Morbidity and Mortality Conference

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

2. General Data N.M.41 y.o. G3P2 (2002)PU 37 3/7 wks AOG by LMP

3. CHIEF COMPLAINT Right Upper Quadrant Pain

4. 3 days PTA RUQ pain OB consult GI referral Imp: Cholelithiasis vs. acid peptic disease Dx: HBT UTZ Tx: Pinaverium & Al-Mg OH History of Present Illness

5. Few hours PTA Progressive RUQ pain ER consult History of Present Illness Admission

6. Review of Systems • No fever, weakness, anorexia, weight loss • No headache, BOV, dizziness, sore throat • No cough, colds, dyspnea • No chest pain, palpitations, easy fatigability, orthopnea, PND • No hypogastric pain, dysuria, hematuria, urinary frequency • No easy bruisability nor bleeding tendencies • No edema

7. Past Medical History • No DM, HPN, Bronchial asthma, PTB, acid peptic disease • No allergies to food nor drugs • No previous surgeries

8. Menstrual & OB-GYN History • Menarche: 13 y/o, 4-6 days, every 30 days, 5 ppd no dysmenorrhea • G1 1990, LFT, male, 6.1 lbs., SVD, in Cavite, no complications • G2 1996, LFT, male, 7.1 lbs., SVD, in Cavite, no complications • G3 unremarkable PNCUs; normal BP monitorings & U/A, meds: Mulitivitamins & FeS04 • No artificial family planning method used

9. Family Medical History • DM – father • No hypertension, asthma, PTB, CVA, CV disease, cancer, hematologic disorder

10. Personal Social History • Housewife • Non-smoker • Non-alcoholic beverage drinker • No regular exercise, does the household chores

11. Physical Examination • Conscious, coherent, ambulatory, not in cardio-respiratory distress • BP 110/80 HR 85 RR 19 T36.8 C • Ht. 4’11” Wt. 64.2 kgs. BMI 28.6 • No skin dermatoses nor jaundice • Pink palpebral conjunctiva, anicteric sclera; no lymphadenopathy, neck vein engorgment nor thyromegaly

12. Physical Examination • Symmetrical chest expansion, no rib retractions, clear breath sounds • Adynamic precordium, normal rate and regular rhythm, no murmurs • Globular abdomen, striae gravidarum, normoactive bowel sounds, tense, w/ direct RUQ tenderness, (-) Murphy’s sign, FHT 142 bpm • No costovertebral angle tenderness

13. Physical Examination • Extremities: • Full equal pulses, pink nail beds • No cyanosis, edema nor varicosities • Internal Exam: • Admits fingertip, closed cervix, intact int. Os

14. Salient Features • 41 y/o, female, obese • Multigravid, PU 37 3/7 wks. AOG by LMP • Progressive RUQ pain • direct RUQ tenderness

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

16. Course in the Hospital

17. Upon Admission • GI referral • Hepatobiliary 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

18. Problem: 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

19. Problem: Pulmonary P> Oxygen at 2LPM/NC Given Furosemide Normal CXR Normal ECG ABG showed mild hypoxemia D-dimer = 1000 ng/ml

20. Problem: Pulmonary P> Referred to Pulmonology • Enoxaparin 40 mg SQ BID • Pulmonary CT Angiography: pulmonary embolism, pneumonia not ruled out

21. Problem: Pulmonary 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/NC Repeat CBC: leukocytosis Repeat CXR: atelectasis vs. pneumonia Repeat ABG was normal Cefuroxime & Clindamycin Decreasing WBC count

22. Problem: Hematologic S> 6th HD: (+) gross hematuria CBC: anemia Crea 0.7 O> no hypogastric nor CVA tenderness A> Hematuria 2° to LMWH

23. Problem: Hematologic P>UTZ-KUB: urinary bladder hematoma & normal kidneys Urology referral (blood clots in urine) Cystogram: Normal Cystoscopy: Urinary bladder bleeding & hematoma; blood clots evacuation & Cystoclysis Transfused 1 ‘u’ PRBC & repeat CBC Enoxaparin was discontinued IVC filter placement

24. Upon Discharge 24th HD: • Resolution of hematuria • Patient was sent home stable. • THM: • Nexium 40mg/tab OD • Laxoberal 45cc gtts

25. Final Diagnosis • Pulmonary Embolism • Anemia secondary to blood loss secondary to urinary bladder hematoma • G3P3 (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)

26. DISCUSSION

27. Pulmonary Embolism • common disorder, with substantial associated morbidity and mortality • a nonspecific clinical presentation • often poses a significant diagnostic challenge • Dyspnea – most frequent symptom • Tachypnea – most frequent sign Hlavac,M., MBChB, FRACP. Latex Enhanced Immunoassay D-dimer and Blood Gases Can Exclude Pulmonary Embolism in Low-Risk Patients Presenting to an Acute Care Setting.CHEST 2005; 128: 2183-2189

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

30. Pulmonary Embolism • Increased pulmonary vascular resistance • Impaired gas exchange • Alveolar hyperventilation • Increased airway resistance • Decreased pulmonary compliance

32. Diagnosis

34. Arterial 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 of arterial blood gas measurement in suspected pulmonary embolism. Am J Respir Crit Care Med 2000; 162:2105.

36. D – 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

37. V/Q Scan High probability • Segmental/lobar perfusion defect w/ normal ventilation Low probability • Perfusion defect w/ matched ventilation abnormality

38. V/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

39. Pulmonary Angiography • Sensitivity of 90% • Specificity of 95% • Previously 'the gold standard' • Underused because of a 5% morbidity & 2% mortality • Complications: 1) catheter insertion 2) contrast reactions 3) cardiac arrhythmia 4) respiratory insufficiency 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 Annals of Family Medicine. Vol.5, No.1, January/February 2007

40. Pulmonary CT Angiogram • Sensitivity of 90% • Specificity of 89 - 95% • Advantages: 1) non-invasive 2) less operator dependent 4) images the lungs, mediastinum and pleura 5) reveal non-embolic lesions presenting w/ symptoms identical to PE w/c are likely to produce non-diagnostic VQ scan 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 Annals of Family Medicine. Vol.5, No.1, January/February 2007

45. Treatment

46. Heparin • 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

47. Enoxaparin • Low molecular weight heparin • MOA: Inhibits more specifically Factor Xa by binding w/ ATIII with the same pentasaccharide sequence as UFH • Not generally monitored except in renal insufficiency & pregnancy • Therapeutic level = 0.5-1.0 unit/mL • Given at 1 mg/kg per dose SQ BID or 1.5 mg/kg SQ OD

48. Advantages of Enoxaparin • Superior bioavailability • Limited non-specific binding • Non-dose-dependent half-lives • No need for laboratory monitoring • Associated with less HIT & osteopenia • Lower mortality • Fewer recurrent thrombotic events • Less major bleeding van Dongen, CJ, et al. Fixed dose subcutaneous low molecularweight heparins versus adjusted dose unfractionated heparinfor venous thromboembolism Cochrane Database Syst Rev 2004.

49. 7th 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 (The 7th ACCPConference on Antithrombotic and Thrombolytic Therapy).CHEST. 2004; 126: 338S-400S

50. 7th ACCP Guidelines • Acutely ill medical patients • Active cancer • Previous VTE • Sepsis • Acute neurologic disease • Inflammatory bowel disease • Recommendation: prophylaxis w/ LDUH (Grade 1A) or LMWH (Grade 1A)