Morbidity & Mortality 17-18/9-11-17... · 9/11/2017 · A/P: 59 yo male multiple medical problems presenting with cholecystitis admitted for EUS/ERCP. #cholecystitis- no signs of

Morbidity & Mortality Grand Rounds Hospitalist Program September 11, 2017

Ashkan Etemadian, MD Health Science Assistant Professor Hospitalist Program University of California, Irvine

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Apr 10, 2018

May 29, 2018

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Hospitalist| September 11, 2017

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Goals & Objectives

Goals

• Opportunity for learning and reflection

• Improve quality and safety for our patients

• Learn from medical errors, complications and unanticipated outcomes (without blame)

Objectives

• To improve our medical knowledge

• To recognize clinical reasoning errors

• Improve communication and documentation among the hospitalist, medicine specialist and other departments


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Admission History/Physical- Resident’s Note

CC: cholecystitis, EUS

HPI: 59M PMHx CAD/MI/stent, not active, (reportedly echo benign and was cleared by cards at St mary’s for possible chole), HLD, HTN, DM2, admitted w RUQ pain, tenderness thought cholecystitis although US only with gravel-debris in GB and ducts, with mild elevation LFTs. Had initial leukocytosis, started on ceftriaxone/flagyl. Could not have MRCP due to ankle hardware so was transferred per GI attending for EUS/ERCP.


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Admission H/P Continued

PMH: atrial fibrillation, Heart Failure s/p ICD, MI, HTN, TIA x 3, anxiety disorder, HTN, BPH

Home Medications: Warfarin, Diltiazem, Atorvastatin, Omeprazole, Duloxetine, Buspirione, Ambien, and finasteride

Inpatient: Ceftriaxone, Flagyl, Lovenox BID (therapeutic dose), Dilaudid prn, Zofran prn

Review of systems: denied chest pain, shortness of breath, rash, and headache.


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Admission Physical Exam and Labs

Temp: 36.8 BP: 140/78 HR: 85 RR: 18 SpO2: 96%

8

14.6

159

42.6

133

3.6

102

24

6

0.6 108

8.3

AST: 152, ALT 38, T. bili 6.0, Alk pho 173, T.prot 5.9, albumin 2.9 INR: 1.42

PTT 35.2


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Admission CXR


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Questions for Internal Medicine

1. What is your approach toward a transfer patient?

2. What is your differential diagnosis? And could that change with more prior records?

3. What is the next best step for our patient?


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Outside Records-Summary of History and Labs

First Hospital: Had epigastric pain for 2 days with radiation to back prior to being seen at first community hospital. Admitted to darker colored urine and yellowing of the skin/eyes.

Additional PMH: COPD, asthma, sleep apnea-refuses to use CPAP, PTSD, anxiety, depression.

Cardiology consulted stated he has CHF, unspecified with EKG showing sinus rhythm with RBBB; AICD s/p Vtach

Second Hospital: Pt presented 3 days prior to admission at outside hospital with several days of colicky abdominal pain, N/V, fevers, chills with bilirubin 4.9 on arrival.

2 days prior to transfer: WBC 9.5, Hg 13.6, plat 167, ALT 67, albumin 2.2, AST 376, T.bili 5.6, T. prot 6.1


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Summary Outside Imaging Documents (No images)

Imaging:

Abd US (8 days prior): mild hepatomegaly with coarsened echotexture, Mild gallbladder wall thickening with positive Murphy’s sign without filling defects or biliary tree dilation

HIDA (6 days prior): lack of filling of gallbladder, patent CBD with normal visualization of the small bowel

CT abd with IV (5 days prior): cholelithiasis, gallbladder wall thickening, pericholecystic inflammation, mildly dilated CBD 9 mm, hepatomegaly, trace R pleural effusion and posterior R basilar consolidation


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Resident Admission Assessment/Plan

A/P: 59 yo male multiple medical problems presenting with cholecystitis admitted for EUS/ERCP.

#cholecystitis- no signs of sepsis -admit to med/surg, NPO, IVF, continue ceftriaxone/flagyl, pain

control, zofran prn, notify GI #atrial fibrillation #HTN #HLD #?CHF -continue diltiazem, lipitor -hold warfarin for EUS/ERCP GI and General Surgery saw the patient the following morning.


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Day 3

On echo patient found to have: • Hyperdynamic Left ventricle, 72% • Impaired relaxation pattern of LV diastolic filling • RVSP 27.8 mm Hg • Pacer wire is visualized in RA and RV • No pericardial effusion • Normal valves Abd US showed borderline enlarged gallbladder with borderline

wall thickening and sludge, Murphy negative. Moderate hepatomegaly without evidence of steatosis (correlate with clinical history and lab findings to rule out hepatitis and vascular congestion). Small perihepatic and perisplenic ascites. Spleen 13.1 cm.


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Day 3 continued

EUS performed: -coarse, nodular liver -no gallbladder or CBD stones -large amount of bile -no significant biliary dilitation -ascites around liver (FNA’ed) Seen by hepatology the following day for concern of liver disease. Thought patient could have NAFLD, possibly Child B.


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6 6.3 7.4 6.4 6.6 6.9 8.9

152

127 131

123

132

140

169

38

33 32

27 26 26 28

0

20

40

60

80

100

120

140

160

180

0 1 2 3 4 5 6 7 8

Lab Trends for Bili, AST, ALT

T. Bilirubin AST ALT

Alk phos levels range from 169-271 Albumin ranged from 2.7 to 3.0 during this period


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INR: 1.42 1.54 1.51 1.77 1.79 1.80

159

174

232

241

225

245

275

8 7.7 8.7 9.2 7.8 8.9 10.6 14.6 14.2 15.5 14.5 15.2 14.8 15.7

0

50

100

150

200

250

300

0 1 2 3 4 5 6 7 8

Platelets, WBC, Hg Trend Day 1 to 7

platelets WBC Hg


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Day 6 Medicine and Surgery Evaluation

Surgery states that they will withhold surgery until etiology of INR and T Bili are determined.

The medicine physical exam notes at this time show that this patient does not have stigmata of cirrhosis. We know low platelets with splenomegaly is highly suggestive of it. In this case, this patient had normal platelets with a spleen size of 13.1 cm.


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Questions for GI/Hepatology

1. How do we diagnose cirrhosis?

2. What is the sensitivity and specificity of an US for diagnosis of cirrhosis?

3. What is the role of EUS/ERCP in the evaluation of abnormal liver function?

4. Does our patient have cirrhosis?

5. Please comment on the patients elevated INR, elevated T Bili and AST/ALT ratio.


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Day 7-Early Morning Summary

Rapid Response called on patient given persistent HR in the 150s to 160s. When patient was evaluated at bedside, he stated that he “felt really awful, like a weight is sitting down on my chest”. He described the pain as substernal and non-radiating and likened it to the time he had a heart attack several years ago.

Fluid balance over entire hospital stay is +2.2L.

EKG revealed atrial fibrillation with RVR to the 160s with right bundle branch block and right axis deviation. Patient’s intial BP was 111/59 but began to trend down as tachyarrythmia persisted to 95/64. Metropolol was held in light of tenuous BP. A 500 cc NS bolus was started with addition 250 ml of fluid in the form of 40 meq of Kphos…


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Day 7-During the Day Summary

After re-evaluation decided to give IV Dilt to attempt to rate control. Patient did not respond to subsequent doses of 10 mg IV, 15 mg IV, 20 mg IV, a 5 mg IV push of metoprolol, or a second 20 mg IV push of diltiazem.

Bedside US showed a collapsible IVC, so IVF of D5NS 75 ml was started and a 500 ml NS bolus was ordered.

Discussed case with MICU who gladly accepted for diltiazem gtt for further rate control.

Lactic acid was 5.4


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ECG


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Days 9-11 Summary

Patient atrial fibrillation/flutter responded to further IVFs (now +4L since admission) and stabilized without initiation of IV Diltiazem gtt. Sent out of ICU.

Interventional radiology asked to assess patient for a possible cholecystostomy tube. They denied the request.

Patient with worsening confusion.

Repeat abdominal US shows less distended GB. More suspicion for acalculous cholecystitis.


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Day 12-Back to the ICU Summary

Patient returned to the ICU (now +9.5L since admission) due to “labs continuing to worsen including INR increasing, WBC increasing, tbili increasing (to approx 10s now) and diffusely jaundiced”.

IV Cefepime and Flagyl started.

Lactic acid 8, so more IVFs given. However, this led to respiratory distress and desaturation, and ultimately intubation.

Patient in septic shock. Abdomen concerning for source but CT A/P did not reveal a source. CT C did not show PE, but showed “bilateral symmetric large dense consolidations and surrounding groundglass opacity…compatible with pulmonary edema”. UA positive for an UTI.


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9.8 11.8 12.6 14.7 15.7 16.9

249

191

176

144

119

96

0

50

100

150

200

250

300

8 9 10 11 12 13 14

WBC and platelet trends Day 8 to 13

WBC platelets

INR reaches 3.83, PTT 113.5, Fibrinogen 361


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Last Few Days

Patient develops acute renal failure toward the last few days where creatinine reaches 2.2, HCO3 8

T.Bili peaks at 10.1, AST 6,403 and ALT 737

Patient +22L of fluid since admission.

Patient became hypotensive requiring 3 pressors. CRRT intitiated.

Soon after the patient died.


25 Hospitalist| September 11, 2017

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Questions for Internal Medicine

1. What happened to our patient?

2. What could/should we have done differently?

3. Would the patient have benefitted from a cholecystectomy?

4. What role, if any, did fluids have in this patients compromise?


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Questions for GI/Hepatology

1. It was noted that the AST and ALT were trending up. Worsening INR and PTT were also noted toward the last part of patients hospitalization. Can congestive hepatopathy cause such findings?


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Moderator Comments and Future Suggestions

Particularly for patients transferred from another facility, it is imperative

that we approach their care with a new set of eyes. We should not just

perform tests because they are requested of us.

The responsibilities of the primary medical team are to obtain and review

outside records, as well as coordinate interdisciplinary discussion.

This was clearly an unfortunate situation. What was seemingly a routine

transfer ended up in death. Their was some confusion on our parts as to

the exact nature of the patients illness and/or how to best treat him.

As clinicians we are responsible for the diagnosis and treatment of our

patients today, not what their “past medical history” dictates or what others

have requested or told us. We must objectively treat our patients.

“Standard” medications and “maintenance” fluids need to be verified and

monitored closely.


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Fluids, fluids, fluids…?


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Questions?