Department of Medicine Quality Program

Medical ICU Morbidity and Mortality Conference

Ryan Stephenson, DOKarina Szczepanczyk, MD

July 31, 2015

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 educationThis 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

Case Presentation

• Patient was a 54-year-old male with PMHx of CAD s/p MI (2013), HTN, DM, morbid obesity, OSA presented to Hartford hospital ED with chief complaint of urinary retention and shortness of breath

• He reports having poor appetite for about a week, has not been eating for the past 5 days and not urinating for the past 3 days

• He believes this shortness of breath started about 1 week ago

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Case Presentation

Medical history: morbid obesity, OSA, CAD s/p MI with PCI (2013), HTN, DMSurgical history: Left scalp cyst removal, I&D right buttock abscessAllergies: NKDASocial History: Lives at home with family. Former social worker. Occasional tobacco, no alcohol, former crack cocaine use. Family history: No DM, HTN, CAD.

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Case Presentation

ROS: anorexia, oliguria, abdominal and back pain, SOB, bilateral lower extremity edema (L>R)

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lasix 20 mg qdayhydrocortisone 1% creamisosorbide mononitrate ER 30Klor-con 20 mEqlisinopril 40 mg dailymetoprolol tartrate 50mg BIDnaproxen 500mg BID

Home meds: amlodipine 10 mg qdayASA 81 mg qdayatorvastatin 80 mg qhsbaclofen 10 mg BIDbrilinta 90 mg BIDescitalopram 20 mg qday

Case PresentationVitals: T- 100.8, HR- 116/m, RR- 18-26/minute, BP-157/117,

Sat- 98% on 4L NC . 456 lbs, BMI 56.General & Neurology: morbidly obese African-American male in significant respiratory distress. AAOx3. HEENT: NC/AT PERRLA; No pallor/IcterusCardiac: S1,S2 + RRR, holosystolic murmur III/VI in Mitral and Tricuspid areas.Pulmonary: Diffuse rhonchi.Abdomen: Soft, non not distended, diffuse tenderness. Extremity: Bilateral trace edemaSkin: Warm, dry. LLE desquamation in groin. 2 small, 3 cm round bullae on distal LLE. L > R edema. 1+ DP and radial pulses.

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Labs and Diagnostics

1.2

17.2

103

52.2

140

4.6

100

17

50

5.947

ANC 900 Bands 31%

Neutrophils 62.3%

PT 15.5PTT 37INR 1.4

ALP 76AST 49ALT 37Bilirubin 1.3/0.8Lipase 23Lactate 7.8

(baseline Cr 1.2)

Ca 8.5 Phos 2.4 Mg 2.3

venous pH 7.17BNP: 1267

UA : clearNitrate -ve LE -veWBC 3, RBC 14

CK: 494Trop: <0.3

ECG

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cxr.

Admission care plan:• Admit to MICU• Consults: Surgery - saw patient in MICU • Nephrology – saw patient in ER• Strict I/Os, check D-dimer, check lactate, trend CKs,

check C-peptide, fingersticks Q4hours• Total abdominal U/S, Doppler LLE, • CT abdomen/pelvis/lower extremities without

contrast• Intubation for airway protection• Obtain central access

Hospital Course – Day 1

Patient arrived to HH ED at 8:40 am8:53 am - Foley inserted in ED and morphine 2mg IV was given. He remained anuric9:54 am - D50% 25g x 2, D5 NS @ 75cc/hr for FS 52 10:23 am - morphine 5mg IV 11:43 am - persistent hypoglycemia (FS 47, 51, 44) so D10 started @ 100cc/hr and D5 NS increased to 100 cc/hr

Hospital Course – Day 1… Continued

11:52 am - Patient developed acute respiratory distress, requiring rescue BiPAP12:08 pm - D50% 25g x 212:22 pm - Dilaudid 1 mg IV12:46 pm - D50% 25 g, FS remained 20 -571:48 pm - Fentanyl 25 mcg x 12:23 pm - patient transferred to MICUNephrology consulted for concern of volume overload in setting of renal failure, HD not recommended and diuresis deemed invaluable given a creatinine of 6.

Hospital course - Day # 1 in MICU...• Lactate 7.8, D-dimer 9000, C-peptide 236, Trp neg x 3 but

CKs remained elevated and were trending up from nearly 500 to 661

• STAT echo - Severe biventricular systolic dysfunction. Trace aortic insufficiency. Left ventricular size is grossly normal. There is severe left ventricular systolic dysfunction with diffuse regional wall motion abnormalities. Estimated left ventricular ejection fraction is <15%.

• Repeat EKG shows new inverted T-waves, ?impending cardiac ischemic event --Cardiology consulted.

• Surgery consult -

Hospital course - Day # 1 continued…• Surgery Consult (Dictated at 4:53 p.m. by resident)IMPRESSION AND PLAN: This is a 54-year-old male in shock, which appears to be septic in nature. At this time, it is likely this patient has necrotizing fasciitis. We have concerned that this patient has a significant deep vein thrombosis and clot burden and a possible sequela of the pulmonary embolism, which could be causing this. If the patient becomes medically stabilized, we recommend a CT of the abdomen and pelvis in the bilateral lower extremities to evaluate for any other underlying pathology, which would be resulting in the same patient's septic picture.

Hospital course - Day # 1 continued…• Intubated for airway protection• Code called 5:04 PM – Ventricular tachycardia• 5:04 PM to 5:19 PM – ACLS

• 5:19 PM - Asystole. Pronounced expired.

Autopsy

Autopsy

Autopsy

Learning objectives• Differentiate between necrotizing fasciitis and

other soft tissue skin infections• Identifying typical and atypical presentations of

necrotizing fasciitis• Identify predictors of mortality and limb loss in

necrotizing soft tissue infections• The LRINEC score• Discuss the management of necrotizing fasciitis

General Overview: Necrotizing fasciitisGroup A streptococci, anaerobic bacteria, gram negative bacteria, polymicrobial infection● Every year in the United States, there are an estimated 3.5 cases of

invasive group A Streptococcus infections per 100,000 people; of these, about 6% are necrotizing

● Associated conditions: diabetes, drug use, obesity, immunosuppression, recent surgery, and traumatic wounds.

● Predisposing factors ◦ History of skin injury, such as laceration or burn◦ Blunt trauma◦ Recent surgery◦ Childbirth◦ Injection drug use

● Traumatic injuries ◦ Fresh water - Aeromonas hydrophila ◦ Seawater - Vibrio vulnificus (cirrhotics who ingest contaminated

oysters)

Local clinical manifestations

● Usually an acute process ● Erythematous (without sharp margins)● Swollen● Warm● Shiny● Exquisitely tender ● Pain out of proportion to physical exam ● Bullous manifestation● Sloughing of the skin

Autopsy

Diagnosis● Laboratory findings are generally nonspecific

◦ Leukocytosis with a marked left shift◦ Coagulopathy◦ Elevations in the serum creatine kinase (CK)◦ Elevated lactate◦ Elevated creatinine concentrations

(These findings, together with the clinical findings described above, should prompt surgical exploration. Once the decision is made that surgical exploration is warranted, it is critical to proceed rather than delay to obtain radiographic imaging )

The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score

● LRINEC score equal to or >6 should be evaluated for the presence of NF

● Developed to distinguish necrotizing fasciitis from severe cellulitis or abscess.

● Based on routinely ordered labs → WBC, Hemoglobin, Na, Cr, Glucose, CRP

● Retrospective observational study divided into a developmental cohort and a validation cohort.

The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score

● Included 145 patients with necrotizing fasciitis and 309 patients with severe cellulitis or abscesses admitted to Changi General Hospital.

● Patients were classified into three groups: low (LRINEC score ≤ 5, <50% risk for nec fasc), moderate (LRINEC score 6-7, 50-75% risk for nec fasc), and high risk (LRINEC ≥ 8, > 75% risk for nec fasc).

● Using LRINEC ≥ 6 as a cut-off for nec fasc yielded PPV of 92% and NPV of 96%. ~90% of patients with necrotizing fascitis had LRINEC ≥ 6 while only 3.1-8.4% of control patients had score ≥ 6.

The LRINEC score

INSERT FIGURE 1536

Discussion

Predictors of Mortality and Limb Loss in Necrotizing Soft Tissue Infections

Predictors of Mortality and Limb Loss in Necrotizing Soft Tissue Infections

HYPOTHESIS: Necrotizing soft tissue infections are associated with a high mortality rate. We hypothesize that specific predictors of limb loss and mortality in patients with necrotizing soft tissue infection can be identified on hospital admission.

● Overall mortality rate was 16.9%, and limb loss occurred in 26% of patients with extremity involvement.

● Independent predictors of mortality: white blood cell count greater than 30 000 x 10(3)/microL, creatinine level greater than 2 mg/dL (176.8 micromol/L), and heart disease at hospital admission.

● Independent predictors of limb loss: heart disease and shock (systolic blood pressure<90 mm Hg) at hospital admission.

● Clostridial infection was an independent predictor for both limb loss and mortality and was highly associated with intravenous drug use and a high rate of leukocytosis on hospital admission. The latter was found to be a good variable in estimating the probability of death.

CONCLUSIONS: Clostridial infection is consistently associated with poor outcome. This together with the independent predictors mentioned earlier should aid in identifying patients on hospital admission who may benefit from more aggressive and novel therapeutic approaches

Treatment● Recommendations per practice guidelines for the

diagnosis and management of skin and soft tissue infections by the Infectious Diseases Society of America.◦ For patients with aggressive infections associated

with signs of systemic toxicity or suspicion of necrotizing fasciitis or gas gangrene → Prompt surgical consultation

◦ Empiric antibiotics - Vancomycin OR Linezolid + piperacillin-tazobactam OR carbapenem OR ceftriaxone and metronidazole

Table 4 from practice guidelines

Figure 1 from practice guidlenes

Summary

● NF is an uncommon disease, with approximately 500 to 1500 cases reported in the US annually

● Early recognition and aggressive debridements is imperative to reduce mortality but is usually challenging

● LRINEC score is a cheap and readily available objective adjunct to risk stratify patients into risk categories of possible NF

● IF suspecting NF, emergent surgical debridement is crucial!! IV Vanco + Zosyn are the empiric treatments of choice

References● Clinical Infectious Diseases: An Official Publication Of The Infectious Diseases

Society Of America [Clin Infect Dis] 2014 Jul 15; Vol. 59 (2), pp. 147-59. Date of Electronic Publication: 2014 Jun 18.

● Wong CH, Chang HC, Pasupathy S, et al. Necrotizing fasciitis: clinical presentation, microbiology, and determinants of mortality. J Bone Joint Surg Am 2003; 85-A:1454.

● Wong CH, Khin LW, Heng KS, et al. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med 2004; 32:1535.

● Anaya DA, McMahon K, Nathens AB, et al. Predictors of mortality and limb loss in necrotizing soft tissue infections. Arch Surg 2005; 140:151.

Acknowledgements:

●Dr. Peruvamba Venkatesh●Dr. Samuel Pope●Dr. Francoise Roux●Dr. Eric Shore●Dr. Guru Kowlgi●Dr. Nik Kapila

Thank-you!Thank-you!!