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Morbidity and Mortality Conference

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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  1. Morbidity and Mortality Conference Stephen K. Liu, M.D. February 27, 2002

  2. 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

  3. 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

  4. 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

  5. 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.

  6. 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

  7. 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

  8. 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

  9. 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

  10. 11/7

  11. 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

  12. 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

  13. 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

  14. 11/9

  15. 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

  16. 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

  17. Hospital Day 8 • A CT guided biopsy of the mediastinal mass was performed by interventional radiology • A trans-thoracic echo was performed

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

  19. 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

  20. 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%

  21. 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

  22. Platelet count 11/13 - heparin flushes and allopurinol d/c’d 11/20 - first dose of CHOP

  23. 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

  24. 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

  25. 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

  26. 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

  27. 12/20

  28. 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

  29. 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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