MORBIDITY%20AND%20MORTALITY%20CONFERENCE

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MORBIDITY AND MORTALITY CONFERENCE

• Zalveen A. Chua MD
• Teresita Aquino MD
• Marivic Punzalan MD

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General Data

• J.A.
• 23 years old
• Male
• Single
• Filipino

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Chief Complaint

• Decrease sensorium

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History of Present Illness

• One Month PTA
• Undocumented fever
• Toothache
• Underwent dental extraction (3 molars)
• Given Mefenamic Acid 500mg for pain relief

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History of Present Illness

• 20 days PTA (10 days post extraction)
• Undocumented fever relieved with Paracetamol
• ()generalized body malaise, ()chills
• No cough, no colds, No dysuria noted
• Consult was done given an unrecalled antibiotic

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History of Present Illness

• Two weeks PTA (16 days post tooth extraction)
• Persistence of fever
• () headache () vomiting ()nape pain
• Consult done at and was advised admission
• Admission was refused due to financial constraints

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History of Present Illness

• 11 days PTA (19 days post extraction)
• Persistence of Symptoms
• Right sided body weakness
• Decrease sensorium with incoherent speech
• Consult was done and patient was admitted
• Cranial CT scan done revealing a left temporal
  lobe abscess with mass effect

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History of Present Illness

• Patient was started on
• 1. Chloramphenicol 500mg IV q 6 hours
• 2. Penicillin G 4,000,000 IU q 6 hours
• Advised Surgery
• Opted to transfer to MMC for the surgical
  management

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Past Medical History

• (-) HPN
• (-) DM
• (-) Asthma

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Family History

• Unremarkable

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Personal and Social History

• Occasional smoker
• Occasional alcoholic beverage drinker
• Fond of playing basketball (hx of trauma?)
• Works as a griller

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Physical Examination

• Patient is drowsy, oriented to 3 spheres not in
  respiratory distress
• Vital signs BP 110/70 HR 58 RR 22 T 36.8
• Skin Good skin turgor, No visible lesions seen
• Head Symmetrical, no palpable masses, no visible
  wounds
• Eye Pink palpebral conjunctiva, anicteric
  sclerae
• Ear No lesions, No discharge, ruptured tympanic
  
• membrane AS, hyperemic tympanic membrane
  AD
• Nose No discharge, No alar flaring
• Throat dry lips and buccal mucosa, no
  tonsillo-pharyngeal
• congestion

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Physical Examination

• Chest and Lungs
• Symmetrical chest expansion, clear breath sounds
• CVS
• Adynamic precordium, No thrills, bradycardic,
  
• no murmurs

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Physical Examination

• Abdomen
• Flat, Hypoactive bowel sounds, soft no
  tenderness
• Extremities
• Symmetrical, Full and equal pulses

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Physical Examination

• Neurologic examination
• Patient is drowsy, with spontaneous eye
• movement, follows commands
• Cranial Nerves
• I n/a VIII intact
• II, III pupils reactive IX,X () gag
• III, IV, VI Full EOMs XII tongue midline
• VII shallow Right NLF

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Physical Examination

• MOTOR
• RUL, RLL 4/5
• LUL, LLL5/5
• Sensory
• No sensory deficits

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Physical Examination

• DTRs
• () Brudzinski () Kernigs sign

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Salient Features

• 23 year old
• Male
• s/p dental extraction
• Undocumented fever
• Headache
• Vomiting
• Nape Pain
• Ruptured TM AS
• Decrease sensorium
• Right sided body weakness

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Impression

• Cerebral abscess L temporal lobe with Mass effect
  secondary to direct contiguous spread probably
  from dental infection vs t/c chronic otitis media
  AS

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Course in the Wards

• Upon admission
• Patient referred to medicine for ID consult and
  clearance
• Diagnostics
• CBC
• Serum Na, K
• Chest X-ray
• PT, PTT
• Repeat cranial CT scan with IV contrast was
  suggested
• 12L ECG sinus bradycardia 54bpm NSSTWC

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Initial Management

• Therapeutics
• Penicillin G 4 million units IV q 4 hours
• Metronidazole 500mg/tab q6 to be shifted to
• IV once on NPO
• Mannitol 100cc q 4 hours
• PNSS1L x 100cc/hr

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Course in the Wards

• 1st HD
• CBC
• Hgb 12.1 Hct 36 WBC 13240 seg 75 lym 11
• Na 134 K 2.6
• PT, PTT Normal
• Chest X-ray No Significant Chest Findings
• 12L ECG sinus bradycardia 37bpm with anteroseptal
  wall ischemia LVH by voltage

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Course in the Wards

• 1st HD
• Patient remained drowsy but coherent
• Vital signs BP 110/80 HR 45 RR 20 T 36.6C
• DAT
• Seen by ID service with the ff suggestions
• Referral to Cardiology
• Referral to Dental Services

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Course in the Wards

• 1st HD
• K correction was started
• Kalium durule 4 durules x 2 doses
• KCL 30meq PNSS 100cc x 8 hours
• Acetylcysteine 600mg OD started
• Repeat K and 12L ECG in AM

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Course in the Wards

• 2nd HD
• Patient seen by cardiology service with the ff
  assessment
• No evidence of active cardiac disease,
  hypokalemia probably nutritional with ongoing
  correction.
• Recommendation No objection to contemplated
  surgery with low to intermediate risk if repeat K
  results are already acceptable

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Course in then Wards

• 2nd HD
• Noted to be more drowsy but arousable
• Pupils 3 mm dilated ERTL
• Mannitol 50 cc IV extra dose was given
• Bricanyl drip 1 amp in D5W 250cc x 10cc/hr to
  attain a heart rate of at least 80bpm
• Need for immediate surgery was contemplated
  pending CP clearance

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Course in the Wards

• 3rd HD
• Patient noted to be unresponsive and cyanotic
• BP 0 CR 34 bpm
• CPR started, Epinephrine 1 amp x 2 doses and
  NaHCO3 1amp x 1 dose given
• Intubation done
• Patient was revived

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Course in the Wards

• 3rd HD
• Due to poor prognosis and worsening condition,
  his father opted DNAR in case of another arrest

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Course in the Wards

• 4th HD
• Patient subsequently expired

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General Approach to the Patient

• The consultant must bear in mind that the
  perioperative evaluation may be the ideal
  opportunity to affect long-term treatment of a
  patient with significant cardiac disease
• The referring physician and patient should be
  informed of the results of the evaluation and
  implications for the patients prognosis
• The consultant can assist in planning for
  follow-up

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Preoperative Clinical Evaluation

• The initial history, physical examination and ECG
  should focus on identification of potentially
  serious cardiac disorders such as
• coronary artery disease (prior MI and
  angina)
• heart failure
• symptomatic arrhythmias
• presence of pacemaker or
  implantable cardioverter defibrillator (ICD)
• history of orthostatic intolerance
  

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Preoperative Clinical Evaluation

• Define disease severity, stability and prior
  treatment
• Factors that help determine cardiac risk
• functional capacity
• age
• comorbid conditions (diabetes
  mellitus, peripheral vascular disease, renal
  dysfunction, and chronic pulmonary disease)
• Type of surgery (vascular procedures and
  prolonged complicated thoracic, abdominal, head
  and neck procedures)

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Preoperative Clinical Evaluation

• Other risk indices
• history of cerebrovascular disease
• preoperative elevated creatinine, gt2mg/dl
• insulin treatment for diabetes mellitus
• high-risk surgery

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Clinical Predictors of Increased Perioperative
Cardiovascular Risk
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Clinical Predictors of Increased Perioperative
Cardiovascular Risk
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Functional Capacity

• Expressed in metabolic equivalent (MET) levels
• Perioperative cardiac and long-term risks are
  increased in patients unable to meet a 4-MET
  demand during most normal daily activities

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Functional Capacity
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Surgery-Specific Risk

• 2 Important factors
• 1. the type of surgery
• 2. the degree of hemodynamic stress
  associated with the procedure

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• Management of Specific Preoperative
  Cardiovascular Conditions

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Clinical Predictors of Increased Perioperative
Cardiovascular Risk
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Further Preoperative Testing to Assess Coronary
Risk
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Functional Capacity

• Expressed in metabolic equivalent (MET) levels
• Perioperative cardiac and long-term risks are
  increased in patients unable to meet a 4-MET
  demand during most normal daily activities

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Functional Capacity
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Surgery-Specific Risk

• 2 Important factors
• 1. the type of surgery
• 2. the degree of hemodynamic stress
  associated with the procedure

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Cardiac Risk Stratification for Noncardiac
Surgical Procedures
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• Management of Specific Preoperative
  Cardiovascular Conditions

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Hypertension

• Stage 3 hypertension (SBP greater than or equal
  to 180 mmHg and DBP greater than or equal to 110
  mmHg should be controlled before surgery)
• Establishment of an effective regimen can be
  achieved over several days to weeks of
  preoperative outpatient treatment
• If surgery is more urgent, rapid acting agents
  can be administered
• Continuation of preoperative antiypertensive
  treatment through the perioperative period is
  critical

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Valvular Heart Disease

• Symptomatic stenotic lesions are associated with
  risk of perioperative heart failure or shock
• Symptomatic regurgitant valve disease is usually
  better tolerated perioperatively and maybe
  stabilized preoperatively with intensive medical
  therapy and monitoring

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Valvular Heart Disease

• Regurgitant valve disease can be treated
  definitively with valve repair or replacement
  after noncardiac surgery
• Exceptions include severe valvular regurgitation
  with reduced left ventricular function

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Myocardial Disease

• Dilated and hypertrophic cardiomyopathy are
  associated with an increased incidence of
  perioperative heart failure
• Management is aimed at maximizing preoperative
  hemodynamic status and providing intensive
  postoperative medical therapy and surveillance

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Arrhythmias and Conduction Abnormalities

• Therapy should be initiated for symptomatic or
  hemodynamically significant arrhythmias
• Indications for antiarrhythmic therapy and
  cardiac pacing are identical to the nonoperative
  setting

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Arrhythmias and Conduction Abnormalities

• Frequent ventricular beats and/or asymptomatic
  non-sustained ventricular tachycardia have not
  been associated with an increased risk of MI or
  cardiac death in the perioperative period
• Aggressive monitoring or treatment in the
  perioperative period generally is not necessary

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Implantable Pacemakers or ICDs

• The type and extent of evaluation of a pacemaker
  or ICD depend on
• the urgency of the surgery
• whether a pacemaker has unipolar or
  bipolar leads
• whether electrocautery is bipolar
  or unipolar
• the distance between electrocautery
  and pacemaker
• pacemaker dependency
• ICD devices should be programmed off immediately
  before surgery and then on again postoperatively

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Supplemental Preoperative Evaluation

• Assessment of left ventricular function
• Exercise stress testing
• Pharmacological stress testing
• Ambulatory ECG monitoring
• Coronary angiography

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Supplemental Preoperative Evaluation

• In most ambulatory patients, the test of choice
  is exercise ECG testing which
• 1. provides an estimate of functional
  capacity
• 2. detects myocardial ischemia
• In patients with important abnormalities on
  resting ECG (LBBB, LVH with strain pattern, or
  digitalis effect), exercise ECG or exercise
  myocardial perfusion imaging should be considered

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Recommendations for Preoperative Noninvasive
Evaluation of Left Ventricular Function

• Class I Patients with current or poorly
  controlled heart failure (If previous evaluation
  has documented severe left ventricular
  dysfunction, repeat preoperative testing may not
  be necessary)
• Class IIa Patients with prior heart failure and
  patients with dyspnea of unknown origin
• Class III As a routine test of left ventricular
  function in patients without prior heart failure

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Recommendations for Preoperative 12-Lead Rest ECG

• Class I Recent episode of chest pain or ischemic
  equivalent in clinically intermediate- or
  high-risk patients scheduled for an intermediate-
  or high-risk operative procedure
• Class IIa Asymtomatic persons with diabetes
  mellitus

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Recommendations for Preoperative 12-Lead Rest ECG

• Class IIb
• 1. Patients with prior coronary
  revascularization
• 2. Asymptomatic male gt45 years old or female
  gt55 years old with 2 or more atherosclerotic risk
  factors
• 3. Prior hospital admission for cardiac
  causes
• Class III As a routine test in asymptomatic
  subjects undergoing low-risk operative procedures

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Recommendations for Exercise or Pharmacological
Stress Testing

• Class I
• 1. Diagnosis of adult patients with
  intermediate pretest probability of CAD
• 2. Prognostic assessment of patients
  undergoing initial evaluation for suspected or
  proven CAD
• 3. Demonstration of proof of myocardial
  ischemia before coronary revascularization
• 4. Evaluation of adequacy of medical therapy

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Recommendations for Exercise or Pharmacological
Stress Testing

• Class IIa Evaluation of exercise capacity when
  subjective assessment is unreliable
• Class IIb
• 1. Diagnosis of CAD patients with high or low
  pretest probability
• those with resting ST depression less
  than 1 mm
• those taking digitalis
• those with ECG criteria for LVH

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Recommendations for Exercise or Pharmacological
Stress Testing

• Class IIb
• 2. Detection of restenosis in high-risk
  asymptomatic subjects within the initial months
  after percutaneous coronary intervention
• Class III
• 1. For exercise stress testing, diagnosis of
  patients with resting ECG abnormalities that
  preclude adequate assessment (pre-excitation
  syndrome, electronically paced ventricular
  rhythm, rest ST depression gt1 mm or left bundle
  branch block)

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Recommendations for Exercise or Pharmacological
Stress Testing

• Class III
• 2. Severe comorbidity likely to limit life
  expectancy or candidacy for revascularization
• 3. Routine screening of asymptomatic men or
  women
• 4. Investigation of isolated ectopic beats
  in young patients