Morbidity and Mortality Conference

1
Morbidity and Mortality Conference

• Tim Gardner, MD
• December 12, 2001
• A 00228974-2

2
Outside Hospital Presentation

• History of Present Illness
• 56 y/o white female
• Diffuse abdominal pain at 7 pm
• Encouraged by her husband to present to the
  Emergency Room at 1000 pm
• Patient refused presumably secondary to her
  severe agoraphobia

3
Outside Hospital Presentation

• History of Present Illness (cont)
• Bloody Diarrhea at 4 am
• Lightheadedness and confusion
• No vomiting, fevers, chills, chest pain,
  palpitations or dyspnea
• Arrived at outside ED at 1000 am

4
Outside Hospital Presentation

• Past Medical History
• 1. GENERALIZED ANXIETY DISORDER
• 1989 - Symptom onset s/p MVA
• 1995 - Admitted to DHMC following husbands MI
• 2. SEVERE AGORAPHOBIA
• 2001 - Admitted to DHMC
• Patient homebound for six months prior to
  presentation
• 3. RECURRENT PANIC DISORDER
• 4. MAJOR DEPRESSIVE DISORDER

5
Outside Hospital Presentation

• Past Medical History (cont)
• 5. ASTHMA
• 6. CHRONIC BRONCHITIS/COPD
• 7. OSTEOPOROSIS
• 8. HYPOTHYROIDISM
• Past Surgical History
• 1. HYSTERECTOMY without oophorectomy
• 1994 secondary to endometriosis
• 2. CHOLECYSTECTOMY
• 1974 secondary to biliary colic

6
Outside Hospital Presentation

• Medications
• 1. Imipramine 100 mg po qhs
• 2. Quetiapine 50 mg po qam, noon, and 100 mg po
  qhs
• 3. Clonazepam 1 mg po qid
• 4. Levothyroxine 0.025 mg po qd
• 5. Trazadone 50-100 mg po qhs prn
• NKDA

7
Outside Hospital Presentation

• Family History
• MOTHER ASCVD died at age 82 from old age
• FATHER Alcoholism, Glucose Intolerance
• SISTER Nervous Ninny
• CHILDREN AW
• Social History
• Married 38 years Former Cashier
• Two Children Social ETOH
• 11 Grandchildren 60 Pack Year Tobacco

8
Outside Hospital Presentation

• Physical Exam
• VITALS Temp 37.2 BP 52/palp P 108 RR
  20 PO 99 RA
• GEN Anxious, alert, cooperative, in
  moderate distress
• SKIN No rashes, purpura or other focal
  lesions
• HEENT Conjunctival pallor, NP and OP clear,
  CVP 7cm
• CHEST Lungs CTAB, no wheezing noted
• CARD Tachycardic, normal S1 and S2, no S3 or
  S4, no m/g/r
• ABD Non-distended, RUQ cholecystectomy
  scar, no bowel sounds,
• diffusely tender in all
  quadrants, no rebound, no guarding, no
• masses
• RECTAL Gross blood and mucous, tenderness in the
  posterior vault
• EXT No edema, strength not tested
• NEURO CN grossly intact, oriented x 1

9
Outside Hospital Presentation
LABS
15
138
102
35
227
42
2.9
24
2.6
45
B49 S45 L4 M2 E0 B0
AMYLASE 896
SG 1.016 GL 1 BL 2 PR 4 URO 0
NIT 0 LE Tr WBC Tntc RBC Tntc BAC Num
PTT 28.9 PT 12.6 INR 1.05 FIBR 391
10
Outside Hospital Presentation

• Abdominal and Pelvic CT Scan
• (SHOW)

11
Outside Hospital Presentation

• Hospital Course
• 1025 am - Dopamine gtt started at 5mcg/kg/min
• 1028 am - BP 60/palp
• Dopamine increased to 10 mcg/kg/min
• One unit PRBCs transfused
• 1120 am - BP 60/palp
• Dopamine increased to 20 mcg/kg/min
• 1125 am - Cefotetan 2 gm IV and Gentamicin 160
  mg IV
• 1215 pm - BP 62/palp
• Phenylephrine 60 mcg/min started
• 1245 pm - BP 65/palp
• Patient intubated secondary to hypoxia
• 130 pm - Transported to DHMC via DHART
• Total 8 Units Crystalloid and
  1 Unit PRBC

12
DHMC Presentation

• Physical Exam
• VITALS Temp 35.8 BP 90/70 P 91 RR 16
• GEN Intubated and sedated
• SKIN No focal lesions
• HEENT Intact pupillary reflex, no conjunctival
  pallor, oro and
• nasopharynx clear, CVP 7 cm
• CHEST Course rhonchi on inspiration in
  bilateral lung bases, no
• wheezes
• CARD Regular, normal S1 and S2, no S3 or S4,
  no m/g/r
• ABD Mildly distended, no bowel sounds, no
  masses, no rebound, no
• guarding, liver and spleen
  non-palpable, left lower quadrant
• fullness
• EXT No edema, warm bilaterally, 2/2 DP
  and PT pulses bilaterally
• NEURO Sedated, oculocephalic reflex intact

13
DHMC Presentation
LABS
13
143
115
32
251
151
32
5.7
14
2.2
39
MG 0.66 CA 5.9 PO 3.4
N58 B28 L8 M8 E0 B0
AG14


PTT 34 PT 17.2 INR 1.6 TT 19 DD
11260 FIBR 247
ABG PH 7.05 PCO2 52 PO2 79 HCO3 14
TB 1.3 DB 1.2 AP 92 AST 1613 ALT
1080 AMY 463 LIP 81 ALB 2.1
L-Lactate 6.3 Ammonia 12
14
DHMC Presentation
Initial Problem List

• Prolonged Hypotension
• Metabolic and Respiratory Acidosis
• Acute Transaminase Elevation
• Acute Renal Failure - Oliguria
• Calcified Heterogeneous Sigmoid Colon Mass
• Acute Respiratory Failure
• Multiple Band Forms
• Coagulopathy

15
DHMC Presentation
Emergent Bedside Colonoscopy

• FINDINGS
• Ischemic Black Mucosa
• Distal Descending Colon - 35 cm from anus
• Hard, Immobile Fecalith at Site of Ischemia
• Intermittent, Erythematous Patches of Ischemia
• Sigmoid Colon - distal to the fecalith
• Emergent Exploratory Laparotomy Recommended

16
DHMC Presentation
Exploratory Laparotomy

• FINDINGS
• Ileum and colon necrosis
• 20 cm proximal to ileocecal valve --gt 35 cm
  proximal to anus
• Large 4x5 cm fecalith completely obstructing
  descending colon
• Normal mucosa distal to fecalith
• PROCEDURES
• Subtotal colectomy with resection of distal
  ileum
• Ileostomy
• Feeding jejunostomy feeding tube placement

17
DHMC Hospital Day 1

• Hospital Course
• Started on CVVHD
• Maintained on Pressure Support
• Ventilation
• Started on IV Metronidazole and
• IV Ciprofloxacin
• Started on TPN

MEDS Metronidazole 500 mg IV q8 Ciprofloxacin
400 mg IV q12 Famotidine 20 mg IV
bid Levothyroxine 0.012 mg qd Docusate 100 mg
bid Heparin 5000 mg SQ bid Norepinephrine
gtt Dopamine gtt Fentanyl gtt Midazolam gtt TPN
LABS


PTT 43 PT 20.1 TT 17 INR 2.1 FIBR
306 DD 6040
TB 2.2 DB 2.2 AP 88 AST 854 ALT 810
ABG PH 7.29 PCO2 39 PO2 92 HCO3 16
14
12.5
129
40
144
113
40
4.9
15
2.8
18
DHMC Hospital Days 2-3

• Hospital Course
• PA Catheter placed
• CVP 19 PA 53/34 CI 4.3 SVR 503
• Phenylephrine gtt started
• Thrombocytopenia worsens
• Heparin discontinued
• Oliguria Resolving
• Febrile to 39.0 degrees

LABS


PTT 49 PT 17.6 TT 18 INR 1.7 FIBR
637 DD 2925
TB 4.3 DB 3.6 AP 297 AST 88 ALT 199
ABG PH 7.36 PCO2 46 PO2 86 HCO3 26
WBC 15 HGB 11 PLT 32 CR 2.3
Blood, Urine, Sputum Cultures negative
19
DHMC Hospital Days 4-7

• Hospital Course
• PA catheter removed
• CVVH discontinued - HD started
• PAIG positive
• Persistently febrile
• Antibiotics discontinued
• CT scan to evaluate abdomen

LABS


PTT 35 PT 14.3 INR 1.2
TB 9.3 DB 8.0 AP 351 AST 95 ALT
79
WBC 14.6 HGB 9 PLT 65 CR 5.3
Blood, Urine, Sputum Cultures negative
20
DHMC Hospital Days 4-7 (cont)

• CT Scan
• (SHOW)

21
DHMC Hospital Days 8-14

• Hospital Course
• Vasopressors discontinued
• Thrombocytopenia resolved
• Psychiatric regimen restarted
• Persistently febrile
• Enterococcus in urine culture
• Vancomycin and Gentamicin started

LABS
TB 20.0 DB 16.0 AP 647 AST 188 ALT 168
138
100
48
9
13.1
315
3.3
4.2
24
27
22
DHMC Hospital Days 15-28

• Hospital Course
• Extubated - Hospital Day 18
• Slowly resolving delirium
• Intermittent fevers
• Transferred to floor - Hospital Day 23
• Worsening hepatic function

LABS
TB 42.6 DB 32.9 AP 755 AST 322 ALT
308 INR 5.6
141
105
33
9
11.5
245
3.2
3.7
24
27
23
Bilirubin Levels


24
Transaminase Levels


25
Hepatocyte Bilirubin Metabolism
1

• Hyperbilirubinemia
• Overproduction.
• Impaired uptake, conjugation, or excretion.
• Leakage from damaged hepatocytes.

5

2

3
4
Blood
Bile
5
26
Indicators of Hepatocyte Injury

• Serum Aminotransferases
• Intracellular enzymes.
• Catalyze transfer of amino groups to
  ketoglutarate.
• ALT predominantly liver.
• AST livergtcardiac musclegt skeletal musclegt
  kidney.
• Poor correlation with extent of hepatocellular
  necrosis.
• Rapid fall with a rising bilirubin and prolonged
  PT is often associated with a poor prognosis.

27
Hepatic Failure

• DDX
• Ischemic Injury - Shock Liver
• Hepatotoxic Drugs
• Cholestasis
• Genetic Liver Abnormality
• Hepatitis
• LABS
• Ferritin gt2000 HepBSAg
  negative ANA negative
• Iron 72 HepBSAb
  positive AMA negative
• TIBC 155 HepC
  negative ASMA negative

28
DHMC Hospital Days 29-36

• Hospital Course
• Hypotensive on floor - transferred to ICU
• Persistent high fevers
• Enterococcus Faecalis in blood
• Meropenem started and Vancomycin continued
• Worsening delirium
• Worsening hepatic failure

LABS
TB 56.0 DB 43.5 AP 1491 AST 680 ALT
646 INR 4.5
131
94
66
9
34.9
131
3.0
3.0
21
27
29
DHMC Hospital Day 37
Hospital Course

• Sudden hematemesis and hematochezia
• Refractory hypotension to vasopressors
• Bedside echocardiogram shows organizing
  pericardial clot
• Patient becomes unresponsive
• Patient made CMO by family
• Patient dies peacefully at 400 pm
• Permission for full autopsy granted

30
Ischemic colitis with necrosis
31
No evidence of thromboemboli or vasculitis
32
Uremic Pericarditis
F
G
M

• Diffuse granulation tissue (G) with surface
  fibrinous exudate (F)

• No microscopic evidence for myocarditis or MI

33
Liver lobule architecture
PORTAL TRACT
ZONES
3 2 1
CENTRAL VEIN
PORTAL TRACT
PORTAL TRACT
34
Hepatic lobule overview
PORTAL TRACT
PORTAL TRACT
PORTAL TRACT
PORTAL TRACT
PORTAL TRACT
PORTAL TRACT
CENTRAL VEIN
(Trichrome stain)

• Minimal congestion or fibrosis identified

35
Autopsy portal tract, normal
Viral Hepatitis
36
Portal-central area with centrilobular necrosis
(Zone 3)
Edge of Portal tract
Edge of Central V.
37
Centrilobular necrosis (Zone 3)
38
Centrilobular necrosis (Zone 3)
39
The autopsy findings excluded...
1. Hepatotoxic drugs No evidence for chronic
drug damage such as fatty change, granulomas,
eosinophils, fibrosis 2. Viral hepatitis No
evidence of acute or chronic portal tract
inflammation, piecemeal necrosis, single cell
necrosis (also negative serology) 3. Extrahepatic
obstruction No evidence of bile duct plugging,
strictures, pancreatic obstruction, stones 4.
Alcoholic hepatitis No evidence of increased
fibrosis, fatty change, acute inflammation,
Mallorys hyaline 5. Genetic liver
abnormalities No evidence of iron overload,
alpha-1 antitrypsin bodies, copper deposition
40
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