Mortality Meet for Month of July

8/21/2019 Mortality Meet for Month of July

1/51

Dr.Basavaraju.G.VDr.Keshava murthy.M.LDr.Pushpa

DR KIRANKUMARDr.Divyashree.

Dr.NaushadDr,Anusha

Dr.Shivprakash


2/51

PICU 1 PICU 2 PICU 3

Total cases 148 213 115 476

Directadmission 120 199 74 393

Transfer Incases

28 14 41 83

DAMA cases 10 12 21 43

Deaths 25 3 5 33


3/51

may june july

Total no. Of cases 476

No. of deaths 33

No. of DAMA cases 43

No. of ventilatedcases

36


4/51

Total no of referred 8Total no admission refusedby attender

10

Total no of referred due tonon availability of ventilator

6

Total no of reffered due tonon availability of PICU bed

0


5/51

5yr TOTAL

Febrileconvulsion

7 4 0 11

Seizuredisorder

4 20 19 43

Meningoenc

ephalitis

2 8 12 22

GBS 0 5 0 5

GDD 3 7 5 15

TBM 0 0 4 4


6/51

5yr Total

ALRI 62 18 4 84

WALRI 1 3 0 4

ALTB 1 6 0 7

BRONCHIOLI

TIS

5 0 0 5

CLD 0 0 2 2

ASTHMA 0 0 3 3

BRONCHO

PNEUMONIA

6 0 0 6

EMPYEMA 1 0 0 1


7/51

5yr TOTAL

CCHD 3 0 0 3

ACHD 5 6 1 12

PPHN 2 1 0 3


8/51

< 1 yr 1

5 yr > 5 yr TOTAL

Acute GE 23 3 1 27

Chronicliver disease

0 1 3 4

Hepatitis 0 1 2 3

Wilsonsdisease

0 1 2 3


9/51

5 YRS TOTAL

HTN 1 2 3

ARF

AGN 1 2 3NEPHROTICSYNDROME

1 4 5

CRF 2 2


10/51

total no of dengue cases=115

dengue cat a =71

dengue cat b=35

dengue cat c=9

ns1 antigen positive at our hospital=18

IgM antibodies positive=52 at our hospital

IgM antibodies positive OUTSIDE AT NIV=10

dengue kit were not available at our hospital for aperiod of 11 days


11/51

OP 1

KEROSENE 1

GOOD NIGHT 1

MULTIPLE TABLETS 1DROWNING 2


12/51

BLUNT TRAUMA ABDOMEN 1

HEAD INJURY 8

SUBGLOTTIC GRANULOMA 1

SNAKE BITE 2PROTEIN LOSING ENTEROPATHY 1

CONG HYDROCEPHALUS 1


13/51

NUTRITIONAL ANEMIA 11

THALLESEMIA 1

SICKLE CELL ANEMIA 1

APLASTIC ANEMIA 2LEUKEMIA 1


14/51

Bugs in ICU

Total no of blood culture sent-362No of culture grown- 201)NFGNB-6(sensitive to meropenem,cip, oflox, netilmycin,mrp,piptaz,amikacin)2)CONS-3(sensitive ceftriaxone,cefotaxim, mrp,, cipro,oflox, gentamycin,amikacin)3)Streptococci 1 ( vancomycin)4)Staph aureus-2 (vancomycin, linezolid)5)Klebsiella-5(pipta, meropenem, oflox )6) E Coli 1 ( meropenem,oflox, piptaz )7) S typhi- 2( cip,oflox, amikacin,mrp,piptaz)

BAL- 35No of culture grown- 22NFGNB-6(cipro,oflox,meropenem, piptaz)

Klebsiella-5(oflox,meropenam, piptaz)MRSA-2( VANCO, LINEZOLID)Pseudomonas-7( mrp,piptaz)Enterobacter-2 (mrp,oflox,amikacin)


15/51

Bugs in ICUCSF- 28

No growth

ascitic fluid-1

Pseudomonas ( piptaz, oflox, meropenem)

Urine- citrobacter-2( piptaz)


16/51

Name - SUNANDAAge - 11yrs

Sex - female

Ip no 103719

AddressGujana halli, kunegal tumkur, karnataka

D.O.A 06/07/14

D.O.D 07/07/14 @ 3 am

Duration1 day

Diagnosis ? Tetanus with autonomic disturbances.


17/51

11 yrs old female child sunanda admitted withcomplaints of

Difficulty in opening the mouth 1 day

Abnormal movements of both upper limbs and

lower limbs, multiple episodes x 1 day,


18/51

p/h 15 days back

pt had fever , nausea, vomiting , generalised weaknessfor 4 days

mild jaundice noticed on day 4 of fever

Shown to a local doctor treated with IM injection


19/51

At admission- PR-110/ min, RR-32/min, BP-98/60 mm of Hg

spo2-95% in RA,, Grbs 98,

Pallor and icterus absent

Locked jaw

GCS-13/15, consciouss ,there was hypertonia involvingall the 4 limbs with exageratted reflexes, with

abnormal arching of the bodyb/l pupils reactive, normal size

P/A liver 2 cm BRCM span of 7 cm


20/51

Provisionally diagnosed as a case of tetanus

In view of tetanus pt was started on C Penicillin, tetanusimmunoglobulins, diazepam

Chlorpromazine was planned but not started( nonavailability of drug)

Subsequently pt had fluctuations in the heart rate, bloodpressure, excussive sweating

Autonomic disturbance was suspected in view of that ptwas started on midazolam infusion and magnesiumsulphate , subsequently pt had arrythmias andsuccumbed secondary to autonomic disturbance


21/51

Hb-14.2 TLC-16,800, P73 PCV-41 Platelets-5.14 lacs Urea-30 Cr-0.7

TB-3 DB-1.2 PROTEIN-8.3 ALBUMIN-4.2 OT-88 PT-168 S Na+ 150 S K+ 5.5 CL - 114


22/51

Learning points

Anticipate complications when there is autonomic

disturbance. ?Availabilty of the drug


23/51

NameAtiya taj

Age 9yrs

Sex female

Ip no

104093Address Gammana halli gubbi taluk, tumkur,

karnataka

D.O.A 19/7/14

D.O.D19/7/14

Diagnosis AGN with ARF with ventriculararrythmias


24/51

9 yrs old Child admitted with

c/o fever x 8 day

c/o cough and cold x 8 days

Throat pain x 8 days

Decrease urine output and difficulty in breathing since 2 days

Shown to a local doctor , treated with fluid boluses and referredhere

At admission HR 102/min, pulse not palpable, RR 36/min, BPnot recordable, CFT > 5secs, peripheries cold. spo2 75% RA. GCS12/15

R/Sthere was tachypnoea, SCR/ICR + , with b/L crepts

P/A -no organomegaly

CVS - S1 and s2 + murmur not appreciated

Oral cavity ulcers + , tonsils enlarged , pharynxs congested


25/51

Out side reportsHb-11.2 gm/dl

TLC-16,400 ,P 84, L 13,

Platelets 4.6 lacs

Urea -325

Creatinine-9

In our hospital , fluid bolus was started , subsequently anECG was taken which shown ventricular arrythmias,


26/51

Suspected as a case AGN with electrolyte disturbances with ? ARF

NS 3 Boluses 20ml/kg were given.subsequently calcium gluconatewas started and ceftriaxone was given

Pt was started on ionotropes( noradrenaline and adrenaline added)after fluid boluses .

For arrythmias lignocaine was startedBut pt was succembed secondary to ventricular arrythmias

Hb-11.5

TLC-9000

P72,L23

Platelets-5.45 lacsp/s NNBP with neutrophilia with reactive thrombocytosis

CRP-35

C3- 71 mg/dl(89-135)


27/51

Learning points

Early referral & transportation & intervation

Communication


28/51

Name

gowthamAge 8yr

Sex male

Ip no 103652

Address 6 th main 16 th cross vijayanagar bangalore.

D.O.A 03/7/14

D.O.D 6/7/14

Diagnosisdiptheria


29/51

Child admitted withc/o fever x 4 days

c/o throat pain x 4days

c/o neck swelling x 2 days ,

Difficulty in swallowing x 2 days Difficulty in breathing x 1 day

Altered sensorium x 1 day

With the above complains pt shown in rajarajeshwarimedical college there pt had cardiac arrest ,cpr was doneand pt was intubated and reffered here,


30/51

At rajarajeshwari hospital , while intubating resident noticed thatthere was a whitish yellow membrane in the pharyngotonsillararea.

Pt was received in our hospital with ET tube insitu with PR-100/min, R/R-26/ min, BP-89/49 mm of Hg

GCS-10/15 R/S - air entry decreased on left side Chest expansion decreased on left side X with bag and tube ventilation CVS NORMAL P/A

NORMAL

CNS-GCS-10/15 Rest of the system WNL


31/51

Suspected a case diphtheria, crystalline penicillin started,adrenaline infusion is started After 7 hrs of admission pt had tachycardia(HR 180/min) So myocarditis was suspected , inv showed Trop I 0.5( 12 hrs, urea and creatinine started increasing ( U 194,CR -3.9)

pt had features of sepsis with bleeding from RT Tube, and oralcavity. Started fluid according to ARF regime,Whole blood

transfusion was given, inj piptaz was added. aPTT (56)wasderanged FFP was given . subsequent electrolyes showed hyperkalemia, inj calcium, K bind ,

asthaline neb was started. Pt collapsed on day 3 of admission dueDIC


32/51

3/7/14 4/7/14 5/7/14Hb 11.8 10.9 8.5

TLC 15.500 20,800 47,700

DC P80L15 P82

PC 59,000 27,000 29,000

PCV 34 30 23


33/51

3/7/14 4/7/14 5/7/14

Na+ 135 130 130K+ 5.4 5.3 6.3

CL- 101 105 100

Urea 117 176 194

cr 1.1 2.8 3.9

crp 163


34/51

We were not able to give ADS because of non availability

Not able to do Peritoneal dialysis because ofthrombocytopenia


35/51

Namekaveri

Age 15 yrs

Sex female

Ip no

103618Address madugeri v mallube tq kolar karnataka .

D.O.A 02/7/14

D.O.D 9/7/14

Diagnosis? SLE

? LEPTOSPIROSIS.


36/51

Kaveri 15 yrs old child admitted with complains of

Fever x 15 days Rashes over body x 15 days Headache x 15 days Pain abdomen x 15 days Nasal and gum bleeding x 10 days

Black coloured stools x 3 days Facial puffiness and tiredness x 3 days O/E PR-94/min, RR-28/min, BP-96/54 mm of Hg , SPO2- 98%, CRT->3 sec Pallor +++ , edema +, compensated shock + , periorbital edema +

,bleeding gums + P/A liver palpable 4 cm BRCM , span of 8 cms, smooth surface, firm in

consistency. Rest of the system WNL


37/51

Pt shown in jalappa hospital kolar there they havenoticed anemia (2.2) Hb and thrombocytopeniatreated with a PRBC and platelet transfusions andreferred here.

Outside reports Hb-2.2, TLC- 8100 (P60, L30), PC-5000

P/S Dimorphic anemia with thrombocytopenia

Reticulocyte count-5.6%

Bone marrow-dry tap

Na+ 131, k+ 3.5, ca+ 8.9, urea-16, cr-0.46, ESR-40


38/51

Pt was treated with fluid boluses RL, treated withCEFTRIAXONE, doxycycline, pantoprazole, PRBCwas given in view of pallor and 2 points of platelettransfusions were given in view ofthrombocytoopenia

On day 2 again blood transfusion and on day 4 c-pen was added in view of leptospirosis

On 6/7/14 again platelet transfusion was given


39/51

2/7/1

4

3/7 5/7 6/7 7/7 8/7

Hb 6.5 6.3 8.5 7 6.1 5.4

TLC 15,800

14 100 12 100 11000

11600

11700

DC P75 P82 P76 P69 P68 P74

PCV 19.8 18.7 25.1 19.2 16.2

PC 2000 13,000

34,000

15000

13000

4000

PT 18.6(1

5)

15(15)

APTT

38(30)

30(30)


40/51

2/7 5/7 7/7 9/7

Na 135 132 135 136

K 2.9 3.1 3.9 3.8

CL 110 103 107 106

UREA 23 22 26

CR 0.7 0.5 0.5

CRP 44.9

TP 4.6 6.4

AB 2.5 3.1


41/51

2/7/14 P/S- occ fragmented cells, polchromatophillic cells markedincreased, occ nucleated RBC, NEUTROPHILIC

LEUCOCYTOSIS,sever thrombocytopenia

4/7/14 Rare Nucleated RBCS, no definative anticoagulants seen, neutrophilcleucocytosis, severe thrombocytopenia, minimal toxic changes

6/7/14 Fragmented RBCS, OCC N RBC, relative neutrophilia, severethrombocytopenia


42/51

Weil felix-neg

Ns1 Ag-neg HIV- neg

Blood culture neg

Urine for leptospira- neg

BM=Normocellular marrow with erythoid predominance Ds DNA- neg

Antinuclear Ab- neg

C3 -78 (83-177)

ESR-40

USG ABD and CHEST= mild ascities, b/L pleural effusion,mild pericardial effusion with posterior segmentconsolidation


43/51

There was gradual improvement in nasal and gumbleeding

Nephrology opinion- ? SLE

Dr. anand sir opinion -? SLE

In view of SLE METHYLPREDNISOLNE was started on8/7/14.

On 8thnight ,Pt again had bleeding from gums and nose

which was associated with headache and altered sensoriunand pallor

PRBC , Platelets ,FFP transfusions were given

pt succumbed secondary to ?intracerebral bleed.


44/51

Learning points

? CAUSE ? Methyprednisolone might have started earlier


45/51

Name bharath

Age 3yrs, 5 mths

Sex male

Ip no 103631

Addressvinayaka nagar kabadahalli v tumkur,Karnataka

D.O.A 03/7/14

D.O.D 09/7/14

Diagnosis?rickettesial encephalitis


46/51

Child admitted withc/o fever x 8 days

rashes all over the body involving palms and soles x 7 days

multiple episodes of convulsions GTCS type involving palms and solesx 1 day

At admission HR-114/min, RR-28/ min, CRT- < 3 Sec, BP-96/60 mm of Hg,spo2 98 %

Pt was in altered sensorium with GCS of 10/15 with no signs of meningealirritation

No neurological deficits, cranial nerves were normalP/A- hepatomegaly 5-6 cm BRCM span of 10 cmNo splenomegalyR/S and CVS were NPROVISIONALLY DIAGNOSED as a case of rickettesial encephalitis


47/51

In view of that pt was treated with doxycycline and azithromycin .andeptoin for convulsions

After admission pt had multiple episodes of convulsion treated withphenobarb and 3 % Nacl for raised ICT

ON DAY OF ADMISSION pt was intubated for multiple episodes ofconvulsions and poor GCS Leveteracetam was added for convulsions blood transfusion was given

for anemia On day 4 pt had hypernatremia Na 150 , 3% nacl stopped On day 5 pt was extubated but trial of extubation was failed

on day 6 there was thick yellowish secretion from ET tube, pt had highgrade of fever with features of sepsis ? VAP was suspected Antibiotics was changed to PIPTAZ, fluconazole was added

subsequently inotropes were added for shock On day 7 pt collapsed secondary to refractory septic shock


48/51

3/7 4/7 5/7 8/7

Hb 8.7 7.9 11 11

TLC 21000 17600 20,100 14 700

DC P71, L20 P71,L26 P74,L23 P78PC 96000 68000 1.1 lac 1.95 lac

CRP >100 81 >100

Ns1AG NEG

WEIL

FELIX

NEG


49/51

3/7 4/7 5/7 6/7 7/7 8/7Na 135 136 150 153 148 139

K 3.1 2.8 3 2.7 4.4 4.6

CL 106 103 115 115 113 82


50/51

REPEAT weil felix neg

IgM DENGUEneg

blood culture-neg

tracheal aspirate- neg


51/51

Learning points

VAP BUNDLES

Mortality Meet for Month of July

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