Morbidity and Mortality Rounds

1
Morbidity and Mortality Rounds

• Dr. Shounak Das
• July 27, 2007

2
History

• HPI
• 53 y.o. Hispanic female admitted through the ER
  with fever hypotension
• h/o diabetes, morbid obesity, CAD 8 years s/p
  CABG complicated by CVA with residual hemiplegia
• 1 month PTA admitted with PE
• PPM placed 3 weeks PTA
• 1 day PTA developed chills, nausea, vomiting

3
History

• PMH
• diabetes
• CAD
• CVA
• dyslipidemia
• PSH
• CABG
• R knee surgery
• lap choly

• hypertension
• morbid obesity
• pulmonary embolus

• PPM placement
• IVC filter

4
History

• meds (home)
• aspirin 81 mg daily
• lisinopril 10 mg daily
• actos 45 mg daily
• 70/30 insulin 20 units bid
• toprol XL 50 mg daily

• allergies
• NKDA

5
History

• FH
• ve for diabetes hypertension
• SH
• married
• non-smoker no EtOH

6
History

• ROS
• denies chest pain or palpitations
• no cough
• denies abdominal pain or recent change in bowel
  habits
• denies dysuria
• weight gain is noted
• she complains of slight headache

7
Physical Exam

• General
• ill-looking obese patient

• Vital signs
• HR 88 (reg) RR 24
• BP 80/51 T 103.4
• HEENT
• PERRLA/EOMI/anicteric/oropharynx normal/no
  lymphadenopathy
• Chest
• clear to auscultation bilaterally/mild
  inflammation around pacemaker pocket no
  fluctuance/drainage

8
Physical Exam

• CVS
• RRR/NL S1 S2/no extra sounds, rubs, or murmurs
• Abdo
• Nl bowel sounds/ soft, non-tender/no
  hepatosplenomegaly
• Neuro
• CN II-XII intact/R-sided weakness (UgtL)
• Extremities
• 1 bilateral ankle edema
• Skin
• no rashes

9
Labs
60N 16L 12M 11B
10.9
132
107
37
194
14.1
106
3.0
16
1.6
32.4
AG 9
Ca2 6.3 7.6corr Mg2 0.8 TP 5.3 Alb
2.4
INR 1.3 fibrinogen 309 CRP 11

AST 27 ALT 13 Alk Phos 85 T bili 0.9

10
Labs

• CXR low volumes no infiltrate
• u/a 25 WBC/hpf
• blood cultures 2/2 ve for MSSA
• TEE RA lead 2-3 mm mobile vegetation/thrombus

11
Course in Hospital

• started on IV vancomycin initially, then switched
  to nafcillin once sensitivities confirmed
• started on pressors
• intubated hospital day 2
• started on CVVHD hospital day 8 for ARF
• pacemaker removed hospital day 11
• MOF persistent hypotension despite maximal
  pressors
• withdrawal of care hospital day 15

12
Pacemaker Infections

• incidence roughly 5
• 90 of these are pocket infections
• remaining are deeper infections i.e. device
  related endocarditis
• risk factors diabetes, recent manipulation of
  device, temporary pacers
• 90 caused by s. epidermis or s. aureus
• 1/3rd early (3-6 mos.) 2/3rds late (after
  3-6 mos.)
• lead removal recommended for device-related
  endocarditis