Morbidity & Mortality Grand Rounds Hospitalist Program

Transcription

1 Morbidity & Mortality Grand Rounds Hospitalist Program September 11, 2017 Ashkan Etemadian, MD Health Science Assistant Professor Hospitalist Program University of California, Irvine

2 Upcoming M&M Dates Jan 9, 2018 Apr 10, 2018 May 29, 2018 If you have a case for our M&M conference please Omar Darwish, DO at odarwish@uci.edu 2 Hospitalist September 11, 2017

3 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 3 Hospitalist September 11, 2017

4 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. 4 Hospitalist September 11, 2017

5 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. 5 Hospitalist September 11, 2017

6 Admission Physical Exam and Labs Temp: 36.8 BP: 140/78 HR: 85 RR: 18 SpO 2 : 96% AST: 152, ALT 38, T. bili 6.0, Alk pho 173, T.prot 5.9, albumin 2.9 INR: 1.42 PTT Hospitalist September 11, 2017

7 Admission CXR 7 Hospitalist September 11, 2017

8 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? 8 Hospitalist September 11, 2017

9 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 Hospitalist September 11, 2017

10 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 10 Hospitalist September 11, 2017

11 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. 11 Hospitalist September 11, 2017

12 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. 12 Hospitalist September 11, 2017

13 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. 13 Hospitalist September 11, 2017

14 180 Lab Trends for Bili, AST, ALT Alk phos levels range from Albumin ranged from 2.7 to 3.0 during this period T. Bilirubin AST ALT 14 Hospitalist September 11, 2017

15 Platelets, WBC, Hg Trend Day 1 to INR: platelets WBC Hg 15 Hospitalist September 11, 2017

16 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. 16 Hospitalist September 11, 2017

17 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. 17 Hospitalist September 11, 2017

18 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 18 Hospitalist September 11, 2017

19 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 Hospitalist September 11, 2017

20 ECG 20 Hospitalist September 11, 2017

21 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. 21 Hospitalist September 11, 2017

22 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. 22 Hospitalist September 11, 2017

23 WBC and platelet trends Day 8 to INR reaches 3.83, PTT 113.5, Fibrinogen WBC platelets 23 Hospitalist September 11, 2017

24 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. 24 Hospitalist September 11, 2017

25 25 Hospitalist September 11, 2017

26 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? 26 Hospitalist September 11, 2017

27 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? 27 Hospitalist September 11, 2017

28 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. 28 Hospitalist September 11, 2017

29 Fluids, fluids, fluids? 29 Hospitalist September 11, 2017

30 30 Questions?