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M&M Conference Department of Medicine

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  1. M&M ConferenceDepartment of Medicine Maureen C. Nash, M.S., M.D. April 10, 2002

  2. 45 y/o diabetic female s/p recent MVR/CABG presenting with weakness and SOB • 28 days post-op sent to ED by VNA • Global fatigue • Progressive SOB / DOE requiring home oxygen • Nausea with decreased PO intake • Orthopnea and LE edema • Denied CP, fevers, PND, cough, abd pain • Chronic anticoagulation with last INR 3.9 eight days earlier • FSBG 400s • Approx 7# wt gain over one week

  3. 45 y/o diabetic female s/p MVR/CABG presenting with weakness and SOBPrior hospitalization: • Discharged from the hospital 8 days earlier • Initially presented to outside ED with DKA 12/24 • EKG with inferior and anterolateral changes • Asystolic arrest with emergent transfer to DHMC intubated on dopamine/norepinephrine • DHMC cath with LCX dominant 100% blocked->stented open, IABP placed • 12/25 echo LVEF 25-30%, 1+MR and multiple WMAs

  4. 45 y/o diabetic female s/p MVR/CABG presenting with weakness and SOBPrior hospitalization continued: • Transferred to Brigham & Women’s for possible LV Assist Device +/- heart transplant 12/25 • Cardiogenic and septic shock: • Lines changed, IABP/pressors continued • Vancomycin, cefotaxime and metronidazole • Clinical improvement then recurent DKA • ARF • Shock liver • ? new CVA

  5. 45 y/o diabetic female s/p MVR/CABG presenting with weakness and SOBPrior hospitalization continued: • Transfer back to DHMC 12 days later (1/4) • Progressive dyspnea • Repeat echo 4+MR, EF 40% • Repeat cath showed LCX prox 60-70% and LAD prox and mid 60% • S/P CABG x 2 and MVR 1/23/02 (DHMC HD#19) • Post op: renal insufficiency, respiratory insufficiency, and biventricular failure • D/C’d 2/14 (HD#52/POD#21) with home VNA

  6. Little regular medical care until 6 months PTA Cigarette use: 1ppd Type I DM x 20+ yrs Retinopathy DKA six months earlier HgbA1C 10.7 1985 admission for DKA, pneumonia, pancreatitis and alcohol abuse S/P C-section and tubal ligation Other PMH:

  7. Medications on admission • ASA 81mg po qd • warfarin n 2.5mg po qd with INR goal 3-3.5 • ramipril 1.25mg po bid • carvedilol 3.125mg po bid • aldactone 25mg po qd • digoxin 0.25mg po qd • metoclopramide 10mg po bid • omeprazole 20 mg po qd • NTG 0.4mg SL prn • insulin lispro 10u sq qam, Lantus 28u sq qhs • Trazadone 25mg po qhs prn

  8. Social History: Lives with significant other Quit tobacco with recent MI 2 months ago No alcohol or DOA 4 children Family History: Father with DM Brother with DM No ASCVD Allergies: NKDA

  9. Exam • T 36.7 HR 86 RR 20 BP 104/65 O2sat 87% (RA) • Gen: Pleasant, NAD • Neck: +JVD, no bruits • Lungs: decreased at bases, egophony • CV: RRR, audible click at S1, scar healing s SOI • Abd: +BS soft, NTND • Ext: left calf tenderness, no palpable cord, distal pulses diminished bilateral but symmetric • Skin: cool, 1+ pitting edema to ankle, small eschar on left calf

  10. Labs • WBC: 12.7 (78n 0b) INR: 3.1 AP: 1064 • H/H: 11.5/39.9 Tb: 0.6 Db: 0.3 • PLT: 381,000 AST/ALT: 14/20 • 140 | 102 | 19 / 224 Alb: 3.1 • 4.0 | 26 | 0.9 \ • CK: 32 Trop: 0.14 (at dc 1.59) • ECG: low voltage QRS, 1st deg AVB, no acute ST-T changes • CXR: bilateral pleural effusions

  11. EKG

  12. Hospital day 1-2 • S/P bilateral pigtail catheters • Titrate ACE inhibitor and spironolactone • Continue carvedilol continued at current dose • WBC inc to 14, INR inc to 5.7 • DC planning begun

  13. Hospital day 3-4 • Pigtail catheters discontinued • Increasing O2 requirement to 50% FM • Lung exam: dec BS bilateral bases, JVP to ears • Echo: RV “not severely compromised” • d/c carvedilol and ramipril for diuresis • CXR – reaccumulation of right effusion • WBC to 29.1 with 21 bands then to 34.1; INR 7.3 • Declining UO despite aggressive diuresis attempts • New RUQ respirophasic abd pain • LFT’s wnl except Alk Phos 569 • RUQ U/S: • Loculated rt pleural effusion • Cholelithiasis without evidence of acute cholecystitis • GB polyp versus adherent gallstone

  14. Hospital day 5-6 • Pt remained stable on 50% FM, continued RUQ pain, post-prandial emesis, anorexia • Afeb, WBC 35.5, INR 2.2, Cr 1.4, LDH 179 • Bilateral pigtails replaced by IR • Fluid c/w transudate • Gram stain with WBC, no organisms • Consider catheterization • Obtain CT C/A/P

  15. Hospital day 7-8 • Cont RUQ pain, N/V • Trial metoclopramide • Continued pigtail drainage bilaterally • No CP/SOB or fevers • WBC 18.7 • Cr increasing 1.5 to 2.5 to 3.1 with falling UOP • Hgb falls from 11.0 to 8.2 to 7.7 • Pt transfused • Abnormal LFT’s- GGT =241, LDH=176, tbili and Dbili wnl, albumin = 2.1

  16. Hospital day 9 • “Depressed…frustrated with progress…lethargic, amotivational, apathetic” • sertraline 25mg qd • Decreased O2 requirement • pigtail catheters removed • WBC 43.6 but remains afebrile - likely reactive. Blood culture x 2 ordered • ARF stabilizing with Cr 3.2 • Less RUQ pain/N/V • Cardiac condition stable • Presumed UTI – start ciprofloxacin

  17. Hospital day 10 • SBP in 70’s • Hypoxia - O2sat 80’s on 50% FM • Nausea and dry heaves x hours • WBC 52.3 (76n 11b) occasional dohle body, +toxic granulations • Urine cx - klebsiella • Minimal UOP, Cr 3.9 • EXAM: JVP to angle of jaw, +Kussmaul’s, +HJR, dec BS bilat except at apices, ?right sided S4

  18. CCU Transfer • Alert, diaphoretic, toxic appearing • JVP 10cm, dim BS bil, Abd quiet, soft, +BS • Liver- large, tender • Ext cool/clammy • Intubated for airway protection • PA cath: • CVP 13 RV 43/5 PA 38/22 PWP 15 • CI 3.1 SVR 600

  19. CCU day 2 • 1of 4 blood cultures positive Gram + Bacilli • Hgb 7.8, hemolysis w/u and transfusion • UOP 10-40 cc/hr, Cr 3.1 • Albumin 1.2, Ca and Mg low • CO/CI: 4.6/2.6 CVP: 14 PWP 24 SVR 840 • LFT: Tb 0.8 Db 0.6 AP: 437 AST 10 ALT 9 Lipase 5 • ABG: 7.42/34/89 on 60% • Pulmonary Consult: • Loculated rt effusion – consider guided thoracentesis • If cx neg, consider steoids for post-pericardiotomy syndrome • Renal Consult: • Nonoliguric ARF now volume overload, trial lasix gtt • ID Consult: • Multiple possible sources • Tap effusion, cont cipro, pip/tazo, vanco x 1 • Consider repeat CT C/A/P

  20. Hospital day 12-13 • Blood cx: GPC in clusters • Diagnostic thoracentesis • GPC in clusters  methicillin sensitive staph aureus • Repeat RUQ U/S: • Distended GB, GB wall thickened (4mm) • Small stones with sludge • Trace pericholecystic fluid • CBD minimally enlarged (6mm)

  21. Randomized trial of insulin-glucose infusion followed by subcutaneous insulin treatment in diabetic patients with acute myocardial infarction (DIGAMI study): Effects on mortality at 1 yearMalmberg K, et al. J Am Coll Cardiol 1995;26:57-65

  22. Impact of diabetes on mortality after the first myocardial infarction Miettinen H, et al. Diabetes Care 1998;21(1):69-75.

  23. Hospital day 12-13 cont: • Gen Surgery consult: • Acute cholecystitis • S/P lap chole: findings-old blood and clot in colonic gutter, GB inflamed with 2-3 areas of greenish-black discoloration, stone impacted in cystic duct, liver tip down to anterior iliac crest • U/S guided thoracentesis: • Orange, cloudy fluid, 23K wbc, pH 6.67 • Gram stain: many wbc, many GPC clusters • CT surgery consult: • Empyema • S/P thoracotomy with decortication • 1200 cc pus removed, excellent decortication of lung with good reexpansion

  24. Hospital day 14-16 • Continued pressor requirements • Low SVR c/w septic shock • Renal function improved • Improved pulmonary status • Minimal vent support, extubation considered • Abx continued (nafcillin/cipro/metronidazole) • WBC continued 40-50’s • Increasing bilirubin: Tbili 6.4, Dbili 5.5 • ?Residual SIRS vs left chest undrained vs ?prosthetic valve endocarditis vs medication side effects

  25. Hospital day 17-20 • Progressive metabolic acidosis • Increasing pressor requirements • Urine cx: non-candida yeast • LFT’s worsening, abd fluid tapped • TEE neg for vegetations • Cr below 2.0 but continued weight gain presumably due to third spacing • Day 17 ABG 7.27/35/96 • Day 19 ABG 7.21/44/82 • Day 20 ABG 7.22/41/77 • Abx changed to meropenem and amphotericin • DNR written after much family discussion

  26. Hospital day 21 • Clinical condition continuing to deteriorate • Family decision to withdraw support • Extubated and pressors discontinued: • HR to 20’s in 15s, asystole at 90s • Agonal respirations end 3 minutes later • Permission for autopsy granted