1 / 41

WINNING THE BATTLE

WINNING THE BATTLE. BUT LOSING THE WAR A Brief Case Presentation Michael Caselnova, M.D. GOALS. Case presentation Brief review of diagnoses encountered Lessons learned Recommendations to improve care. The Case . Day 0 67 y/o WM presented to another facility with: Abdominal pain

libitha
Download Presentation

WINNING THE BATTLE

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. WINNING THE BATTLE BUT LOSING THE WAR A Brief Case Presentation Michael Caselnova, M.D.

  2. GOALS • Case presentation • Brief review of diagnoses encountered • Lessons learned • Recommendations to improve care

  3. The Case • Day 0 • 67 y/o WM presented to another facility with: • Abdominal pain • Hypotension • Diaphoretic • “pale”

  4. ADDITIONAL FINDINGS • CT abdomen showed: • 7 cm AAA with large retroperitoneal hematoma • PMH significant for coronary stent

  5. The Problem? • NO Cardiothoracic surgeon available at the outlying facility • Decision made to transfer pt by air to our facility • Transfused during transport • Met by CT surgeon and anesthesiology on helipad and taken directly to OR

  6. FINDINGS ON ARRIVAL • SBP in 60-80 range • Cyanosis of abdomen and legs • No peripheral pulses • As he was being placed on table: • pH 6.8 • SBP unobtainable

  7. Procedure • “EMERGENCY LIFE SAVING REPAIR OF ABDOMINAL AORTIC ANEURYSM” • 18 mm straight dacron tube graft

  8. Findings at time of surgery • Large retroperitoneal hematoma, R>L • Compression of vena cava • Free intra abdominal blood • Coagulopathy • Hypothermia 33.8 degrees • ? Hepatic tumor on palpation • TEE showed good LV function • BP 120/70 post op

  9. Received • 15 units PRBC • 10 units FFP • 20 units cryoprecipitate • Platelets • TPN post op

  10. POD 1 Small mucoid bloody stools x 7 • POD 2 2 more bloody stools and abd pain • GI consult • CT read as 3.5-4 cm exophytic liver mass • Alk phos normal • Bili normal • AST 165

  11. Preliminary Dx • Ischemic colitis from profound hypotension • Needs CT w contrast but Azotemic • AFP requested (later came back normal)

  12. POD 4 • Neurology consult for weakness and numbness of lower extremities • Initial impression: • Either direct compression of lumbar plexus by retroperitoneal hematoma or • Cord ischemia due to hypotension • Prognosis good for recovery of function

  13. POD 5 • Colonoscopy: ischemic colitis in section of rectum and sigmoid and descending colon • No areas of circumferential ischemic colitis • No areas that looked like they wouldn’t heal • Rec: FEED

  14. POD 9 • Fever to 102.6 • Pulmonary consult • Atelectasis on CXR • WBC on POD 8 was 19.5 • Had been started on Moxi and Vanc • Blood Cult growing GNR • Moxi stopped and pip/tazo added

  15. POD 12 • BC growing Pseudomonas and Klebsiella pneumoniae • Urine C&S 2 GNR • Few candida from central line • ID consult- candida felt likely colonization BUT concern for graft so fluconazole rec for 2-4 wks • One culture pos for staph epi sens to all • Vanco stopped

  16. POD 18 • Discharged to ECF in outlying city • Fluconazole for 30 days po • Pip/tazo for one more week • BATTLE WON! • BUT…..

  17. POD 37 • Brought to ER with fever, nausea, vomiting abd pain • No dysuria • Few days of diarrhea but no hematochezia • CT: air and fluid in aortic lumen, surrounding the graft, and anterior to aorta at level of prox graft anastomosis consistent w infection/abscess formation • Abnormal area of low attenuation in liver- possible infarct/infection/can’t exclude mass

  18. Transfer to our facility • CT surgeon accepted pt- felt the air and fluid were expected findings post op • Hospitalist Consult requested • Afebrile on arrival • Pt was on oral cipro and augmentin • WBC 11K, Hgb 12.2, plt 127K, alb 1.9, alk phos 409, CXR w hazy opacity R either atelectasis or infiltrate, but improved from previous

  19. Cultured again • Pip/tazo and vanco • C dif neg • Gram pos cocci in 1of 2 BC from referring facility • RUQ tenderness • NO mention of hepatic mass in the DC summary

  20. RUQ sono-thickened GB wall and sludge • Amylase and lipase normal • Gen Surg consult • HIDA neg for acute cholecystitis and EF was 42%; decreased uptake R side of liver

  21. POD 44 • Renal function worsening BUN 49, Cr 2.9 • Plt 76K, WBC 15.8, INR 2.87 • Nephrology Consult-? Vanco, ? ATN, ? obstruction • Renal sono normal • Start CRRT dialysis • CT directed liver Bx done POD 41-results pending

  22. POD 45 • ID consult- ? Sepsis • Vanco continued but imipenem added • Transaminases increasing, ? Hepatorenal syndrome • Heme/onc consult for liver mass (path still pending) • Can’t treat malignancy due to overall condition

  23. POD 46 • CTA chest/abd/pelvis • Increasing R pleural effusion • Increasing ascites • Perigraft fluid w air, ? Infectious process • Decision made w family to change status to DNR

  24. POD 47 • Pt expired • Final Dx on liver Bx was primary malignant liver neoplasm-report signed on POD 54 • LOST THE WAR

  25. Abdominal Aortic Aneurysm • Diameter > 3.0 cm at level of renal arteries • Risk factors include age1,2, smoking3, male sex4, HTN5, family Hx1, atherosclerosis • Most are asymptomatic until rupture, but if symptoms are present (abd or back pain or tenderness on palpation) the risk for rupture is higher • Ruptured AAA typically presents with abd or back pain, hypotension, pulsatile abd mass

  26. AAA • Overall survival rate for ruptured AAA is 25%; 50% survive to reach hospital but 50% reaching hospital don’t survive6 • If BP is stable, the aneurysm rupture is temporarily contained

  27. ISCHEMIC COLITIS • Caused by reduction in intestinal blood flow, by occlusion, vasospasm, or hypoperfusion of mesenteric vessels • More common in elderly • Majority develop non-gangrenous ischemia and resolve w/o sequelae, but can develop stricture7 • 15% develop gangrene7 • Splenic flexure and rectosigmoid junction most vulnerable sites • Occurs in 1-7% of aortoiliac surgery8,9

  28. ISCHEMIC COLITIS • Findings include: • Abdominal pain and tenderness which is usually mild • Rectal bleeding or bloody diarrhea within 24 hrs of onset of pain • May develop ileus or proceed to severe gangrene with shock

  29. ISCHEMIC COLITISDX • CLINICAL SETTING • PHYSICAL EXAM • RADIOLOGIC • ENDOSCOPIC • NO SPECIFIC LAB FINDINGS • PLAIN FILMS USUALLY NON SPECIFIC • MRI/MRA NOT USEFUL • CT W CONTRAST OFTEN NONSPECIFIC • COLONOSCOPY WITHOUT PREP, MINIMAL AIR INSUFFLATION

  30. ISCHEMIC COLITIS TX • In absence of perforation or gangrene • Supportive care, bowel rest, IVF to maintain perfusion • Empiric broad spectrum Abx • NGT if ileus present • ? TPN

  31. ISCHEMIC COLITISTX • Surgical intervention if clinical worsening • Surgical intervention for colonic infarction • Generally surgery performed without prep

  32. PRIMARY HEPATOCELLULAR CARCINOMA • Usually develops in setting of chronic liver Disease • Often untreatable at time of Dx • Usually asymptomatic until late in course • Fever may develop with central tumor necrosis • Lab findings usually nonspecific • AFP not elevated in all cases- 40% are normal12 • Extrahepatic spread in 10-20% at time of Dx10, 11

  33. Primary hepatocellular carcinoma • Most common metastase are to lung, intraabdominal lymph nodes, bone, adrenal gland

  34. PRIMARY HEPATOCELLULAR CARCINOMA DX • Usually have underlying liver disease • Rising alpha fetoprotein (but not all tumors secrete AFP) • CT or MRI- dominant solid nodule, hypervascular, venous invasion with elevated AFP • Percutaneous Bx

  35. AAA POST OP • Hematoma present in all patients-usually resolves in 7-65 days in 82% of patients • Perigraft fluid resolves over 3 mos • Perigraft gas usually resolves in one week

  36. LESSONS LEARNED • INCLUDE IN DISCHARGE SUMMARY ANYTHING SIGNIFICANT WHICH NEEDS FOLLOW UP-SUBSEQUENT PROVIDERS WILL BE RELYING ON IT • REVIEW OTHER MEDICAL RECORDS WHEN RE ADMITTING PATIENT- PRIOR H&P, CONSULTS, RADIOLOGY, ETC

  37. LESSONS LEARNED • TRY TO GET CONSULTING HOSPITALIST TO DO DISCHARGE SUMMARY AND DEATH CERTIFICATE • JUST KIDDING!

  38. REFERENCES • 1. Hirsch, AT, Haskal, ZJ, Hertzer, NR, et al. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease Circulation 2006; 113:e463 • 2. Singh, K, Bonaa, KH, Jacobsen, BK, et al. Prevalence of and risk factors for abdominal aortic aneurysms in a population-based study : The Tromso Study. Am J epidemiol 2001; 154:236 • 3. Powell, JT, Greenhalgh, RM. Clinical Practice. Small abdominal aortic aneurysms. N Engl J Med 2003; 348: 1895 • 4. Singh, K, Bonaa, KH, Jacobsen, BK, et al. Prevalence of and Risk Factors for abdominal aortic aneurysms in a population-based study. Am J Epidemiol 2001; 154: 236 • 5. Lederle, FA, Johnson, GR, Wilson, SE, et al. Prevalence and associations of abdominal aortic aneurysm through screening. Aneurysm Detection and Management Veterans Affairs Cooperatice Sdtudy Group. Ann Intern Med 1997; 126: 441

  39. REFERENCES • 6. Thomas, PR, Stewart, RD. Abdominal aortic aneurysm. Br J Surg 1988; 75: 733 • 7. Greenwald, DA, Brandt, LJ. Colonic ischemia. J Clin Gastroenterol 1998; 27: 122 • 8. Hagihara, PF, Ernst, CB, Griffen WO, Jr. Incidence of ischemic colitis following abdominal aortic reconstruction. Surg Gynecol Obstret 1979; 149: 571 • 9. Brewster, DC, Franklin, DP, Cambria, RP, et al. Intestinal ischemia complicating abdominal aortic surgery. Surgery, 1991; 109:447 • 10. Kew, MC, Dos Santos, HA, Sherlock, S. Diagnosis of primary cancer of the liver. Br Med J 1971; 4: 408 • 11. Yoon,KT, Kim, JK, Kin do, Y, et al. Role of 18F-fluorodeoxyglucose positron emission tomography in detecting extrahepatic metastasis in pretreatment staging of hepatocellular carcinoma. Oncology 2007; 72 Suppl 1:104

  40. References • 12. Chen, DS, Sung, JL, Sheu, JC, et al. Serum alpha-fetoprotein in the early stage of human hepatocellular carcinoma. Gastroenterology 1984; 86: 1404

  41. ?

More Related