Morbidity and Mortality

Morbidity and Mortality
by:Randy Hoover MD

Eponyms: Livedo reticularis associated with stroke-like episodes is known as?
* Sly’s Syndrome
* Sneddon’s Syndrome
* Riley-Day Syndrome
* Shwachman’s Syndrome
* Richter’s Syndrome
73 year old woman presents to an outside acute care clinic with a chief complaint of back pain.
* Upper-thoracic region
* Described as a “bunch,” mild in severity
* Constant, no radiation or change with position, not respirophasic
* Similar to recent transient episodes

History of Present Illness
* Associated with fatigue and malaise
* Night prior to presentation, unable to get comfortable; sweats and nausea
* Recent nose bleeds
* No fevers or rigors
* No chest pain, SOB or abdominal pain
* No bowel or bladder symptoms

Past Medical History
* Chronic A.Fib
o Anticoagulated on warfarin
* H/O Atypical Chest Pain
o Cath 12/00, normal
* Chronic Low Back Pain
* HTN
* CRI
o Baseline Creatinine 1.5
* COPD
* Chronic Diarrhea
* Temporal Lobe epilepsy
* S/P Appendectomy, herniated bowel repair

Medications
* Diltiazem CD 360 mg po qd
* Losartan 50 mg po qd
* Triamterene 50 mg po qd
* Warfarin 5 mg po qhs
* Metoprolol XL 50 mg po qd
* Amlodipine 5 mg po qd

ADR’s: Morphine, ACE Inhibitors
Social History
* Widowed mother of 2
* Consumes a glass of sherry and of cognac daily
* Current 2 ppd smoker
o Approx 100 pk year history
* Lives alone and functions independently

Physical Exam
Gen: 73 yowf, pleasant, NAD, who appeared older than her stated age
T=97.9 P=89 R=18 BP=126/90
Heent: EOMI, PERLA, OP pink and moist. Sclera anicteric
Neck: Supple, JVP =6 cm
Lungs: Poor air movement but otherwise clear
CV: Irreg Irreg no MRG and variable S1
AB: + Bs, soft, non-tender, non-distended, no masses, no hepatosplenomegaly
Back: Tender in the mid-dorsal region. Pain could be reproduced. No paravertebral or bony tenderness. No muscular spasm
Ext: No c/c/e
Labs
Initial Radiology
* RUQ Ultrasound: Multiple gallstones, no
wall thickening, no free fluid or dilated ducts
* CT Abdomen: Gallbladder is distended, no gallstones, slightly enlarged common hepatic and common bile ducts

Further Evaluation
* 2 weeks later: Seen by general surgery at DHMC for possible symptomatic cholelithiasis
o Pt extremely reluctant to undergo surgery
o “ I’ve not been significantly bothered by this”
o Referred to GI for possible ERCP
* 1 month later: Seen by GI
o Persisently elevated alk phos and amylase
o Thought secondary to etoh vs stone passage

-Management Options-
What would you do next?
* Ursodeoxycholic acid
* HIDA scan
* MRCP
* ERCP
* Recommend Surgery
* Watchful waiting

-Test Characteristics-
Magnetic Resonance Cholangiopancreatography (MRCP)
MRCP (Thin Slab)
* ERCP
o Could only cannulate pancreatic duct
o Dye injected into pancreatic duct showed local dilatation
o Brushings of pancreatic duct
o Sent to IR for transhepatic cholangiogram
* Percutaneous Transhepatic Cholangiogram
o Mildly distended intra/extrahepatic ducts
o Narrowing of distal common bile duct
o No dye spilling into duodenum, cholecystostomy tube placed

Admitted for monitoring
Physical Exam
Labs
Assessment and Plan
* Hypertensive urgency
o EKG without signs of ischemia. Pt with lethargy and + proteinuria
o IV Labetalol PRN until SBP decreased < 180
o Restart oral antihypertensive agents: diltiazem, losartan, metoprolol, and amlodipine
* Ductal dilatation s/p ERCP and PTC
o Hydrate
o Monitor LFTs and for signs of post-ERCP pancreatitis
o Cefotetan for prophylaxis
o F/U on Brushings
Post-ERCP Pancreatitis
* Serum amylase elevated in 75% of patients
* 5% have clinical pancreatitis
* MOST mild/moderate, rarely (0.4%) severe
* Usually with therapeutic (versus diagnostic)
* Prediction rules
o Amylase < 276, lipase < 1000 @ 2 hours
* Prevention
o Technical, stents, pharmacologic
+ Antibiotics, calcitonin, glucagon, nifedipine, C1-inhibitors, secretin, anticoagulation, corticosteroids, somatostatin, octreotide, gabexate mesilate, IL-10
Hospital Days 2-4
* Hypertension/A.fib
o Improved with oral agents
* Post ERCP pancreatitis
o Amylase 600
o Lipase 3780
o NPO, pain control, continue IV Hydration
* Cholecystostomy tube falls out
o IR contacted: recommend monitoring LFTs
* Day 4
o Feeling much better, tolerating clear liquids, LFTs stable at baseline
Hospital Day 5
* C/o Increasing RUQ pain, worsening abdominal distention, and nausea
* Labs:
* Plan: NPO, adequate pain management, follow LFTs, place PICC line and begin TPN
Hospital Day 6
* Worsened abdominal pain and distention.
* New rhonchi bilateral lung bases
* Labs:
* CT Abdomen and Pelvis

Hospital Day 7
* Worsening abdominal pain and distention
* Return to IR
o Attempted to drain bile pool around liver, but unable to do so
o Replace cholecystostomy tube
* Somnolent and short of breath
o ABG: 7.25/50/77 on 2 L, oxygen increased to 4 liters
o CXR: CHF
o Lasix 20 mg IV
o Appeared to stabilize

Hospital Day 8
* Somnolent and unarousable
* Acute Abdomen
o Absent bowel sounds, + guarding and rebound
o Urgent surgical consultation
* Exploratory Laparatomy
o Bile Leak from right medial lobe of liver at previous puncture site, cultures sent
o Cholecystectomy: gallbladder full of stones, signs of chronic cholecystitis
o T-Tube inserted
o No masses noted
* Transferred to ICU on ventilator

Hospital Day 9-13
* Fever spikes
o Peritoneal fluid growing Enterococci
o Hospital acquired pneumonia
* Brushings Returned:
Bile Duct: negative for malignancy, + inflammation
Pancreatic Duct: ATYPICAL; atypical ductal epithelial cells. Metaplastic and benign mucosal cells present
Hospital Day 14
* Defervesced
* Oliguric, rising BUN/CR
* Increased ventilatory requirements
* Increasing LFTs
Family Meeting
* Family Meeting
o Daughter indicated that her mother would not want her life prolonged by aggressive measures
o Family requested to withdraw support
o Pt made DNR/DNI
* Support withdrawn
o Pt died peacefully 3 hours later
* Family refused autopsy
Haunting Questions
At what point did this go wrong?
What was her diagnosis?

Morbidity and Mortality.ppt