid a
  day
• Pleurodesis planned when drainage decreased

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Hospital Days 30-35

• G-tube placed by interventional radiology
• Platelets began to rise again
• trial of heparin
• CT drainage down to 60 cc on the left and 430 cc
  on the right
• planned pleurodesis canceled as the drainage was
  greater than 50 cc/24hr

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Hospital Days 36-43

• Chest tubes continued to have minimal drainage
  bilaterally
• left chest tube pulled, right side remained on
  water seal
• Second cycle of CHOP given
• Pt pulled out G-tube during the night
• Re-inserted at the bedside, tube feeds held

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Hospital Day 44

• Pt developed a worsening lung exam
• ABG 7.1/146/64.6
• Pt once again agreed to re-intubation
• A portable CXR was obtained post-intubation

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12/20
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Hospital Day 45

• Patient decided to be DNR
• Self extubated overnight
• Three hours after extubation, the patient told
  the nurses that he wanted to die
• Withdrawal of support

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Issues Discussed

• Patient decision making and the role of
  physicians
• Management of pleural effusions
• Re-expansion pulmonary edema
• Lymphoma and CHOP
• Thrombocytopenia
• Volume status, hypoalbuminemia, and nutrition