Transcript Ileostomy - VCU Department of Surgery

VCU
DEATH AND COMPLICATIONS
CONFERENCE
Brief Overview of Case
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S/p ileostomy takedown, crohn’s disease
Fungemia, sepsis, MI, death
Introduction for Every Case
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Complication
 Fungemia,
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Procedure
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sepsis, MI, death
Ileostomy takedown
Primary Diagnosis
 Hx
crohn’s disease s/p bowel resection,
takedown of EC fistula and end ileostomy
Clinical History
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HPI
 22
yo man with crohn’s disease s/p small
bowel resection with ileostomy for SBO,
complicated with EC fistula, high output
ileostomy, takedown of fistula, multiple
hospitalizations for management of
dehydration.
 During last hospitalization for
dehydration 1/27, he was resuscitated
and decision made for takedown
ileostomy
PMHX
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Past Medical
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Past Surgical
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Crohn’s
HTN
Coronary artery aneursym (right main and LAD) diagnosed
10/2012 no cardiology follow-up
As stated previously, in addition multiple PICC lines, last placed
prior to 1/27 admission for IV hydration and TPN.
Pertinent medications: carvedilol, percocet, dilaudid
Social hx: smoker, marijuana use, occasional ETOH
Timeline of Key Events
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Pod 1 – uneventful, HR high 90s
Pod 2 – HR low 100, febrile in the evening, cultures
sent
Pod3
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Febrile, tachycardic 109-120, low sbp transiently in late morning,
Yeast in blood cx in the afternoon, fluconazole started
Pod4
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RRT for hypotension and tachycardia, bolus given, fluconazole continued,
TPN and PICC in place
Oxygenation 99-100% RA
Team saw patient on rounds, continued resuscitation, ID consulted,
micafungin started
Increasing tachycardia, tachypnea, ekg obtained, cardiology cs for st
depression, echo performed
2/2/13
2/4/13 36 hours later
POD 4 continued
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Labs sent including enzymes: Troponin 7
ECHO: Left ventricular systolic function is mildly
reduced. EF 45%. There is severe apical wall
hypokinesis.
Ct PE obtained
Transfer to ICU, on arrival went to PEA, report of 6
second seizure activity by code team
ACLS protocol, pressors started, cardiac arrest x3
thereafter, pronounced at 1:35pm
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Review Protections, O.C.G.A. 31-7-130 et seq. and 31-7-140 et
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Analysis of Complication
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Was the complication potentially avoidable?
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Would avoiding the complication change the outcome
for the patient?
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Yes
Yes, sepsis from fungemia, ?role of his coronary artery aneurysm
and death
What factors contributed the complication?
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Timing of initiation of antifungal
Keeping the potential source of infection in place, continuing TPN
through it
Inadequate communication and hand-off
Lack of timely escalation of care
Possibly change of line upon recent admission
? Role of coronary artery aneurysm
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“The clinical courses of patients with coronary artery aneurysms usually
depend on the severity of the associated atherosclerotic stenoses. Even in
the absence of stenosis, abnormal flow patterns within the aneurysm may
lead to thrombus formation with subsequent vessel occlusion, distal
thromboembolization, or myocardial infarction”
Fungemia
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Eur J Clin Microbiol Infect Dis 2007, retrospective
study to ID risk factors
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ICU patients 3000 pts, 2 major risk factors recent Abx, central line
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Minor: TPN, immunosuppresion, steroid use, pancreatitis, operation in
preceeding week.
Timing of therapy
Garey et, al. Clin Infect Dis 2006
 Retrospective multicenter study, 230 pts fluconazole
 15.4% mortality with same day therapy as blood cx
 23.7% if therapy was started on day 1, 36.4% on day 2,
and 41.4% if it was started day 3 (P = .0009)
 Multivariate analysis revealed increasing mortality with
delay in therapy
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UPDATE
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Cardiovascular
Heart (395 grams)
-Concentric thickening and luminal narrowing of left anterior descending and
right coronary arteries.
-Mild left ventricular hypertrophy.
Small and large bowels
-Multiple intact anastomotic sites.
-Focal dusky and congested appearance.
-No evidence of bowel perforation, necrosis.
-Severe diffuse adhesions throughout abdominal cavity.
-Focal right abdominal wall discoloration underlying ileostomy site.
Immediate Cause of Death:
1. Septicemia
2. Pulmonary Edema
References
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Ostrosky-Zeichner L., Sable C., Sobel J., et
al: Multicenter retrospective development and
validation of a clinical prediction rule for
nosocomial invasive candidiasis in the intensive care
setting. Eur J Clin Microbiol Infect Dis 26. (4): 271276.2007
Garey K.W., Rege M., Pai M.P., et al: Time to
initiation of fluconazole therapy impacts mortality in
patients with candidemia: a multi-institutional
study. Clin Infect Dis 43. (1): 25-31.2006
Sellke: Sabiston and Spencer's Surgery of the Chest,
8th ed.