MORBIDITY AND MORTALITY CONFERENCE

2. MORBIDITY AND MORTALITY CONFERENCE Zalveen A. Chua MD Teresita Aquino MD Marivic Punzalan MD

3. General Data • J.A. • 23 years old • Male • Single • Filipino

4. Chief Complaint Decrease sensorium

5. History of Present Illness One Month PTA • Undocumented fever • Toothache • Underwent dental extraction (3 molars) • Given Mefenamic Acid 500mg for pain relief

6. History of Present Illness 20 days PTA (10 days post extraction) • Undocumented fever relieved with Paracetamol • (+)generalized body malaise, (+)chills • No cough, no colds, No dysuria noted • Consult was done given an unrecalled antibiotic

7. History of Present Illness Two weeks PTA (16 days post tooth extraction) • Persistence of fever • (+) headache (+) vomiting (+)nape pain • Consult done at and was advised admission • Admission was refused due to financial constraints

8. History of Present Illness 11 days PTA (19 days post extraction) • Persistence of Symptoms • Right sided body weakness • Decrease sensorium with incoherent speech • Consult was done and patient was admitted • Cranial CT scan done revealing a left temporal lobe abscess with mass effect

11. Past Medical History • (-) HPN • (-) DM • (-) Asthma

12. Family History Unremarkable

13. Personal and Social History • Occasional smoker • Occasional alcoholic beverage drinker • Fond of playing basketball (hx of trauma?) • Works as a “griller”

14. Physical Examination Patient is drowsy, oriented to 3 spheres not in respiratory distress Vital signs: BP: 110/70 HR 58 RR 22 T: 36.8 Skin: Good skin turgor, No visible lesions seen Head: Symmetrical, no palpable masses, no visible wounds Eye: Pink palpebral conjunctiva, anicteric sclerae Ear: No lesions, No discharge, ruptured tympanic membrane AS, hyperemic tympanic membrane AD Nose: No discharge, No alar flaring Throat: dry lips and buccal mucosa, no tonsillo-pharyngeal congestion

15. Physical Examination Chest and Lungs Symmetrical chest expansion, clear breath sounds CVS Adynamic precordium, No thrills, bradycardic, no murmurs

16. Physical Examination Abdomen Flat, Hypoactive bowel sounds, soft no tenderness Extremities Symmetrical, Full and equal pulses

17. Physical Examination Neurologic examination Patient is drowsy, with spontaneous eye movement, follows commands Cranial Nerves I: n/a VIII: intact II, III: pupils reactive IX,X (+) gag III, IV, VI: Full EOMs XII: tongue midline VII: shallow Right NLF

18. Physical Examination MOTOR RUL, RLL : 4/5 LUL, LLL:5/5 Sensory No sensory deficits

19. Physical Examination • DTR’s: ++ • (+) Brudzinski (+) Kernig’s sign

20. Salient Features • 23 year old • Male • s/p dental extraction • Undocumented fever • Headache • Vomiting • Nape Pain • Ruptured TM AS • Decrease sensorium • Right sided body weakness

21. Impression • Cerebral abscess L temporal lobe with Mass effect secondary to direct contiguous spread probably from dental infection vs t/c chronic otitis media AS

22. Course in the Wards Upon admission Patient referred to medicine for ID consult and clearance Diagnostics CBC Serum Na, K Chest X-ray PT, PTT Repeat cranial CT scan with IV contrast was suggested 12L ECG sinus bradycardia 54bpm NSSTWC

24. Initial Management Therapeutics Penicillin G 4 million units IV q 4 hours Metronidazole 500mg/tab q6 to be shifted to IV once on NPO Mannitol 100cc q 4 hours PNSS1L x 100cc/hr

25. Course in the Wards 1st HD • CBC Hgb 12.1 Hct 36 WBC 13240 seg 75 lym 11 • Na 134 K 2.6 • PT, PTT: Normal • Chest X-ray: No Significant Chest Findings • 12L ECG sinus bradycardia 37bpm with anteroseptal wall ischemia LVH by voltage

27. Course in the Wards 1st HD • Patient remained drowsy but coherent • Vital signs BP 110/80 HR 45 RR 20 T 36.6C • DAT • Seen by ID service with the ff suggestions • Referral to Cardiology • Referral to Dental Services

28. Course in the Wards 1st HD • K+ correction was started Kalium durule 4 durules x 2 doses KCL 30meq + PNSS 100cc x 8 hours • Acetylcysteine 600mg OD started • Repeat K and 12L ECG in AM

29. Course in the Wards 2nd HD • Patient seen by cardiology service with the ff assessment No evidence of active cardiac disease, hypokalemia probably nutritional with ongoing correction. Recommendation: No objection to contemplated surgery with low to intermediate risk if repeat K results are already acceptable

30. Course in then Wards 2nd HD • Noted to be more drowsy but arousable • Pupils 3 mm dilated ERTL • Mannitol 50 cc IV extra dose was given • Bricanyl drip 1 amp in D5W 250cc x 10cc/hr to attain a heart rate of at least 80bpm • Need for immediate surgery was contemplated pending CP clearance

31. Course in the Wards 3rd HD • Patient noted to be unresponsive and cyanotic • BP 0 CR 34 bpm • CPR started, Epinephrine 1 amp x 2 doses and NaHCO3 1amp x 1 dose given • Intubation done • Patient was revived

32. Course in the Wards 3rd HD • Due to poor prognosis and worsening condition, his father opted DNAR in case of another arrest

33. Course in the Wards 4th HD • Patient subsequently expired

34. General Approach to the Patient • The consultant must bear in mind that the perioperative evaluation may be the ideal opportunity to affect long-term treatment of a patient with significant cardiac disease • The referring physician and patient should be informed of the results of the evaluation and implications for the patient’s prognosis • The consultant can assist in planning for follow-up

35. Preoperative Clinical Evaluation • The initial history, physical examination and ECG should focus on identification of potentially serious cardiac disorders such as: coronary artery disease (prior MI and angina) heart failure symptomatic arrhythmias presence of pacemaker or implantable cardioverter defibrillator (ICD) history of orthostatic intolerance

36. Preoperative Clinical Evaluation • Define disease severity, stability and prior treatment • Factors that help determine cardiac risk: functional capacity age comorbid conditions (diabetes mellitus, peripheral vascular disease, renal dysfunction, and chronic pulmonary disease) • Type of surgery (vascular procedures and prolonged complicated thoracic, abdominal, head and neck procedures)

37. Preoperative Clinical Evaluation • Other risk indices: history of cerebrovascular disease preoperative elevated creatinine, >2mg/dl insulin treatment for diabetes mellitus high-risk surgery

38. Clinical Predictors of Increased Perioperative Cardiovascular Risk

39. Clinical Predictors of Increased Perioperative Cardiovascular Risk

41. Functional Capacity • Expressed in metabolic equivalent (MET) levels • Perioperative cardiac and long-term risks are increased in patients unable to meet a 4-MET demand during most normal daily activities

42. Functional Capacity

43. Surgery-Specific Risk • 2 Important factors: 1. the type of surgery 2. the degree of hemodynamic stress associated with the procedure

44. Management of Specific Preoperative Cardiovascular Conditions

45. Clinical Predictors of Increased Perioperative Cardiovascular Risk

46. Further Preoperative Testing to Assess Coronary Risk

50. Functional Capacity • Expressed in metabolic equivalent (MET) levels • Perioperative cardiac and long-term risks are increased in patients unable to meet a 4-MET demand during most normal daily activities