Morbidity and Mortality Morbidity and Mortality RoundsRounds

Dr. Shounak DasDr. Shounak DasJuly 27, 2007July 27, 2007

HistoryHistoryHPIHPI: :

• 53 y.o. Hispanic female admitted through the ER 53 y.o. Hispanic female admitted through the ER with fever + hypotensionwith fever + hypotension

• h/o diabetes, morbid obesity, CAD 8 years s/p h/o diabetes, morbid obesity, CAD 8 years s/p CABG complicated by CVA with residual CABG complicated by CVA with residual hemiplegia hemiplegia

• 1 month PTA admitted with PE1 month PTA admitted with PE• PPM placed 3 weeks PTAPPM placed 3 weeks PTA• 1 day PTA developed chills, nausea, vomiting1 day PTA developed chills, nausea, vomiting

HistoryHistoryPMHPMH: :

• diabetesdiabetes• CADCAD• CVACVA• dyslipidemiadyslipidemia

PSHPSH: : • CABGCABG• R knee surgeryR knee surgery• lap cholylap choly

• hypertensionhypertension• morbid obesitymorbid obesity• pulmonary emboluspulmonary embolus

• PPM placementPPM placement• IVC filterIVC filter

HistoryHistory

meds meds (home)(home)::

• aspirin 81 mg dailyaspirin 81 mg daily• lisinopril 10 mg dailylisinopril 10 mg daily• actos 45 mg dailyactos 45 mg daily• 70/30 insulin 20 units bid70/30 insulin 20 units bid• toprol XL 50 mg dailytoprol XL 50 mg daily

allergiesallergies::

• NKDANKDA

HistoryHistoryFHFH::

• +ve for diabetes + hypertension+ve for diabetes + hypertension

SHSH::• marriedmarried• non-smoker; no EtOHnon-smoker; no EtOH

HistoryHistory

ROSROS:: • denies chest pain or palpitationsdenies chest pain or palpitations• no coughno cough• denies abdominal pain or recent change in denies abdominal pain or recent change in

bowel habitsbowel habits• denies dysuriadenies dysuria• weight gain is notedweight gain is noted• she complains of slight headacheshe complains of slight headache

Physical ExamPhysical Exam

Vital signsVital signs::• HR: 88 (reg) RR: 24 HR: 88 (reg) RR: 24 • BP: 80/51BP: 80/51 TT°: 103.4°: 103.4HEENTHEENT::• PERRLA/EOMI/anicteric/oropharynx normal/no PERRLA/EOMI/anicteric/oropharynx normal/no

lymphadenopathylymphadenopathyChestChest::• clear to auscultation bilaterally/mild inflammation clear to auscultation bilaterally/mild inflammation

around pacemaker pocket; no fluctuance/drainagearound pacemaker pocket; no fluctuance/drainage

GeneralGeneral:: • ill-looking obese patientill-looking obese patient

Physical ExamPhysical ExamCVSCVS::• RRR/NL SRRR/NL S11 + S + S22/no extra sounds, rubs, or murmurs/no extra sounds, rubs, or murmurs

AbdoAbdo::• Nl bowel sounds/ soft, non-tender/no hepatosplenomegalyNl bowel sounds/ soft, non-tender/no hepatosplenomegalyNeuroNeuro::• CN II-XII intact/R-sided weakness (U>L)CN II-XII intact/R-sided weakness (U>L)ExtremitiesExtremities::• +1 bilateral ankle edema+1 bilateral ankle edemaSkinSkin::• no rashesno rashes

LabsLabs

10.910.9

32.432.414.114.1 106106

1321323.03.0 1616

107107 37371.61.6 194194

CaCa2+2+: 6.3 7.6: 6.3 7.6corrcorr

MgMg2+2+: 0.8: 0.8TP: 5.3TP: 5.3Alb: 2.4Alb: 2.4

AST: 27AST: 27ALT: 13ALT: 13Alk Phos: 85Alk Phos: 85T bili: 0.9T bili: 0.9

INR: 1.3INR: 1.3fibrinogen: 309fibrinogen: 309CRP: 11CRP: 11

60%N60%N16%L16%L12%M12%M11%B11%B

AG = 9AG = 9

LabsLabs CXR: low volumes; no infiltrateCXR: low volumes; no infiltrate u/a: 25 WBC/hpfu/a: 25 WBC/hpf blood cultures: 2/2 +ve for MSSAblood cultures: 2/2 +ve for MSSA TEE: RA lead – 2-3 mm mobile TEE: RA lead – 2-3 mm mobile

vegetation/thrombusvegetation/thrombus

• started on IV vancomycin initially, then switched to started on IV vancomycin initially, then switched to nafcillin once sensitivities confirmednafcillin once sensitivities confirmed

• started on pressorsstarted on pressors• intubated hospital day #2 intubated hospital day #2 • started on CVVHD hospital day #8 for ARFstarted on CVVHD hospital day #8 for ARF• pacemaker removed hospital day #11pacemaker removed hospital day #11• MOF; persistent hypotension despite maximal MOF; persistent hypotension despite maximal

pressorspressors• withdrawal of care hospital day # 15withdrawal of care hospital day # 15

Course in HospitalCourse in Hospital

Pacemaker InfectionsPacemaker Infections incidence roughly 5%incidence roughly 5% 90% of these are “pocket infections”90% of these are “pocket infections” remaining are “deeper infections” i.e. “device –remaining are “deeper infections” i.e. “device –

related endocarditis”related endocarditis” risk factors: diabetes, recent manipulation of risk factors: diabetes, recent manipulation of

device, temporary pacersdevice, temporary pacers 90% caused by s. epidermis or s. aureus90% caused by s. epidermis or s. aureus 1/31/3rdrd “early” (3-6 mos.); 2/3rds “late” (after 3-6 “early” (3-6 mos.); 2/3rds “late” (after 3-6

mos.)mos.) lead removal recommended for device-related lead removal recommended for device-related

endocarditisendocarditis