Morbidity and mortality conference
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Morbidity and Mortality Conference. Stephen K. Liu, M.D. February 27, 2002. Initial Presentation - Feb 2001. A 76 y/o male presented to his physician’s assistant at the VA Medical Center in WRJ with a chief complaint of a dry cough for several months. Initial Presentation.

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Morbidity and Mortality Conference

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Morbidity and mortality conference

Morbidity and Mortality Conference

Stephen K. Liu, M.D.

February 27, 2002


Initial presentation feb 2001

Initial Presentation - Feb 2001

  • A 76 y/o male presented to his physician’s assistant at the VA Medical Center in WRJ with a chief complaint of a dry cough for several months


Initial presentation

Initial Presentation

  • The pt believed that the cough improved after getting a course of amoxicillin for a dental infection

    • ROS: negative for fever, chills, night sweats, shortness of breath, or weight loss

    • PE: decreased breath sounds at the right base

    • CXR: bilateral (R>L) pleural effusions

  • Followup was difficult


History

History

  • Two months later-

    • CT scan (without contrast) : large left mediastinal mass encasing the aorta

  • Over the ensuing months, the pt canceled multiple follow-up appointments, an enhanced CT scan, and a planned diagnostic thoracentesis.

    • It was difficult to reach him by phone

    • Letters were sent regarding his results


History1

History

  • Pt had avoided further work-up and treatment of his pleural effusions for the past nine months due to anxiety, denial, the recent death of his ex-wife, and a desire to try herbal remedies first.


Presentation to the drop in clinic november 2001

Presentation to the Drop-In Clinic - November 2001

  • On presentation, the patient was significantly SOB with minimal effort, including talking

  • The patient agreed to admission for a diagnostic and therapeutic thoracentesis

  • Advance directives: full-code


History2

Past Medical History

HTN

Basal Cell Carcinoma

DJD

Medications

None

ALL: Erythromycin

SocHx:

Quit smoking over 50 yrs ago, no alcohol misuse

Six children

Retired insurance agent

Previously enjoyed racquetball and rowing.

FHx:

father - lung CA

brother - prostate CA

History


Physical exam

Physical Exam

Gen: Somnolent but arousable, ill appearing, cachectic

VS: T 97.5 BP 150/84 HR 86 RR 30

SpO2 85% RA 96% 4L NC

HEENT: PERRL, EOMI, OP-dry MM, no erythema

Neck:Supple, no LAD, JVP < 5 cm

CV:RRR, no S3 or S4

Resp:Decreased BS L>R, dull to percussion 2/3 up lung fields, minimal air movement in apices , decreased tactile fremitus at both bases

Abd: ND, +BS, Soft, NT, no palpable masses or HSM, no palpable inguinal LN

Ext: No edema, no palpable axillary adenopathy

Neuro: Arousable with some difficulty, oriented to date but not to place


Laboratory data

Ca- 9.7

T.Bili - 0.7

Alk Phos - 52

AST - 34

ALT - 30

GGT - 38

Laboratory Data

14.4

8.5 252

41.8

89%Gran 7%lymphs 3%monos

0.1%eos 0.1% baso

130 90 23

119

4.5 32 0.7

ABG 7.255/84/82.5

PT - 12.8

INR - 1.0

PTT - 49.2


Morbidity and mortality conference

11/7


Admission to wrj vamc

Admission to WRJ VAMC

  • Thoracentesis performed

  • Pleural Fluid Analysis:

    • pH 7.350

    • Glucose 120

    • LDH 131

    • Protein 3.8

    • RBC 5800

    • Nucleated Cells 450

      • 10% segs

      • 22% macrophages

      • 5% mesothelial

      • 63% lymphs

Gram Stain:

1+ WBC

No orgs


Hospital day 3

Hospital Day 3

  • Patient awoke with dyspnea and tachypnea

    • Increased O2 requirements

    • ABG 7.18/104/79/29

    • CXR showed an increased effusion on the left without a pneumothorax and the persistent effusion on the right

  • Transfer to the MICU

  • Therapeutic left thoracentesis performed at the bedside


Hospital day 31

Hospital Day 3

  • Increased somnolence, then became unarousable

  • Emergently intubated

  • Propofol gtt begun

  • Chest tube inserted on the right

  • 2-3L of pleural fluid filled the Pleura-Vac in minutes before the chest tube was clamped

  • Pt became hypotensive and tachycardic requiring a dopamine gtt to maintain pressures


Morbidity and mortality conference

11/9


Hospital day 4

Hospital Day 4

  • Pt remained hypotensive and on dopamine

  • The blood pressure was extremely sensitive to propofol

  • Additional labs returned

    • LDH 170

    • uric acid 2.5

    • albumin 1.9

  • Swan placed :

    • RA 25/16 RV 49/15 PA 44/17 PAOP 20

    • CO 4.4 CI 2.3 SVR 1417

      • Dopamine gtt - 6


Hospital days 5 7

Hospital Days 5-7

  • Pt continued to require numerous fluid boluses in addition to maintenance IVF to maintain Urine OP and BP

  • Left sided pigtail catheter placed

  • CT of the chest/abd/pelvis obtained

  • Platelets begin trending down to 70 - all non-essential meds including heparin flushes discontinued


Hospital day 8

Hospital Day 8

  • A CT guided biopsy of the mediastinal mass was performed by interventional radiology

  • A trans-thoracic echo was performed


Morbidity and mortality conference

Homogeneous population of lymphocytes with a scant to moderate amount of vacuolated cytoplasm.


Morbidity and mortality conference

Poorly cohesive small lymphocytes with irreg. hyperchromatic nuclei, some with eosinophilic cytoplasm; rare plasma cells.

By flow cytometry:

Monoclonal kappa light chain, CD19+, CD20+, slight CD23, CD10-, CD5-. C/w B-cell lymphoprolif. disorder.

Diagnosis: B-cell lymphoma


Hospital days 9 14

Hospital Days 9 - 14

  • Extubated, then re-intubated after only two hours for respiratory failure

  • Extubated again two days later

  • Both chest tubes drained a liter of fluid/day

  • Massive anasarca

  • Platelets began to rise

  • First round of CHOP given at 67%


Hospital days 15 19

Hospital Days 15-19

  • Pt developed rigors

  • Pleural fluid sent for culture

    • Initial Gram stain showed GPC/GNR

    • Started on pip/tazo

    • Culture grew out coag neg Staph and Providencia rettgeri

  • Pt re-intubated for worsening respiratory status

    • Etiology thought to be due to failure of the left chest tube

  • Platelets fell to a low of 36


Platelet count

Platelet count

11/13 - heparin flushes and allopurinol d/c’d

11/20 - first dose of CHOP


Hospital days 20 29

Hospital Days 20-29

  • Extubated, given platelet transfusions, and pressors weaned off

  • Repeat echo showed improved hemodynamics

    • s/p one cycle of CHOP

  • Chest tubes continued to drain a liter of fluid a day

    • Pleurodesis planned when drainage decreased


Hospital days 30 35

Hospital Days 30-35

  • G-tube placed by interventional radiology

  • Platelets began to rise again

    • trial of heparin

    • CT drainage down to 60 cc on the left and 430 cc on the right

    • planned pleurodesis canceled as the drainage was greater than 50 cc/24hr


Hospital days 36 43

Hospital Days 36-43

  • Chest tubes continued to have minimal drainage bilaterally

    • left chest tube pulled, right side remained on water seal

  • Second cycle of CHOP given

  • Pt pulled out G-tube during the night

    • Re-inserted at the bedside, tube feeds held


Hospital day 44

Hospital Day 44

  • Pt developed a worsening lung exam

    • ABG 7.1/146/64.6

  • Pt once again agreed to re-intubation

  • A portable CXR was obtained post-intubation


Morbidity and mortality conference

12/20


Hospital day 45

Hospital Day 45

  • Patient decided to be DNR

    • Self extubated overnight

  • Three hours after extubation, the patient told the nurses that he wanted to die

  • Withdrawal of support


Issues discussed

Issues Discussed

  • Patient decision making and the role of physicians

  • Management of pleural effusions

  • Re-expansion pulmonary edema

  • Lymphoma and CHOP

  • Thrombocytopenia

  • Volume status, hypoalbuminemia, and nutrition


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