Morbidity and Mortality Conference

1. Morbidity and Mortality Conference Tim Gardner, MD December 12, 2001 A# 00228974-2

2. Outside Hospital Presentation History of Present Illness 56 y/o white female Diffuse abdominal pain at 7 pm Encouraged by her husband to present to the Emergency Room at 10:00 pm Patient refused – presumably secondary to her severe agoraphobia

3. Outside Hospital Presentation History of Present Illness (cont) Bloody Diarrhea at 4 am Lightheadedness and confusion No vomiting, fevers, chills, chest pain, palpitations or dyspnea Arrived at outside ED at 10:00 am

4. Outside Hospital Presentation Past Medical History 1. GENERALIZED ANXIETY DISORDER 1989 - Symptom onset s/p MVA 1995 - Admitted to DHMC following husband’s MI 2. SEVERE AGORAPHOBIA 2001 - Admitted to DHMC Patient homebound for six months prior to presentation 3. RECURRENT PANIC DISORDER 4. MAJOR DEPRESSIVE DISORDER

5. Outside Hospital Presentation Past Medical History (cont) 5. ASTHMA 6. CHRONIC BRONCHITIS/COPD 7. OSTEOPOROSIS 8. HYPOTHYROIDISM Past Surgical History 1. HYSTERECTOMY without oophorectomy 1994 secondary to endometriosis 2. CHOLECYSTECTOMY 1974 secondary to biliary colic

6. Outside Hospital Presentation Medications 1. Imipramine 100 mg po qhs 2. Quetiapine 50 mg po qam, noon, and 100 mg po qhs 3. Clonazepam 1 mg po qid 4. Levothyroxine 0.025 mg po qd 5. Trazadone 50-100 mg po qhs prn NKDA

7. Outside Hospital Presentation Family History MOTHER: ASCVD died at age 82 from “old age” FATHER: Alcoholism, Glucose Intolerance SISTER: “Nervous Ninny” CHILDREN: A+W Social History Married 38 years Former Cashier Two Children Social ETOH 11 Grandchildren 60 Pack Year Tobacco

8. Outside Hospital Presentation Physical Exam VITALS: Temp = 37.2 BP = 52/palp P = 108 RR = 20 PO 99% RA GEN: Anxious, alert, cooperative, in moderate distress SKIN: No rashes, purpura or other focal lesions HEENT: Conjunctival pallor, NP and OP clear, CVP = 7cm CHEST: Lungs CTAB, no wheezing noted CARD: Tachycardic, normal S1 and S2, no S3 or S4, no m/g/r ABD: Non-distended, RUQ cholecystectomy scar, no bowel sounds, diffusely tender in all quadrants, no rebound, no guarding, no masses RECTAL: Gross blood and mucous, tenderness in the posterior vault EXT: No edema, strength not tested NEURO: CN grossly intact, oriented x 1

9. Outside Hospital Presentation LABS 15 138 102 35 227 42 2.9 24 2.6 45 B49 S45 L4 M2 E0 B0 AMYLASE = 896 SG = 1.016 GL = 1+ BL = 2+ PR = 4+ URO = 0 NIT = 0 LE = Tr WBC = Tntc RBC = Tntc BAC = Num PTT = 28.9 PT = 12.6 INR = 1.05 FIBR = 391

10. Outside Hospital Presentation Abdominal and Pelvic CT Scan (SHOW)

11. Outside Hospital Presentation Hospital Course 10:25 am - Dopamine gtt started at 5mcg/kg/min 10:28 am - BP 60/palp Dopamine increased to 10 mcg/kg/min One unit PRBCs transfused 11:20 am - BP 60/palp Dopamine increased to 20 mcg/kg/min 11:25 am - Cefotetan 2 gm IV and Gentamicin 160 mg IV 12:15 pm - BP 62/palp Phenylephrine 60 mcg/min started 12:45 pm - BP 65/palp Patient intubated secondary to hypoxia 1:30 pm - Transported to DHMC via DHART Total 8 Units Crystalloid and 1 Unit PRBC

12. DHMCPresentation Physical Exam VITALS: Temp = 35.8 BP = 90/70 P = 91 RR = 16 GEN: Intubated and sedated SKIN: No focal lesions HEENT: Intact pupillary reflex, no conjunctival pallor, oro and nasopharynx clear, CVP = 7 cm CHEST: Course rhonchi on inspiration in bilateral lung bases, no wheezes CARD: Regular, normal S1 and S2, no S3 or S4, no m/g/r ABD: Mildly distended, no bowel sounds, no masses, no rebound, no guarding, liver and spleen non-palpable, left lower quadrant fullness EXT: No edema, warm bilaterally, 2+/2 DP and PT pulses bilaterally NEURO: Sedated, oculocephalic reflex intact

13. DHMC Presentation LABS 13 143 115 32 251 151 32 5.7 14 2.2 39 MG = 0.66 CA = 5.9 PO = 3.4 N58 B28 L8 M8 E0 B0 AG=14 PTT = 34 PT = 17.2 INR = 1.6 TT = 19 DD = 11260 FIBR = 247 TB = 1.3 DB = 1.2 AP = 92 AST = 1613 ALT = 1080 AMY = 463 LIP = 81 ALB = 2.1 ABG: PH = 7.05 PCO2 = 52 PO2 = 79 HCO3 = 14 L-Lactate = 6.3 Ammonia =12

14. DHMC Presentation Initial Problem List • Prolonged Hypotension • Metabolic and Respiratory Acidosis • Acute Transaminase Elevation • Acute Renal Failure - Oliguria • Calcified Heterogeneous Sigmoid Colon Mass • Acute Respiratory Failure • Multiple Band Forms • Coagulopathy

15. DHMC Presentation Emergent Bedside Colonoscopy • FINDINGS: • Ischemic Black Mucosa • Distal Descending Colon - 35 cm from anus • Hard, Immobile Fecalith at Site of Ischemia • Intermittent, Erythematous Patches of Ischemia • Sigmoid Colon - distal to the fecalith • Emergent Exploratory Laparotomy Recommended

16. DHMC Presentation Exploratory Laparotomy • FINDINGS: • Ileum and colon necrosis • 20 cm proximal to ileocecal valve --> 35 cm proximal to anus • Large 4x5 cm fecalith completely obstructing descending colon • Normal mucosa distal to fecalith • PROCEDURES: • Subtotal colectomy with resection of distal ileum • Ileostomy • Feeding jejunostomy feeding tube placement

17. DHMC Hospital Day #1 • Hospital Course: • Started on CVVHD • Maintained on Pressure Support • Ventilation • Started on IV Metronidazole and • IV Ciprofloxacin • Started on TPN MEDS: Metronidazole 500 mg IV q8 Ciprofloxacin 400 mg IV q12 Famotidine 20 mg IV bid Levothyroxine 0.012 mg qd Docusate 100 mg bid Heparin 5000 mg SQ bid Norepinephrine gtt Dopamine gtt Fentanyl gtt Midazolam gtt TPN LABS PTT = 43 PT = 20.1 TT = 17 INR = 2.1 FIBR = 306 DD = 6040 TB = 2.2 DB = 2.2 AP = 88 AST = 854 ALT = 810 ABG: PH = 7.29 PCO2 = 39 PO2 = 92 HCO3 = 16 14 12.5 129 40 144 113 40 4.9 15 2.8

18. DHMC Hospital Days #2-3 • Hospital Course: • PA Catheter placed • CVP = 19 PA = 53/34 CI = 4.3 SVR = 503 • Phenylephrine gtt started • Thrombocytopenia worsens • Heparin discontinued • Oliguria Resolving • Febrile to 39.0 degrees LABS PTT = 49 PT = 17.6 TT = 18 INR = 1.7 FIBR = 637 DD = 2925 TB = 4.3 DB = 3.6 AP = 297 AST = 88 ALT = 199 ABG: PH = 7.36 PCO2 = 46 PO2 = 86 HCO3 = 26 WBC = 15 HGB =11 PLT =32 CR = 2.3 Blood, Urine, Sputum Cultures = negative

19. DHMC Hospital Days #4-7 • Hospital Course: • PA catheter removed • CVVH discontinued - HD started • PAIG positive • Persistently febrile • Antibiotics discontinued • CT scan to evaluate abdomen LABS PTT = 35 PT = 14.3 INR = 1.2 TB = 9.3 DB = 8.0 AP = 351 AST = 95 ALT = 79 WBC =14.6 HGB = 9 PLT = 65 CR =5.3 Blood, Urine, Sputum Cultures = negative

20. DHMC Hospital Days #4-7 (cont) CT Scan (SHOW)

21. DHMC Hospital Days #8-14 • Hospital Course: • Vasopressors discontinued • Thrombocytopenia resolved • Psychiatric regimen restarted • Persistently febrile • Enterococcus in urine culture • Vancomycin and Gentamicin started LABS 138 100 48 TB = 20.0 DB = 16.0 AP = 647 AST = 188 ALT = 168 9 13.1 315 3.3 4.2 24 27

22. DHMC Hospital Days #15-28 • Hospital Course: • Extubated - Hospital Day #18 • Slowly resolving delirium • Intermittent fevers • Transferred to floor - Hospital Day #23 • Worsening hepatic function LABS TB = 42.6 DB = 32.9 AP = 755 AST = 322 ALT = 308 INR=5.6 141 105 33 9 11.5 245 3.2 3.7 24 27

23. Bilirubin Levels

24. Transaminase Levels

25. Hepatocyte Bilirubin Metabolism 1 • Hyperbilirubinemia: • Overproduction. • Impaired uptake, conjugation, or excretion. • Leakage from damaged hepatocytes. 5 2 3 4 Blood Bile 5

26. Indicators of Hepatocyte Injury • Serum Aminotransferases: • Intracellular enzymes. • Catalyze transfer of amino groups to ketoglutarate. • ALT: predominantly liver. • AST : liver>cardiac muscle> skeletal muscle> kidney. • Poor correlation with extent of hepatocellular necrosis. • Rapid fall with a rising bilirubin and prolonged PT is often associated with a poor prognosis.

27. Hepatic Failure DDX: Ischemic Injury - “Shock Liver” Hepatotoxic Drugs Cholestasis Genetic Liver Abnormality Hepatitis LABS Ferritin = >2000 HepBSAg = negative ANA = negative Iron = 72 HepBSAb = positive AMA = negative TIBC = 155 HepC = negative ASMA = negative

28. DHMC Hospital Days #29-36 • Hospital Course: • Hypotensive on floor - transferred to ICU • Persistent high fevers • Enterococcus Faecalis in blood • Meropenem started and Vancomycin continued • Worsening delirium • Worsening hepatic failure LABS TB = 56.0 DB = 43.5 AP = 1491 AST = 680 ALT = 646 INR=4.5 131 94 66 9 34.9 131 3.0 3.0 21 27

29. DHMC Hospital Day # 37 Hospital Course • Sudden hematemesis and hematochezia • Refractory hypotension to vasopressors • Bedside echocardiogram shows organizing pericardial clot • Patient becomes unresponsive • Patient made CMO by family • Patient dies peacefully at 4:00 pm • Permission for full autopsy granted

30. Ischemic colitis with necrosis

31. No evidence of thromboemboli or vasculitis

32. Uremic Pericarditis F G M • Diffuse granulation tissue (G) with surface fibrinous exudate (F) • No microscopic evidence for myocarditis or MI

33. Liver lobule architecture PORTAL TRACT ZONES 3 2 1 CENTRAL VEIN PORTAL TRACT PORTAL TRACT

34. Hepatic lobule overview PORTAL TRACT PORTAL TRACT PORTAL TRACT PORTAL TRACT PORTAL TRACT PORTAL TRACT CENTRAL VEIN (Trichrome stain) • Minimal congestion or fibrosis identified

35. Viral Hepatitis Autopsy portal tract, normal

36. ZONE 1 ZONE 2 ZONE 3 Portal-central area with centrilobular necrosis (Zone 3) Edge of Portal tract Edge of Central V.

37. Centrilobular necrosis (Zone 3)

38. Centrilobular necrosis (Zone 3)

39. The autopsy findings excluded... 1. Hepatotoxic drugs: No evidence for chronic drug damage such as fatty change, granulomas, eosinophils, fibrosis 2. Viral hepatitis: No evidence of acute or chronic portal tract inflammation, piecemeal necrosis, single cell necrosis (also negative serology) 3. Extrahepatic obstruction: No evidence of bile duct plugging, strictures, pancreatic obstruction, stones 4. Alcoholic hepatitis: No evidence of increased fibrosis, fatty change, acute inflammation, Mallory’s hyaline 5. Genetic liver abnormalities: No evidence of iron overload, alpha-1 antitrypsin bodies, copper deposition