Morbidity and Mortality Conference Maria Monina T. Clauna, M.D. May 24, 2007 Makati Medical Center

Morbidity and Mortality Morbidity and Mortality ConferenceConference

Maria Monina T. Clauna, M.D. May 24, 2007

Makati Medical Center

General DataGeneral Data

N.M.41 y.o.

G3P2 (2002)PU 37 3/7 wks AOG by LMP

CHIEF COMPLAINTCHIEF COMPLAINT

History of Present IllnessHistory of Present Illness

3 days PTA RUQ painOB consult

GI referralImp: Cholelithiasis vs.

acid peptic diseaseDx: HBT UTZTx: Pinaverium & Al-Mg

OH

History of Present IllnessHistory of Present Illness

Few hours PTA

Progressive RUQ painER consult

AdmissionAdmission

Review of SystemsReview of Systems

No fever, weakness, anorexia, weight lossNo headache, BOV, dizziness, sore throatNo cough, colds, dyspneaNo chest pain, palpitations, easy fatigability, orthopnea, PNDNo hypogastric pain, dysuria, hematuria, urinary frequencyNo easy bruisability nor bleeding tendenciesNo edema

Past Medical HistoryPast Medical History

No DM, HPN, Bronchial asthma, PTB, acid peptic diseaseNo allergies to food nor drugsNo previous surgeries

Menstrual & OB-GYN HistoryMenstrual & OB-GYN History

Menarche: 13 y/o, 4-6 days, every 30 days, 5 ppd no dysmenorrheaG1 1990, LFT, male, 6.1 lbs., SVD, in Cavite, no complicationsG2 1996, LFT, male, 7.1 lbs., SVD, in Cavite, no complicationsG3 unremarkable PNCUs; normal BP monitorings & U/A, meds: Mulitivitamins & FeS04No artificial family planning method used

Family Medical HistoryFamily Medical History

DM – father No hypertension, asthma, PTB, CVA, CV disease, cancer, hematologic disorder

Personal Social HistoryPersonal Social History

HousewifeNon-smokerNon-alcoholic beverage drinkerNo regular exercise, does the household chores

Physical ExaminationPhysical Examination

Conscious, coherent, ambulatory, not in cardio-respiratory distressBP 110/80 HR 85 RR 19 T36.8 CHt. 4’11” Wt. 64.2 kgs. BMI 28.6 No skin dermatoses nor jaundicePink palpebral conjunctiva, anicteric sclera; no lymphadenopathy, neck vein engorgment nor thyromegaly


Symmetrical chest expansion, no rib retractions, clear breath soundsAdynamic precordium, normal rate and regular rhythm, no murmursGlobular abdomen, striae gravidarum, normoactive bowel sounds, tense, w/ direct RUQ tenderness, (-) Murphy’s sign, FHT 142 bpmNo costovertebral angle tenderness


Extremities:Full equal pulses, pink nail bedsNo cyanosis, edema nor varicosities

Internal Exam:Admits fingertip, closed cervix, intact int. Os

Salient FeaturesSalient Features

41 y/o, female, obeseMultigravid, PU 37 3/7 wks. AOG by LMPProgressive RUQ paindirect RUQ tenderness

Admitting ImpressionAdmitting Impression

T/c Cholelithiasis vs. Acid Peptic Disease G3P2 (2002), Pregnancy Uterine 37 3/7 weeks AOG by LMP, not in labor

Course in the HospitalCourse in the Hospital

Upon AdmissionUpon Admission

GI referralHepatobiliary UTZ: cholelithiases w/ cholecystitis

Underwent elective primary LTCS, delivered a live baby girl & followed by open cholecystectomy w/ IOC

Histopathologic findings: acute cholecystitis w/ 27 cholelithiasis

Problem: PulmonaryProblem: Pulmonary

S>1st HD: (+)DOB while on BT, I&0 2530/900cc

O> BP 110/70, HR 110, RR of 40, T 37.2°C,

O2 sats 96-97% on room air, distended neck veins JVP 7cmH2O & bibasal rales

A> T/c pulmonary congestion probably secondary to fluid overload, r/o pulmonary embolism


P> Oxygen at 2LPM/NC

Given FurosemideNormal CXR Normal ECG ABG showed mild hypoxemiaD-dimer = 1000 ng/ml


P> Referred to Pulmonology

Enoxaparin 40 mg SQ BIDPulmonary CT Angiography: pulmonary embolism, pneumonia not ruled out


S> 4th HD: (+) DOB

O> BP 120/90, HR 120, RR of 30, T 37.7°C O2 sats 87% on room air and clear BS

A> t/c Hospital acquired pneumonia

P> Oxygen at 2LPM/NCRepeat CBC: leukocytosis

Repeat CXR: atelectasis vs. pneumoniaRepeat ABG was normalCefuroxime & ClindamycinDecreasing WBC count

Problem: HematologicProblem: Hematologic

S> 6th HD: (+) gross hematuria

CBC: anemia Crea 0.7

O> no hypogastric nor CVA tenderness

A> Hematuria 2° to LMWH

Problem: HematologicProblem: Hematologic

P> UTZ-KUB: urinary bladder hematoma & normal kidneysUrology referral (blood clots in urine)Cystogram: NormalCystoscopy: Urinary bladder bleeding & hematoma; blood clots evacuation & CystoclysisTransfused 1 ‘u’ PRBC & repeat CBCEnoxaparin was discontinuedIVC filter placement

Upon DischargeUpon Discharge

24th HD:Resolution of hematuriaPatient was sent home stable.THM:

Nexium 40mg/tab ODLaxoberal 45cc gtts

Final DiagnosisFinal Diagnosis

Pulmonary EmbolismAnemia secondary to blood loss secondary to urinary bladder hematomaG3P3 (3003); s/p Primary LTCS, delivered a live baby girl, APGAR 7/9, 3.1 kgs. (01/19/07)s/p Open Cholecystectomy w/ IOC ( 1/19/07)s/p Cystoscopy (01/27/07)s/p IVC filter placement (01/31/07)

DISCUSSIONDISCUSSION

Pulmonary EmbolismPulmonary Embolism

common disorder, with substantial associated morbidity and mortalitya nonspecific clinical presentationoften poses a significant diagnostic challengeDyspnea – most frequent symptomTachypnea – most frequent sign

Hlavac,M., MBChB, FRACP. Latex Enhanced Immunoassay D-dimer and Blood GasesCan Exclude Pulmonary Embolism in Low-Risk Patients Presenting to an

Acute Care Setting.CHEST 2005; 128: 2183-2189


Risk Factors:- long air travel- obesity- cigarette smoking- oral contraceptives- pregnancy- post menopausal hormone replacement- trauma- medical conditions (Cancer, Hypertension, COPD etc.)

- Thrombophilia


Increased pulmonary vascular resistanceImpaired gas exchangeAlveolar hyperventilationIncreased airway resistanceDecreased pulmonary compliance

DiagnosisDiagnosis

Arterial Blood GasArterial Blood Gas

ABG measurements & pulse oximetry have a limited role in diagnosing PE Usually reveal hypoxemia, hypocapnia & respiratory alkalosis

Rodger, MA, Carrier, M, Jones, GN, et al. Diagnostic value ofarterial blood gas measurement in suspected pulmonary

embolism. Am J Respir Crit Care Med 2000; 162:2105.

D – dimer AssayD – dimer Assay

Sensitivity of 96 - 100%

Highest negative predictive value when used to exclude VTE & PE in younger patients without associated co-morbidity/ history of VTE & w/ short duration of sxs

Annals of Family Medicine. Vol.5, No.1, January/February 2007

V/Q ScanV/Q Scan

High probabilitySegmental/lobar perfusion defect w/ normal ventilation

Low probability Perfusion defect w/ matched ventilation abnormality

V/Q ScanV/Q Scan

Sensitivity of 40%

Unfortunately, the combination of clinical & V/Q scan probability found in most patients (up to 72%) has a diagnostic accuracy of only 15-86%

Value of the ventilation/perfusion scan in acute pulmonary embolism. Results

of the prospective investigation of pulmonary embolism diagnosis(PIOPED). The PIOPED Investigators. JAMA 1990; 263:2753.

Cross, J.J.L. A Randomized Trial Scintigraphy for the of Spiral CT and Ventilation Perfusion Diagnosis of Pulmonary Embolism.

Clinical Radiology 1998; 53: 177-182

Pulmonary AngiographyPulmonary Angiography

Sensitivity of 90%Specificity of 95%Previously 'the gold standard'Underused because of a 5% morbidity & 2% mortalityComplications:

1) catheter insertion2) contrast reactions3) cardiac arrhythmia4) respiratory insufficiency


Clinical Radiology 1998; 53: 177-182Annals of Family Medicine. Vol.5, No.1, January/February 2007

Pulmonary CT Angiogram Pulmonary CT Angiogram

Sensitivity of 90%Specificity of 89 - 95% Advantages:

1) non-invasive2) less operator dependent4) images the lungs, mediastinum and

pleura5) reveal non-embolic lesions

presenting w/ symptoms identical to PE w/c are likely to produce non-diagnostic VQ scan


Clinical Radiology 1998; 53: 177-182Annals of Family Medicine. Vol.5, No.1, January/February 2007

TreatmentTreatment

HeparinHeparin

Heterogeneous mixture of sulfated mucopolysaccharides.MOA: Accelerates inhibition of clotting factor proteases (Factor II, IX, X, XI & XII) by Antithrombin III to form equimolar stable complexes

EnoxaparinEnoxaparin

Low molecular weight heparinMOA: Inhibits more specifically Factor Xa by binding w/ ATIII with the same pentasaccharide sequence as UFHNot generally monitored except in renal insufficiency & pregnancyTherapeutic level = 0.5-1.0 unit/mLGiven at 1 mg/kg per dose SQ BID or

1.5 mg/kg SQ OD

Advantages of EnoxaparinAdvantages of Enoxaparin

Superior bioavailabilityLimited non-specific bindingNon-dose-dependent half-livesNo need for laboratory monitoringAssociated with less HIT & osteopeniaLower mortalityFewer recurrent thrombotic eventsLess major bleeding

van Dongen, CJ, et al. Fixed dose subcutaneous low molecularweight heparinsversus adjusted dose unfractionated heparinfor venous thromboembolism

Cochrane Database Syst Rev 2004.

77thth ACCP Guidelines ACCP Guidelines

Grade 1 recommendations – strong indication that the benefits do/don’t outweigh risks, burden & costs

Grade 2 suggests that individual patients’ values may lead to different choices

Geerts, W.H. Prevention of Venous Thromboembolism (The7th ACCPConference on Antithrombotic and Thrombolytic

Therapy).CHEST. 2004; 126: 338S-400S


Acutely ill medical patientsActive cancerPrevious VTESepsisAcute neurologic diseaseInflammatory bowel diseaseRecommendation: prophylaxis w/ LDUH (Grade 1A) or LMWH (Grade 1A)


When there is a contraindication to anticoagulant prophylaxis

Recommendation: use of mechanical prophylaxis with GCS or IPC (Grade 1C)


Recommend against the use of aspirin alone as prophylaxis against VTE for any patient group (Grade 1A)

Prophylaxis with low dose unfractionated heparin 2-3x daily for major obstetric & gynecololgic surgery


Long distance travel (flights of 6 h duration)avoidance of constrictive clothing around the lower extremities or waistavoidance of dehydrationfrequent calf muscle stretching

(Grade 1C)


Properly fitted, below-knee GCS providing 15-30 mmHg of pressure at the ankle (Grade 2B)Single prophylactic dose of LMWH injected prior to departure (Grade 2B)Recommend against the use of aspirin for VTE prevention associated w/ travel (Grade 1B)

Emerging AnticoagulantsEmerging Anticoagulants

Weitz, J.I. Emerging Anticoagulants for the Treatment of Thromboembolism.Thromb Haemostat. July 2006. 96: 274-284

Duration of AnticoagulationDuration of Anticoagulation

Patients w/ a 1st PE or DVT & an irreversible risk factor (protein S deficiency), should be treated for at least 6-12 months and indefinite anticoagulation should be considered.

Buller, HR, Agnelli, G, Hull, RD, et al. Antithrombotic therapy for venous thromboembolic disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest

2004; 126:401S.

Duration of Anticoagulation for Venous Thromboembolism

EventDuration of

Anticoagulation

Situational DVT 6 wks. - 3 mos.

Idiopathic DVT 3-6 mos. (minimum)

Recurrent idiopathic DVT 12 mos. (minimum)

VTE w/ ongoing risk factors Long term/ indefinite

Pulmonary embolism 6 mos. (minimum)

Massive pulmonary embolism long term/ indefinite

Inferior Vena Caval FilterInferior Vena Caval Filter

Indications:1) Absolute contraindication to

anticoagulation (eg, active bleeding) 2) Recurrent PE during adequate

anticoagulant therapy 3) Complication of anticoagulation (eg,

severe bleeding)

Inferior Vena Caval FilterInferior Vena Caval Filter

Complications:1) related to the insertion process

(bleeding/ venous thrombosis at the insertion site)

2) Filter misplacement3) Filter migration 4) Filter erosion & perforation of the IVC

wall5) IVC obstruction due to filter

thrombosis

Inferior Vena Caval FilterInferior Vena Caval FilterFilter insertion was successful in 98.6% of patients and resulted in an immediate complication in 11.8%.The median duration of filter implantation was 166 days. 17.0% (37 of 217 patients) had at least one venous thromboembolic event.Filter retrieval was attempted in 25.3% of patients after a median of 51 days.Removal was successful at the first attempt in 92.7% of patients.Conclusion: The filter could be easily inserted and successfully removed up to 1 year after insertion.

S. Laporte, et al. A Prospective Long-term Study of 220 PatientsWith a Retrievable Vena Cava Filter for Secondary Prevention of

Venous Thromboembolism CHEST. 2007;131;223-229

Thank you!Thank you!

Thrombin Factor XIII

Fibrinogen Fibrin Cross-linked fibrin

Plasmin

Fibrin degradation products (D-

Dimer)

D - dimer AssayD - dimer Assay

Coagulation PathwayCoagulation Pathway

Heparin

Differential DiagnosisDifferential Diagnosis

Acute Myocardial InfarctionPneumonia, bronchitis, exacerbation of asthma or chronic obstructive pulmonary diseaseCongestive Heart FailurePneumothoraxAnxiety

Barry, P., et al. Current Diagnosis of Venous Thromboembolism in Primary Care: A Clinical Practice Guideline from the American Academy of Family Physicians andAmerican College of Physicicans.


Pulmonary CT AngiogramPulmonary CT Angiogram

CT Pulmonary Angiogram can replace pulmonary angiography in patients with non diagnostic V/Q scan and negative leg ultrasound finding

Schwartzman, K., et al.

Barry, P., et al. Current Diagnosis of Venous Thromboembolism in Primary Care: A Clinical Practice Guideline from the American Academy of Family Physicians andAmerican College of Physicicans.


Chest X-rayChest X-ray

12-Lead ECG12-Lead ECG

Arterial Blood GasArterial Blood Gas

pO2 84.8

pH 7.44pCO2 34.4

HCO3 23.3

O2 Sat. 96.8

B.E. -0.1Total CO2 24.3

RR 32Condition 2 LPM/NC

WarfarinWarfarin

Has a long half life in plasma (36 hours)Reduction of all vitamin K-dependent coagulation proteins into the therapeutic range requires 4-5 days of therapyHeparin therapy should be overlapped w/ warfarin for a minimum of 5 days & continued until the INR has been w/in the therapeutic range (2.0 to 3.0) for at least 2 consecutive days

Buller, HR, Agnelli, G, Hull, RD, et al. Antithrombotic therapy for venousthromboembolic disease: The 7th ACCP Conference on Antithrombotic

and Thrombolytic Therapy. Chest 2004; 126:401S.

Unfractionated Heparin (UFH)Unfractionated Heparin (UFH)

IV UFH should be administered by continuous infusionIntermittent IV bolus dosing has been associated with an increased incidence of major bleeding

Levine, MN, et al. Hemorrhagic complications of anticoagulant treatment: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126:287S.

Unfractionated Heparin (UFH)Unfractionated Heparin (UFH)

Achieve a critical therapeutic level of heparin w/in the 1st 24 hrs. of treatment

Inadequate initial heparin therapy increases the probability of recurrent thromboembolism for at least 3 months

Hull, RD, et al. The importance of initial heparin treatment on long-term clinical outcomes of

antithrombotic therapy. The emerging theme of delayed recurrence. Arch Intern Med 1997; 157:2317.

Repeat Arterial Blood GasRepeat Arterial Blood Gas

pO2 93

pH 7.43pCO2 43.4

HCO3 28.8

O2 Sat. 98.3

B.E. 4.03Total CO2 30.1

RR 32Condition 2 LPM/NC

CBC MonitoringCBC Monitoring

Day 0 1st HD 4th HD 5th HD 7th HD 9th HD 11th HD 13th HD

Hgb 13.7 11.9 7.4 11.2 9.7 9.5 11.3 11.4

Hct 41.6 35.9 22.7 35 30 29.8 34.8 35.7

WBC 10,250 24,090 19,780 17,920 10,220 9,550

Segm 86 74 82 85 82 83

Lympho 6 7 9 7 7 9

Platelet 353T 333T 367T 490T 823T 805T

2 3

Repeat Chest X-rayRepeat Chest X-ray

Documents

Morbidity and Mortality Conference Maria Monina T. Clauna, M.D. May 24, 2007 Makati Medical Center