Morbidity and Mortality Conference Morbidity and by cuiliqing

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									Morbidity and Mortality
     Conference
    Brendan Cavanaugh
      April 24, 2002
           Initial Presentation
• 58 y.o. male s/p AVR and ascending aortic
  aneurysm repair 10 months prior
• 1-2 minute episode of facial/lingual numbness
• Double vision
• Slurred speech
• No focal weakness, confusion, aura, seizure
  activity, headache, syncope, chest pain or dyspnea
• Two similar episodes in the last 10 months
           Review of Systems
•   No recent medication changes
•   No recent illnesses
•   No recent trauma
•   No recent vision changes
•   Good performance status
         Past Medical History
• H/O ascending aortic aneurysm leading to 4+ AI
• S/P Bentall procedure with St. Jude's valve and
  Cabrol graft to LM (INR goal 2.5-3.5)
• DDD pacemaker
• Nonobstructive CAD (LM 50% by cath 10/00)
• S/P Anterior MI, EF 50%
• HTN
• GERD
• H/O esophageal stricture s/p dilation
Medications:              Social History:
-   HCTZ 25 mg qd         - Married
-   rofecoxib 12.5mg qd
                          - Retired construction
-   metoprolol 75mg qd       worker
-   warfarin 5mg qd
                          - Remote smoking Hx
-   omeprazole 20mg qd
                          - Social alcohol use

ALL:     etodolac
                          Family Hx :
                          CAD, HTN
                     Physical Exam
Gen:     Pleasant, NAD
VS:      Afebrile BP 136/71 HR 72 Resp 20 SpO2 96% RA
Card:    RRR, normal S1, III/VI SEM heard best over the aortic area,
         loud S2, mechanical click
Resp:    CTA bilaterally
Abd:     Soft, NT, ND, +BS
Extr:    No C/C/E. Good peripheral pulses
Neuro:   Alert and oriented, Motor 5/5 throughout; sensory and
         cerebellar exam were normal; gait intact; reflexes 2+
         bilaterally. ? Left facial droop (other CN normal)
                Laboratory Data
      16.2
9.0                 283    PT 21.1
       44.9                INR 2.3
                           PTT 33

                           CTNT: <.03, CPK 149
140   102      12          CA, Mg, Phos all WNL
                     108
3.5   23      1.2
            Contributing data
• EKG: NSR with          • Carotid dopplers: 16-49%
  ventricular pacing at    stenosis of the ICA with
                           irregular surface contour
  72. T wave inversions
                           bilaterally
  in anterolateral leads
                         • CT angiogram: moderate
  which were unchanged     stenosis of basilar artery
  from previous          • TTE: Normal LV size and
                              function. EF 65%. Septal
• CT head: Negative           hypokinesis c/w surgery.
                              Valve function normal
                Day 2
• Awoke with substernal CP
• EKG was obtained………..
•   EKG with ST depressions in II, III, AVF
•   Troponin <.03 X 2
•   Fresh frozen plasma
•   Repeat echo showing hypokinetic inferior
    wall and EF of 40-45%
                    Day 3
•   Pain free, b/p 105/65, pulse 60-70
•   Peak CTNT 0.44, CPK 279
•   Cath: 50% LM, normal distal flow
•   TEE: no vegetation/clot, EF 50%
•   Stress echo:no evidence of cardiac ischemia
              Day 4 and 5
• Transferred to ICCU
• No further pain
• CKs resolved
• Discharge medications: warfarin , ASA,
  atorvastatin, metoprolol, omeprazole
• Follow up with Internist/Cardiology
           Two weeks later….
•   Two hours of crushing substernal CP
•   Respiratory distress, profuse diaphoresis
•   Afebrile, B/P 88/60, 80, 30, 94% on RA
•   Lungs clear, JVP slightly elevated
•   EKG was obtained……….
• EKG: new left axis deviation and
  t wave inversions in the lateral leads
• Troponin <.03, CK 146, INR 2.2
• All other labs normal
• CXR unremarkable
             Management
• IV nitro, metoprolol, MSO4 and heparin
  with some resolution of pain
• TTE 35-40%. Eccentric titling of aortic
  valve. Hypokinetic lateral wall
• Pt given FFP and emergently sent to the
  cath lab.
             Interventions
• Cardiac cath showing showing occluded
  Cabrol limb to LM
• IABP/Swan placed in the lab
• Pt emergently taken to surgery
• Off pump coronary bypass performed:
  LIMA to LAD
                 POD #0-1
•   Dopamine/Neo/Epi/Milrinone gtt
•   Pt remained intubated (PEEP of 7.5)
•   Tmax 38, HR 90’s, MAP 60’s
•   CVP 17, PA 58/30, CO/CI: 4.1/2.0
•   BUN/Creat 15/1.1, good urine output
•   SVT amiodarone started
•   IAPB maintained at 1:1
                  POD #2
• Spiked temp to 38.9, WBC 15.6, pan cultured
• Vitals: B/P 90’s/40’s, HR 90’s
• ABG: 7.44/34/76/90% on 60% and PEEP 7.5
• CVP 14, PA 55/30, SVR 1058, CI 2.0
• CXRopacity right base, increased vascular
  markings bilaterally
• Cefuroxime IV
• Furosemide gtt
       POD #3, CT/ICU Day #4
•   IABP d/c’d
•   Pulmonary status worsening
•   ABG: 7.33/39/49/92% on 80% FiO2
•   IV vecuronium started
•   CXR showing worsening infiltrate/pulm. edema
•   Cefuroxime changed to pip/tazo
•   Transferred to CCS team
•   Trial of IV alprostadil
                   POD #4
• ABG: 7.33/39/49/92% on 100% Fio2
   PEEP increased to 12.5
• Temp 39, WBC 17.7
• Pip/tazocefazolin/aztreonam
• CVP 20, PA 64/31, CI 2.0, MAP 60s’, HR 80’s
• Echo: EF 25-30%, restrictive filling pattern,
  extensive WMA’s in the distribution of the LAD
• IABP placed
                   POD #5-6
                            Medications:
                            1. Milrinone gtt
•   Febrile, WBC 17.7       2. Phenylephrine gtt
                            3. Epinephrine gtt
•   MAP 60’s, HR 100’s
                            4. Dobutamine gtt
•   SVR 850                 5. Furosemide gtt
•   CXR without change      6. Amiodarone gtt
•   PEEP increased to 15,   7. Heparin gtt
    FiO2 down to 60%        8. Vecuronium gtt
•   Creat 1.82.0           9. Midazolam gtt
                            10. Fentanyl gtt
                            11. Insulin gtt
                            12. Cefazolin/Aztreonam IV
                            13. Famotidine/ASA
                POD #7-10
# CV:
  -V-Tach lidocaine gtt
  - Repeat echo showing EF of 25% (CI 2.4)
# Pulmonary:
  - Increasing FiO2 requirements (100%)
# ID
  - Persisting leukocytosis, abx adjusted
# FEN
  - Worsening renal function CVVH
  - New coagulopathy, elevated LFT’s
                 POD #11
•   Worsening acidosis (ph 7.197.02)
•   Increasing pressor requirements
•   V-fib arrest
•   Pt pronounced dead at 1:30 am
•   Autopsy granted
A-02-09
A-02-09
          Final Autopsy Diagnosis
I. Coronary artery atherosclerosis, severe.
        A. Acute myocardial infarction, anteroseptal myocardium
       (days).
               1. Status post CABG with LIMA to LAD (days).
               2. Reperfusion hemorrhage in myocardium.
               3. Cardiogenic shock as evidenced by:
                         a. Acute infarction of large bowel.
                         b. Acute tubular necrosis.
                         c. Acute hepatic passive congestion and
                         centrilobular necrosis.
                         d. Focal infarction of the spleen.
               4. Biventricular hypertrophy.
               5. Bilateral pleural effusions.

        B. Healing myocardial infarction of posterolateral left
       ventricle (weeks).
              Final Autopsy Diagnosis
II. Status post Bentall procedure for repair of idiopathic dilation
       A. Status post aortic valve replacement.
          1. Status post Cabral graft from ascending aorta to left main coronary
             artery and reimplantation of right coronary artery into ascending aorta.

III. Cerebral atherosclerosis by history.
       A. History of transient ischemic attacks, with known
           50% narrowing of basilar artery by angiogram (weeks).

IV. Idiopathic hypercalcuria (years).
      A. Interstitial nephritis, mild.
      B. Nephrolithiasis not identified at autopsy.

								
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