VCUDEATH AND COMPLICATIONS CONFERENCE

Brief Overview of Case

S/p ileostomy takedown, crohn’s disease Fungemia, sepsis, MI, death

Introduction for Every Case Complication

Fungemia, sepsis, MI, death Procedure

Ileostomy takedown Primary Diagnosis

Hx crohn’s disease s/p bowel resection, takedown of EC fistula and end ileostomy

Clinical History HPI

22 yo man with crohn’s disease s/p small bowel resection with ileostomy for SBO, complicated with EC fistula, high output ileostomy, takedown of fistula, multiple hospitalizations for management of dehydration.

During last hospitalization for dehydration 1/27, he was resuscitated and decision made for takedown ileostomy

PMHX

Past Medical Crohn’s HTN Coronary artery aneursym (right main and LAD)

diagnosed 10/2012 no cardiology follow-up Past Surgical

As stated previously, in addition multiple PICC lines, last placed prior to 1/27 admission for IV hydration and TPN.

Pertinent medications: carvedilol, percocet, dilaudid

Social hx: smoker, marijuana use, occasional ETOH

Timeline of Key Events Pod 1 – uneventful, HR high 90s Pod 2 – HR low 100, febrile in the evening, cultures sent Pod3

Febrile, tachycardic 109-120, low sbp transiently in late morning, Yeast in blood cx in the afternoon, fluconazole started

Pod4 RRT for hypotension and tachycardia, bolus given, fluconazole continued, TPN

and PICC in place Oxygenation 99-100% RA Team saw patient on rounds, continued resuscitation, ID consulted, micafungin

started Increasing tachycardia, tachypnea, ekg obtained, cardiology cs for st

depression, echo performed

2/2/13

2/4/13 36 hours later

POD 4 continued

Labs sent including enzymes: Troponin 7 ECHO: Left ventricular systolic function is

mildly reduced. EF 45%. There is severe apical wall hypokinesis.

Ct PE obtained Transfer to ICU, on arrival went to PEA,

report of 6 second seizure activity by code team

ACLS protocol, pressors started, cardiac arrest x3 thereafter, pronounced at 1:35pmPrivileged & Confidential: Subject to Peer Review and Medical

Review Protections, O.C.G.A. 31-7-130 et seq. and 31-7-140 et seq.

Analysis of Complication• Was the complication potentially avoidable?

– Yes• Would avoiding the complication change the

outcome for the patient?– Yes, sepsis from fungemia, ?role of his coronary artery aneurysm and

death• What factors contributed the complication?

– Timing of initiation of antifungal– Keeping the potential source of infection in place, continuing TPN

through it– Inadequate communication and hand-off– Lack of timely escalation of care– Possibly change of line upon recent admission– ? Role of coronary artery aneurysm

– “The clinical courses of patients with coronary artery aneurysms usually depend on the severity of the associated atherosclerotic stenoses. Even in the absence of stenosis, abnormal flow patterns within the aneurysm may lead to thrombus formation with subsequent vessel occlusion, distal thromboembolization, or myocardial infarction”

Fungemia Eur J Clin Microbiol Infect Dis 2007, retrospective

study to ID risk factors ICU patients 3000 pts, 2 major risk factors recent Abx, central line Minor: TPN, immunosuppresion, steroid use, pancreatitis, operation in

preceeding week.

Timing of therapy Garey et, al. Clin Infect Dis 2006 Retrospective multicenter study, 230 pts fluconazole 15.4% mortality with same day therapy as blood cx 23.7% if therapy was started on day 1, 36.4% on day 2,

and 41.4% if it was started day 3 (P = .0009) Multivariate analysis revealed increasing mortality with

delay in therapy

UPDATE

Cardiovascular Heart (395 grams) -Concentric thickening and luminal narrowing of left anterior

descending and right coronary arteries. -Mild left ventricular hypertrophy.

Small and large bowels -Multiple intact anastomotic sites. -Focal dusky and congested appearance. -No evidence of bowel perforation, necrosis. -Severe diffuse adhesions throughout abdominal cavity. -Focal right abdominal wall discoloration underlying ileostomy

site. Immediate Cause of Death: 1. Septicemia 2. Pulmonary Edema

References

Ostrosky-Zeichner L., Sable C., Sobel J., et al:  Multicenter retrospective development and validation of a clinical prediction rule for nosocomial invasive candidiasis in the intensive care setting.  Eur J Clin Microbiol Infect Dis 26. (4): 271-276.2007

Garey K.W., Rege M., Pai M.P., et al:  Time to initiation of fluconazole therapy impacts mortality in patients with candidemia: a multi-institutional study.  Clin Infect Dis 43. (1): 25-31.2006

Sellke: Sabiston and Spencer's Surgery of the Chest, 8th ed.