Transcript Medical ICU Morbidity and Mortality

Department of Medicine
Quality Program
Medical ICU
Morbidity and Mortality Conference
Fatma Hammad, MD
Guru Kowlgi, MBBS
June 5 2014
This material is confidential and is utilized as defined in Connecticut State statute 19a-17b Section(4) for evaluating
and improving the quality of health care rendered
Morbidity & Mortality Conference
It is for the department faculty and residents to
peer review case(s) from the inpatient service.
The primary objective is to improve overall
patient care focusing on quality of care delivered,
performance improvement, patient safety and risk
management.
This material is confidential and is utilized as defined in Connecticut State statute 19a-17b Section(4)
for evaluating and improving the quality of health care rendered
Morbidity & Mortality Conference
“I do not want to make the wrong mistake”
- Yogi Berra
Translate all error into education
This material is confidential and is utilized as defined in Connecticut State statute 19a-17b Section(4)
for evaluating and improving the quality of health care rendered
Morbidity & Mortality Conference
Errors are due to:
Processes – 80%
People – 20%
Translate all error into education
This material is confidential and is utilized as defined in Connecticut State statute 19a-17b Section(4) for evaluating
and improving the quality of health care rendered
Goals
• To review recent cases and identify areas for
improvement for (all) clinicians involved
• Patient complications & deaths are reviewed with the
purpose of educating staff, residents and medical
students.
• To identify ‘system issues’, which negatively affect
patient care
• To modify behavior and judgment and to prevent
repetition of errors leading to complications.
• To assess all six ACGME competencies and Institute of
Medicine (IOM) Values in the quality of care delivered
Conferences are non punitive and focus on the goal of
improved and safer patient care
Acknowledgements:
Dr. Peruvamba Venkatesh
Dr. Samuel Pope
Dr. Francoise Roux
Dr. Eric Shore
Dr. Adam Noyes
Dr. Hamid Habibi
Learning Objectives
•
Recognize the significant morbidity and mortality
associated with infective endocarditis (IE)
•
Identify common and uncommon presentations of IE
•
Understand the morbidity and mortality associated
with performing a Lumbar puncture without prior CT
scan in select patients
•
Medical jeopardy questions…
Case Presentation
• Patient was a 50-year-old female with PMHx of
IVDA, HIV with last CD4 count of 420, and viral load
of 2072 presented to Hartford hospital ED with
chief complaint of AMS
• She was found down in her home by her friends,
and had paraphernalia of IV drug use lying around
• Patient was confused and history could not be
elicited from her
• History of admission for pneumonia a 8 months
back when she left against medical advice after 2
days of treatment
8
Case Presentation
Medical history: Injection drug use, HIV CD4 count 420,
Viral load 2072, Tricuspid valve endocarditis, Hepatitis C
infection, MSSA bacteremia
Surgical history: None
Allergies: Compazine, Morphine - Itching
Social History: Lives at home with family. Denies tobacco,
Occasional alcohol, Injection drug use of Cocaine/Heroin
Family history:
Brother – Metastatic cancer of unknown primary
Home meds: Only tramadol p.r.n.
9
ROS: Could not be obtained
Case Presentation
Vitals: T- 103.6, HR- 124/m, RR- 22-30/minute, BP-102/64,
Sat- 94% on 4lNC
General & Neurology: the patient is obtunded, no response
except to sternal rub GCS E2V1M4 = 7;
Babinski positive with bilateral upgoing plantar response
HEENT: NC/AT PERRLA;- pallor/Icterus; Fundus–limited exam
Cardiac: S1,S2 + RRR, holosystolic murmur III/VI in Mitral
and Tricuspid areas.
Pulmonary: Hyperventilation; Minimal crackles bilateral
bases.
Abdomen: Soft, Not distended, diffuse tenderness.
10
Extremity: Bilateral trace edema; macular lesions
Labs and Diagnostics
12
33.7
140
102
28
134
164
3.1
34.9
MCV 71
RDW 17
19
1.1
Ca 8.5 Phos 2.4 Mg 2.3
Neutrophils 88.7 % Bands 4.3%
PT 18
PTT 29
ABG
pH 7.61
pCo2 17
Hco3 18
ALP 117
pO2 69
AST 368
On 4 l NC
ALT 97
Bilirubin 0.9/0.4
Lipase 113
Lactate 5.1
UA : Clear
Nitrate -ve LE -ve
WBC 4, RBC 4
CK: 82
Trop: 1.66, peak 2.68
S.Osm 308
ECG
12
Diagnostic query…
What will you do next?
1. Lumbar puncture
2. Echocardiogram
3. IV Antibiotics
4. CT head
5. CXR
13
Diagnostic query…
What will you do next?
1. Lumbar puncture
2. Echocardiogram
3. IV Antibiotics
4. CT head
5. CXR
14
CSF analysis results
Opening pressure: 18 cm H20
Appearance: Clear, colorless
Xanthochromia: Absent
RBC 132, WBC 42, 74% granulocytes, 6% L, 7%M;
Histiocytes 13%
VDRL negative
HSV PCR negative
Culture: Negative, India ink negative, CMV negative,
Enterovirus negative
Admission care plan:
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•
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Admit to MICU
Consults: Cardiology; Infectious disease/HIV; Cardiac
surgery; Neurology.
Monitor daily weights, strict I/Os, Monitor labs
(BUN/Cr, electrolytes)
Broad spectrum antibiotics
Intubation for airway protection
Hemodynamic support with pressors
Hospital Course – Day 1
Patient arrived at 7:45 am
Fever treated with Tylenol and Normal Saline 4 liters
Vancomycin, ceftriaxone by 8:23 a.m. for empiric
meningitis coverage
MICU resident paged at 11:20 am
Working diagnosis given as per phone conversation –
acute bacterial meningitis
Patient evaluated at 11:45 a.m. LP was being performed
On exam, key points hyperventilation/Babinski +
CT head before LP recommended by MICU resident –
informed that pt. is going for one.
Hospital course - Day # 1 continued…
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•
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Patient had to wait a few hours in ER for bed availability
Re-assessed at 2p.m. CT head not performed and no
order seen in ER Allscripts. Order placed as STAT study by
MICU resident.
At 5p.m. patient assessed third time, no clinical change.
Patient was ready for transport – CT head was supposed
to be done en-route to MICU
Patient arrives in B11I at 6:27 p.m. CT head still not done
After initial stabilization, she was sent for urgent CT scan
Critical result call from radiology at 7:30p.m.
Large left MCA stroke
Resident/Intern rushed to CT – added CTA; stroke
confirmed
Admission Diagnoses
1.
2.
3.
4.
5.
Infective endocarditis with Mitral valve vegetation
Left MCA stroke – embolic (septic)
HIV
Cocaine injection use
Respiratory alkalosis/Metabolic acidosis
Hospital course - Day # 1 continued…
Patient brought back to 11i – intubated for airway
protection overnight
ID, Neuro consult
Concern for septic embolic phenomenon – Continued
on Vancomycin ceftriaxone as empiric coverage.
Needed initiation of norepinephrine for septic shock.
Echocardiogram on Day #1
• Overall left ventricular systolic function normal.
• EF 60%
• Echogenic mass on the posterior leaflet of the
mitral valve about 1.0 X 1.0 cm and likely
represents a valvular vegetation.
• There is mild mitral insufficiency.
• Small(<1 cm) pericardial effusion.
• No evidence for cardiac tamponade
Hospital course - Day # 2
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•
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Echo confirmed Mitral valve vegetation
Cardiology & CT surgery consult
Patient continued on aggressive septic shock
management
No mental function improvement seen
Due to large CVA, was ruled out for valve replacement
Hospital Course- Days 2 to 5
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Input from ID, Cardiology, CT surgery & neurology
Cultures: Blood Culture positive for MSSA
Urine Culture positive for MSSA*
CSF cultures negative
Surveillance blood culture on day 3 remained positive
for MSSA
On day 3 Extent of vegetation confirmed by TEE – Per
Cardiology, pt will not survive without surgery.
Goals of care discussion with family initiated due to
poor hope of neurological recovery
Hospital Course - Day 6
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Goals of care changed to CMO
Patient extubated at 1700
Comfort medications initiated
Patient passed away at 1731
Learning objectives
•
•
•
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Identify indications for a cranial CT scan prior to
a spinal tap
Identify the varied presentation of infective
endocarditis
Identify consequences of brainstem herniation
Discuss the management of infective
endocarditis
Discussion
Morbidity and mortality associated with spinal
tap without ruling out increased intra-cranial
pressure effect
Jeopardy # 2
Which organism requires only 1 positive blood
culture to count as a major Duke’s criteria?
A) MRSA
B) HACEK
C) Streptococcus viridans
D) Coxiella burnetti
Jeopardy# 2
Which organism requires only 1 positive blood
culture to count as a major Duke’s criteria?
A) MRSA
B) HACEK
C) Streptococcus viridans
D) Coxiella burnetti
Duke’s criteria
Duke’s criteria, continued…
Duke’s criteria, continued…
Clinical images of Infective
Endocarditis
Presentations/Complications of IE
CHF/AC
S
Mycotic
aneurys
m
Glomeru
lonephri
tis
Perivalvular
abscess
Infective
Endocarditis
Visceral
infarctio
n
Pericard
itis
Stroke
Blindne
ss
Role of echocardiography
Indications for valve replacement
CHF refractory to standard medical therapy.
Fungal IE.
Persistent sepsis after 72 hours of appropriate
antibiotic treatment.
• Recurrent septic emboli, especially after 2 weeks
of antibiotic treatment.
• Rupture of an aneurysm of the sinus of Valsalva.
• Conduction disturbances cased by a septal
abscess.
• Kissing infection of the anterior mitral leaflet in
patients with IE of the aortic valve
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•
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Lumbar puncture and the risk of herniation:
when should we first perform CT?
(J Neuro 2002)
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How often does LP lead to herniation?
In which cases does LP before CT lead to
herniation?
In which cases is CT indicated before an LP?
How effective is a head CT in identifying patients at
risk of herniation?
When can an LP be done safely without a cranial CT
scan?
How often does LP lead to herniation?
Three pre-CT articles, first two estimate the incidence
< 1%. The third suggests higher percentage, without
stating the denominator.
1st study: retrospective study of LP in 401 patients
with histologically confirmed supra and subtentorial brain tumors.
 Papilledema was seen in 32%. Only one case
showed evidence of herniation.

How often does LP lead to herniation?
2nd study: retrospective study of 129 pts w/ varying
path, 70 w/ papilledema and 59 without
papilledema but increased CSF pressure.
 One case (papilledema 3+), w/ resp arrest 5 mins
after LP followed by death.
 7 other adverse effects , in group without
papilledema were called possible complications of
LP, w/ intervals between 3-24 hrs.

How often does LP lead to herniation?
3rd study: retrospective study in 30 patients
referred to a tertiary center, w/ raised ICP.
 20 had definite papilledema. Five presented w/
meningitis symptoms, but had a cerebral
abscess.
 In 15 of the 30 cases deterioration after LP was
immediate and dramatic; of the 12 patients
who died, 8 had lapsed into coma immediately
following LP.

Circulation of CSF
Types of herniation
Manifestations of brain herniation

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Headache
Lethargy
Coma
Respiratory arrest
Cardiac arrest
Loss of all brainstem reflexes (blinking, gagging, pupils reacting to
light)
Wide (dilated) pupils
High blood pressure
Irregular breathing
Bradycardia
In which cases is CT indicated before an LP?
Papilloedema is closely related to Ventricular filling
pressures. Absence of papilledema in patients with
cerebral tumors, means the CSF is not persistently
raised. However, absence of papilledema does not
exclude the pressure.
• Some SOLs cause the CSF pressure to rise, while
others often quite as large don’t. This difference can
be explained by the role of CSF circulation.
• If a tumor obstructs the CSF flow that it doesn’t reach
the Superior Sagittal Sinus (SSS), CSF pressure will
rise, while absorption continues by subsidiary routes,
at higher pressure. If it doesn’t impair CSF flow to
such an extent and the CSF can still reach the SSS,
absorption remains normal and CSF pressure doesn’t
rise.
•
Elevated CSF pressure without a space
occupying lesion
•
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Benign intracranial hypertension.
Thrombosis of SSS and other sinuses
Subarachnoid hemorrhage.
Bacterial meningitis.
Thrombosis of IJV.
SVC syndrome.
CHF.
Jeopardy # 3
Question: Performing an LP in patients with
papilledema and increased ICP is always
dangerous.
•
•
True
False
Jeopardy # 3
Question: Performing an LP in patients with
papilledema and increased ICP is always
dangerous.
•
•
True
False
Which one is normal?
Stages of papilledema
Common misconceptions
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SOL’s always causes raised intracranial
pressure (ICP).
Raised ICP and papilledema must be due to
SOLs.
LP in a patient with increased ICP and
papilledema is always dangerous.
LP in a patient with normal ICP and without
papilledema is always safe.
LP& CSF related take home points…
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•
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Raised ICP and intracranial hypertension are ambiguous
terms and should be avoided. It should be specified
whether brain shift is the problem or raised CSF pressure
or a combination of two.
Brain shift is characterized by tense dura, flattened gyri,
narrowed sulci, effaced cisterns, compressed/dilated
ventricles and in advanced stages herniation – imaging
diagnosis
Raised CSF pressure refers to the pressure of CSF
expressed in cmH2O or mmHg. Papilledema is the only
reliable clinical sign of raised CSF pressure. It is usually
lacking in acute processes, but sometimes develops within
hours.
LP& CSF related take home points…
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•
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It is impossible to judge the pressure from bedside
observation, papilledema being the only exception to that
rule. Nor can CSF pressure be determined from a CT scan.
LP carries no risk of herniation if there is no brain shift,
again whether CSF pressure is raised or not and
papilledema is present or not.
Interpretation of CT should be focused not only on signs of
focal SOL. But also,
(1) loss of differentiation between gray and white matter
in cases with diffuse cytotoxic edema,
(2) effacement of CSF spaces (sulci, sylvian fissures,
ventricles, and cisterns) and…
(3) additional displacement of brain structures.
Risk stratification:
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LP unsafe and generally unhelpful: Strokes, when LP is
sometimes indicated e.g. if vasculitis is suspected,
subarachnoid hemorrhage, if CT normal but suspicion is
high and head injury, if complicating meningitis is
suspected. In all those cases CT should be performed first.
LP unsafe but helpful: Coma without apparent cause. CT
first, if that is normal, LP is safe. Papilledema without
apparent cause: MRI first (to detect thrombosis of SSS), if
that is normal LP is safe.
LP safe and helpful: Neuro disorders where brain shift is
out of question and CSF exam might aid in diagnosis. MS,
Guillain-Barre’ syndrome, chronic polyneuropathy
Special situations:
Acute meningitis is difficult to fit into the above
classification. It is the premier indication for LP and
should be done without delay. The traditional rule is
to carry out LP without delay is warranted, except in
patients with papilledema and/or focal neurologic
signs or hemiparesis.
• Encephalitis can cause lateral shift or diffuse swelling,
and is an indication for CT before LP.
• HIV positive patients suspected of intracranial
pathology e.g., cryptococcal meningitis, should
(must) be investigated by CT before LP is done.
•
Risk stratification table
Final Take-Home points
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Early identification and risk-stratification of IE
Focus on physical exam findings: Papilledema,
indirect markers such as hyperventilation
Classifying patients at risk by deciding
whether an LP is helpful or not; safe or not
Identifying special situations such as HIV,
acute meningitis, or encephalitis
Knowing indications of surgical management
References
•
Baddour LM, Wilson WR, Bayer AS, et al. Infective endocarditis: diagnosis,
antimicrobial therapy, and management of complications: a statement for
healthcare professionals from the Committee on Rheumatic Fever, Endocarditis,
and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the
Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and
Anesthesia, American Heart Association: endorsed by the Infectious Diseases
Society of America. Circulation 2005; 111:e394.
•
Tice AD, Rehm SJ, Dalovisio JR, et al. Practice guidelines for outpatient
parenteral antimicrobial therapy. IDSA guidelines. Clin Infect Dis 2004; 38:1651.
•
Durack DT, Lukes AS, Bright DK. New criteria for diagnosis of infective
endocarditis: utilization of specific echocardiographic findings. Duke
Endocarditis Service. Am J Med 1994; 96:200.
•
Crevel HV, Hijdra A, de Gans J. Lumbar puncture and the risk of herniation:
when should we first perform CT? J Neurol (2002) 249: 129-137