Morbidity & Mortality
Moderator: Heather Hofmann, MD
Coordinator: Omar S. Darwish, DO
September 19, 2014
M&M Conference Objectives
1. Improve medical knowledge
2. Recognize clinical reasoning errors
3. Improve our relationship with specialties & other departments
4. Improve documentation
2
Department of Medicine |September 19, 2014
Time: 09:36
Location: ED
Evaluation: ED
Chief Complaint
ALOC, blood glucose > 500 on scene, 12 day ETOH
3
Department of Medicine |September 19, 2014
History of Present Illness
Time: 09:36
Location: ED
Evaluation: ED
R1:
43M w/ hx of DM and alcohol use presents today with altered level of
consciousness. Other hx is limited as pt provides only short answers to questions.
Per EMS, large amounts of alcohol were found on scene, and the initial call to the
house came from multiple family members nearby who stated that the patient had
stopped acting like himself.
Attending:
43 year old male with a history of alcohol abuse and type 2 DM. Patient states he
has been on an alcohol binge over the last 2 weeks. Notes that his last drink was
this morning. Notes that he feels tired and smells of alcohol. Denies any chest pain
or suicidal thoughts.
4
Department of Medicine |September 19, 2014
Past Medical History
DM, alcohol use
Time: 09:36
Location: ED
Evaluation: ED
Past Surgical, Family & Social History
Unknown
Medications
Not documented in the chart
Allergies
Patient altered
Review of Systems
No fever, no diarrhea, no cough, no shortness of breath. All systems negative.
5
Department of Medicine |September 19, 2014
Time: 09:36
Location: ED
Evaluation: ED
Vitals
Temp 36.9 degrees C
RR 32 per minute
BP 113/57 mm Hg
Pulse ox 98% on room air
HR 105 bpm
Pain 0/10
Physical Exam
GENERAL APPEARANCE: disheveled, smells of alcohol, increased work of breathing
appears intoxicated
HEENT: Normal cephalic, atraumatic, Pupils equally round, reactive to light
bilaterally, extra-ocular movement in tact. Oropharynx is dry, midline uvula
NECK: Supple, nontender, full range of motion, no cervical lymphadenopathy
LUNGS: Clear to auscultation bilaterally without wheezing, rales, rhonchi, does have
deep breaths with tachypnea
CARDIAC: mildly tachycardic with regular rhythm, no murmurs, rubs or gallops.
Extremities are warm and well perfused.
6
Department of Medicine |September 19, 2014
Physical Exam, cont.
Time: 09:36
Location: ED
Evaluation: ED
ABDOMEN: Soft, nontender, nondistended, no rebound, guarding or rigidity.
Positive bowel sounds in all 4 quadrants
SKIN: normal color, dry warm, no rashes
EXTREMITIES: No significant deformity or joint abnormality. No edema. Peripheral
pulses intact. No varicosities.
NEURO: cranial nerves are grossly in tact, moves all extremities
PSYCHIATRIC: The patient was oriented to name, but not place or time, does
appear to speak Spanish
7
Department of Medicine |September 19, 2014
Time: 09:36
Location: ED
Evaluation: ED
Diagnostics
Point of care labs:
Accucheck >500
Ketones 4.4
Serum:
8
Na
122
Total Protein
7.5
WBC
15.2
K
4.9
Albumin
3.8
Neutr
87%
Cl
83
Alk Phos
145
Lymphs
8%
CO2
<5
T bili
2.1
Monos
5%
BUN
22
AST
223
Cr
2.7
ALT
75
Hb
13.3
Glu
667
Hct
39.6
Ca
7.7
Lactate
>11
MCV
85.6
Mg
3.3
Lipase
97
Phos
10.8
Alcohol, ethyl
204
Plt
198
Department of Medicine |September 19, 2014
Diagnostics, cont.
Urinalysis:
pH
5.5
Spec grav 1.012
Protein
200
Glucose
>1000
Ketones
60
Hb
moderate
WBC
3
LE & nitrite negative
RBC
none
Bacteria few
Squamous <1
Budding yeast few
Urine drug screen negative.
9
Department of Medicine |September 19, 2014
Time: 09:36
Location: ED
Evaluation: ED
Time: 10:40
VBG:
pH
pCO2
Bicarb
BE
6.74
20
3
-32
Diagnostics, cont.
10 Department of Medicine |September 19, 2014
Time: 09:36
Location: ED
Evaluation: ED
Diagnostics, cont.
Report:
There are low lung volumes. There is crowding of
the bronchovascular markings. Subtle perihilar or
retrocardiac infiltrate is not excluded. The
pulmonary vasculature does not appear congested.
Heart size appears stable.
11 Department of Medicine |September 19, 2014
Time: 09:36
Location: ED
Evaluation: ED
Assessment
Time: 09:36
Location: ED
Evaluation: ED
Pt with altered mental status, concern for infection vs DKA vs alcohol intoxication.
Full septic workup with labs ordered, Fluid bolus given prior to lab data given
elevated BG by EMS. Basic blood work concerning for DKA with very elevated BG
and CO2 <5.
Plan
Patient given multiple 1L normal saline boluses, will be started on insulin bolus and
insulin drip, will need to be admitted to ICU for q1hr neuro checks and q1hr
glucose checks. Will also notify ICU of possibility of alcohol withdrawal given long
history of alcohol abuse.
12 Department of Medicine |September 19, 2014
Time: 10:54 / 1.5hrs since presentation
Location: ED
Evaluation: ED
Addendum
ICU notified of concern for future alcohol withdrawal.
Pt given 10 units IV insulin, then started on insulin gtt.
1 amp bicarb given for pH < 6.8. MICU aware of ED course
13 Department of Medicine |September 19, 2014
Discussion
Any Questions for the Moderator from the Audience
Regarding What Has Been Presented?
14 Department of Medicine |September 19, 2014
Questions | Critical Care Attending
1. For us doctors, what is/are the highest priority(s) at this time
regarding the care for this patient in the ER?
2. Can you please interpret the venous blood gas? How does it
differ from an arterial blood gas?
pH
pCO2
Bicarb
BE
15 Department of Medicine |September 19, 2014
6.74
20
3
-32
Discussion | Nephrology Attending
1. What is your differential for this patient with severe, high
anion gap metabolic acidosis?
2. What are the indications for administering bicarbonate?
16 Department of Medicine |September 19, 2014
Discussion
Questions?
17 Department of Medicine |September 19, 2014
Chief Complaint
Time: 12:02 / 2.5hrs since presentation
Location: ED
Evaluation: R1 ICU
increased abdominal pain, nausea, vomiting and headache
18 Department of Medicine |September 19, 2014
History of Present Illness
Time: 12:02 / 2.5hrs since presentation
Location: ED
Evaluation: R1 ICU
Additional information vs. ED evaluation:
• last took his (insulin/diabetic pills)? 5 days prior to admission. History of
hospitalization due to DKA, last 1 year ago.
• recently stopped drinking but relapsed 6 days prior to admission. Estimates he
drank 1 beer per night with last drink night prior to admission, consumed 3
beers. History of ETOH withdrawal, unclear of time course and number of
occurrences.
• Complains of loose stools.
• Denies fever, chills, shortness of breath, constipation
At time of interview the patient was still intoxicated and was unable to provide full
details on his medical history.
19 Department of Medicine |September 19, 2014
Past Medical History
Time: 12:02 / 2.5hrs since presentation
Location: ED
Evaluation: R1 ICU
Diabetes, ETOH Abuse, Last doctor visit more than 1 year
Past Surgical History
No known surgeries.
Family History
Diabetes in sister and uncles
Social History
Former smoker, years ago
Drug use: IV cocaine and crystal
methamphetamine, more than 1
year ago
20 Department of Medicine |September 19, 2014
Medications
Possibly insulin or oral glycemic agents
Allergies
Penicillin – presumed anaphylaxis
Review of Systems
Not documented
Vitals
Temp 36.4 degrees C
RR 32 per minute
Time: 12:02 / 2.5hrs since presentation
Location: ED
Evaluation: R1 ICU
BP 106/51 mm Hg
Pulse ox 99% on room air
HR 90 bpm
Pain 0/10
Physical Exam
General: No respiratory distress. Lying in bed complaining of abdominal pain.
Eyes: Extra-ocular movements are intact.
HEENT: external nose and ears are normal.
Chest: Clear to auscultation bilaterally. No wheezes, rhonchi, rales.
Cardiovascular: Regular rate and rhythm.
Abdomen: Soft, non-distended, non-tender, normal active bowel sounds.
Extremity: no clubbing or cyanosis.
Neurological: CN II-XII grossly intact
21 Department of Medicine |September 19, 2014
Time: 12:44 / 3 hrs since presentation
Location: ED
Evaluation: ICU
Diagnostics
Repeated BMP.
Presentation:
3 hours later:
Na
122
Na
126
K
4.9
K
4
Cl
83
Cl
94
CO2
<5
CO2
<5
BUN
22
BUN
21
Cr
2.7
Cr
2.6
Glu
667
Glu
467
Ca
7.7
Ca
6.7
Mg
3.3
Mg
2.8
Phos
10.8
Phos
8.1
Lactate
>11
Lactate
>11
22 Department of Medicine |September 19, 2014
Assessment/Plan
Time: 14:02 / 4.5 hrs since presentation
Location: ED
Evaluation: ICU
R1:
Patient is a 43 year old male with history significant for ETOH abuse and diabetes who
presents with abdominal pain found to be in DKA.
# DKA - unsure of home medication regimen as
patient was intoxicate during initial interview.
- Insulin Drip
- q1 accuchecks
- q4 BMP
- q4 lactate
- Start D5 once BS below 250
# Lactic Acidosis - secondary to DKA,
complaining of abdominal pain
- BCX x 2
# Diarrhea - complaining of loose stools, no
recent antibiotic history
- C. Diff Culture
23 Department of Medicine |September 19, 2014
# AKI - Cr 2.7 on admission
- Urine electrolytes pending
- UCx
# Alcohol Abuse - blood alcohol 204 on
admission
- CIWA protocol at 1/2 dosing
- Banana Bag hung
# Drug Abuse - urine tox screen negative
# Nausea/Vomiting - secondary to DKA
- Zofran 8mg
# deep venous thrombosis prophylaxis
- SCDs
- Lovenox
Assessment/Plan
Time: 15:12 / 5.5 hrs since presentation
Location: ICU
Evaluation: ICU
Attending:
43 years old male with history of DM, unclear home meds regimen, admitted with DKA,
abdominal pain, pancreatitis and recent Alcohol binging, High anion gap, resp distress, mild
with underlying metabolic acidosis
Plan to start Insulin drip , IVF, keep NPO, monitor lytes and lactic acid Q 4 hours. Pan-cultures
are pending
Banana bag and monitor for alcohol withdrawal symptoms
The patient was critically ill during my evaluation and treatment,
The patient meet criteria for critical illness due to DKA, alcoholism, Pancreatitis
24 Department of Medicine |September 19, 2014
Summary |
The ICU team elucidates the following:
Complains of increased abdominal pain, nausea, vomiting, headache, loose stools.
Intoxicated. Diabetic.
Exam
Persistent tachypnea (RR 32)
General: No respiratory distress. Lying in bed complaining of abdominal
pain.
Chest: Clear to auscultation bilaterally. No wheezes, rhonchi, rales.
Abdomen: Soft, non-distended, non-tender, normal active bowel sounds.
Persistent severe low bicarbonate, elevated lactic acid, hyperglycemia (down from
600’s to 400’s).
25 Department of Medicine |September 19, 2014
Discussion | Nephrology Attending
1. What is the differential diagnosis of lactic acidosis for this
patient?
2. How many meQ of bicarbonate are in 1 AMP and for such a
patient with a pH of 6.74 how much bicarbonate is indicated?
26 Department of Medicine |September 19, 2014
Time: 5-6.5 hrs since presentation
Location: ICU
Temp
HR
RR
Sat
O2 (L)
SBP
FiO2
DBP
MAP
From 2-3 PM, MAP decreased from 65 to 56
27 Department of Medicine |September 19, 2014
From 2-3 PM, oxygen requirements
increased from 2L NC to 100% FiO2
Code Blue.
Time: 15:35 / 6 hrs since presentation
Location: ICU
Evaluation: ICU
Event note:
MD notified at 3:45, patient unresponsive. On arrival, patient was pulseless in PEA,
then asystole. CPR initiated, after 3-4 rounds of CPR, 1mg atropine, 2mg epi, and 67 amps of Bicarb given. Patient had ROSC, showing sinus tachycardia on rhythm
strip. Patient initially was breathing on his own, saturating mid 90s, but had NBNB
emesis with alcoholic odor. Given patient AMS and for airway protection, patient
was intubated by ICU attending. Patient given propofol for sedation given his
agitation. He became hypotensive, and was continued on aggressive IVF hydration
and levophed gtt.
28 Department of Medicine |September 19, 2014
Discussion | Critical Care
1. Why did this patient code?
29 Department of Medicine |September 19, 2014
Diagnostics
30 Department of Medicine |September 19, 2014
Time: 20:55 / 11.5 hrs since presentation
Location: ICU
Additional notes
Location: ICU
Central Line Time Out
No report
Time: 16:12 / 7 hrs since presentation
Bronchoscopy, diagnostic Time Out
No report
Time: 18:25 / 9 hrs since presentation
Quinton Line Time Out
Time: 20:15 / 11 hrs since presentation
Non-tunneled multi-lumen dialysis catheter.
Right side
Procedure in Detail: A time out was performed. After identification of
anatomic landmarks, the catheter was introduced into the vein using the
Seldinger technique and appropriate blood return was obtained. Air was
evacuated from each catheter lumen, and the ports were flushed with normal
saline. The patient tolerated the procedure well.
Estimated Blood Loss (mL): less than 5 cc
31 Department of Medicine |September 19, 2014
Diagnostics
32 Department of Medicine |September 19, 2014
Time: 19:23 / 10 hrs since presentation
Location: ICU
Diagnostics
ABG
Location: ICU
Time: 17:52 / 8.5 hrs since presentation
6.89 / 39 / 60 / 7 / 87% on 100% FiO2
ABG
Time: 19:33 / 10 hrs since presentation
6.99 / 44 / 29 / 10 / 59% on 100% FiO2
ABG
Time: 21:12 / 12 hrs since presentation
7.31 / 41 / 25 / 21 / 67% on 100% FiO2
33 Department of Medicine |September 19, 2014
Nephrology Consult
Reason for referral: acidemia, AKI
34 Department of Medicine |September 19, 2014
Time: 22:05 / 12.5 hrs since presentation
Location: ICU
History of Present Illness
Time: 22:05 / 12.5 hrs since presentation
Location: ICU
Evaluation: Nephrology
43 yo M h/o DM2 noncompliant w/ meds and ETOH abuse who p/w profound
acidemia, and DKA. Pt apparently went to party last night, had significant ETOH
consumption (per niece, no other drugs; 12 day ETOH binge) and presented to ED
w/ N/V and was found to be in DKA. Vitals in ED: AF, HR 105, BP 113/57, RR 32,
saturating 98% on RA. Was noted to have AMS w/ DKA; BG was noted to be 600,
CO2 <5, pH 6.74, UA w/ ketones. Pt was started on insulin gtt, received 4L NS
boluses; no bicarb gtt started. Pt arrived in ICU and at time of arrival, was noted to
soon thereafter be unresponsive in pulseless PEA, then asystole. CPR was initiated,
and after 6-7 amps of bicarb, went into sinus tach; had emesis and possibly
aspirated some of this content; was urgently intubated for airway protection.
Became hypotensive was started on levo gtt. Nephrology was subsequently called
to initiate CRRT vs HD given profound acidemia and worsening clinical condition. Pt
now on 4 pressors w/ progressively worsening O2 saturations. Is on FiO2 100%,
PEEP 18; not connected to vent as Pt desaturates to 60s on vent and as such has
required manual bagging at bedside. Urgent RIJ quinton has been placed.
35 Department of Medicine |September 19, 2014
Time: 22:05 / 12.5 hrs since presentation
Location: ICU
Evaluation: Nephrology
PMH, PSH, FM, SH, Home Meds, Allx, ROS
Essentially unchanged, and unable to obtain with patient intubated.
Current medications:
atropine Injection 1 mg Now
methylPREDNISolone SOD SUCC Injection 125 mg Now
micafungin IVPB 100 mg STAT
nitric oxide gas Inhalation 40 parts per million <Continuous>
piperacillin/tazobactam IVPB 2.25 g every 6 hours
prismaSOL BGK 4/2.5 5000 mL <Continuous>
vecuronium Injection 10 mg STAT
cisatracurium Drip 1 MICROgrams / kg / minute <Continuous>
DOPamine Drip 5 MICROgrams / kg / minute <Continuous>
EPINEPHrine Drip 1 MICROgrams / minute <Continuous>
fentaNYL Drip 25 MICROgrams / hour <Continuous>
insulin regular drip DKA initial order 6.6 units / hour <Continuous>
midazolam Drip 1 mg / hour <Continuous>
norepinephrine Drip 40 MICROgrams / minute <Continuous>
pantoprazole Drip 8 mg / hour <Continuous>
phenylephrine Drip 50 MICROgrams / minute <Continuous>
sodium chloride 0.9% Soln 1000 mL <Continuous>
sodium chloride 0.9% Soln 1000 mL <Continuous>
vasopressin Drip 0.04 units / minute <Continuous>
36 Department of Medicine |September 19, 2014
Time: 22:05 / 12.5 hrs since presentation
Location: ICU
Evaluation: Nephrology
Vitals
Temp 33.2 degrees C
RR 25 per minute
BP 82/34 mm Hg
Pulse ox 47% on 100% ETT
Physical Exam
GENERAL: intubated; sedated; disheveled
HEENT: ETT in place
CV: tachycardic; no rub
PULMONARY: ant coarse manual bagging BS B/L
ABDOMEN: distended; soft
EXTREMITIES: no pedal edema
NEURO: sedated
ACCESS: RIJ quinton
37 Department of Medicine |September 19, 2014
HR 119 bpm
Time: 22:05 / 12.5 hrs since presentation
Location: ICU
Evaluation: Nephrology
Diagnostics
Hour 3:
Hour 7:
Hour 12:
Na
126
Na
136
T Protein
7.5
Na
155
T Protein
K
4
K
2.9
Albumin
3.8
K
1.6
Albumin
1.7
Cl
94
Cl
101
Alk Phos
145
Cl
107
Alk Phos
77
CO2
<5
CO2
8
T bili
2.1
CO2
20
T bili
2
BUN
21
BUN
21
AST
223
BUN
17
AST
462
Cr
2.6
Cr
2.5
ALT
75
Cr
2.4
ALT
201
Glu
467
Glu
315
Glu
217
Ca
6.7
Ca
5.9
Ca
10.1
Mg
2.8
Mg
2.2
Mg
1.7
Phos
8.1
Phos
5.8
Phos
1.2
Lactate >11
Lactate >11
38 Department of Medicine |September 19, 2014
Lactate >11
Impression
Time: 22:05 / 12.5 hrs since presentation
Location: ICU
Evaluation: Nephrology
Fellow:
43 yo M h/o DM2 (noncompliant) and ETOH abuse on 12 day binge p/w N/V found to be in
DKA w/ BG 600, pH 6.74, Bicarb <5, urine ketones, lactate acidosis (>11), transaminitis, s/p
PEA arrest. Nephrology consulted for profound acidemia and initiation of CRRT vs iHD.
#. Mixed respiratory acidosis w/ metabolic acidosis; pH of 6.74 w/ bicarb <5 on
admission; most recent pH 6.99 and bicarb 8
#. DKA: AG of 33; BG 667 on admission; reportedly received 4L NS bolus in ED
#. PEA arrest: ? 2/2 acidemia vs electrolyte abnormalities vs resp compromise
#. Hypotension: currently on 4 pressors
#. Hypokalemia: 2/2 insulin gtt shifting K intracellularly
#. Hyperphosphatemia: phos 10.8 on admission 2/2 AKI
#. AKI: BL Cr unknown but Cr on admission of 2.7; oliguric
#. ARDS: high FiO2 requirements; requiring manual bagging; ? aspiration component
#. Pseudohyponatremia: Na 122; corrected for hyperglycemia on admission to be ~132
#. Coagulopathy: INR 1.25
#. Transaminitis: uptrending LFTs; ? ischemic hepatopathy
39 Department of Medicine |September 19, 2014
Recommendations
Time: 22:05 / 12.5 hrs since presentation
Location: ICU
Evaluation: Nephrology
Fellow:
-had extensive discussion w/ family as well as ICU team. pt is critically ill and family is
aware that without dialysis, Pt has strong likelihood of death given continued pressor
requirements, rapidly declining respiratory condition and rapidly worsening clinical
picture, also has strong likelihood to not survive dialysis. discussed CRRT vs iHD; initially
w/ plans to start iHD as Pt was on 3 pressors at that time and not yet max'd out which
would have effect on acidemia more quickly than CRRT, however, clinical picture
continues to deteriorate and pt now on 4 pressors --> proceed w/ CRRT
-family aware of risk of possible death w/ dialysis and declines compressions if Pt codes
during dialysis
-improve hemodynamics as much as possible
-cont insulin gtt
-can cont K 40meq IV while running CRRT to correct hypokalemia
40 Department of Medicine |September 19, 2014
Impression/Recommendations
Time: 11:00 / 25.5 hrs since presentation
Evaluation: Nephrology
Attending:
Patient presented with DKA and severe anion gap acidosis, also with AKI, most likely due to
DKA and prerenal azotemia. Transferred to the MICU in the afternoon and aggressively
resuscitated with fluids and bicarbonate. Nephrology consulted last night given that aggressive
resuscitation did not alleviate his severe metabolic acidosis, I spoke with ICU attending (around
8 pm) at length regarding this patient while fellow evaluated and discussed the critical nature
of this patient's illness with his family. I agreed that renal replacement therapy was indicated
and consent was obtained for dialysis from patient's family by fellow under my supervision and
after discussion of case with me. Family was fully made aware of the risks of dialysis including
hypotension and death. Consent was obtained for CRRT and patient initiated dialysis (CVVHF).
Patient initially with bradycardia prior to initiation of CVVHF, was made DNR by family per
family meeting. Developed bradycardia while on CVVHF and subsequently had cardiac arrest.
Attending Attestation: I did not see the patient on the day of this note, but I have reviewed the
resident/fellow's note and agree with the findings and plan as documented.
Patient passed away last night before I could see him, however I fully reviewed and discussed
his case with Nephrology fellow and ICU attending. All plans in regards to dialysis were made
under my supervision and consent for dialysis was also obtained by fellow under my
supervision and after discussion with me.
41 Department of Medicine |September 19, 2014
Discussion | Nephrology
1. Is dialysis indicated in severe acidosis with relatively
good renal function/good urine output?
2. What is the difference between HD and CRRT?
42 Department of Medicine |September 19, 2014
Event Note
Time: 23:07 / 13.5 hrs since presentation
Location: ICU
Evaluation: R3 ICU
Was at the bedside throughout the night. Briefly, patient presented to the ER and was found to
have DKA with a severe metabolic acidosis. He was admitted to the ICU. Shortly after arrival to the
ICU, patient underwent a code blue (see earlier note). Subsequently throughout the night, the
patient was persistent acidotic. He received multiple pushes of sodium bicarbonate to improve pH.
Additionally, he was persistent hypotensive despite initiation of multiple pressors. After adding
Epinephrine, patient was noted to have entered a wide complex tachycardia, upon further
evaluation with 12-leak EKG, appeared to have a new RBBB along with anterior wall ST elevation.
Epinephrine discontinued and Phenylephrine started. STAT labs obtained, including troponin.
Additionally, patient was persistently hypoxic (as low as 30%) despite multiple attempts to optimize
ventilation settings, and following ischemic EKG changes, was thought to be too unstable for bilevel ventilation. Paralytics were added and given minimal improvement, he was bag-masked by RT
as a result essentially throughout the night. Additionally, due to persistent metabolic acidosis,
nephrology was consulted and agreed to perform HD. Quinton catheter placed in R internal jugular
in anticipation without complications. Prior to proceeding further, patient's family arrived, including
NOK his brother. At the family meeting, Nocturnist and nephrology fellow as well as myself with the
aid of a Spanish translator clearly discussed patient's current situation and grave prognosis. After
discussion with family, everyone in agreement to attempt dialysis as a last resort, knowing that it
could potentially result in cardiac arrest given patient's instability. Family did agree that if his heart
should stop again while on dialysis, no further measures should to be taken to resuscitate him.
43 Department of Medicine |September 19, 2014
Event Note, cont.
Time: 23:07 / 13.5 hrs since presentation
Location: ICU
Evaluation: R3 ICU
Prior to initiating HD, patient had an episode of sinus bradycardia, at which time his HR decreased
to 30s and MAP declined to 40s. He received 1 push of atropine, which he initially responded to.
Additionally he was started on a dopamine drip. Micafungin was added for possible fungal infection
given uncontrolled DM as well as Solu-medrol given persistent hypotension (after discussion with
family for potential for further worsening of any underlying infection). Very slow rate dialysis was
started at approximately 2300 and after approximately 5 minutes, patient had recurrent
bradycardia (while on Epinephrine, Levophed and Dopamine gtt) which evolved into asystole. Exam
performed which showed fixed and dilated pupils, no heart or lung sounds, no palpable pulse and
no response to painful stimuli. Patient pronounced dead at 2307. Family notified and agreed to
autopsy. Coroner as well as Organ/tissue bank notified.
ICU attending physician present at bedside at time of death.
44 Department of Medicine |September 19, 2014
Diagnostics
Blood cultures
09:45 Right AC:
negative
10:35 Right hand:
Gram stain with GNR 7/20 at 4 AM, Klebsiella pneumonia one culture bottle
pan-sensitive
45 Department of Medicine |September 19, 2014
Autopsy
Preliminary Cause of Death:
Multiorgan failure secondary to metabolic acidosis in the setting of diabetic ketoacidosis
Preliminary Autopsy Results:
NOTE: THIS PROVISIONAL DIAGNOSIS REFLECTS FINDINGS NOTED ON GROSS EXAMINATION AT THE
TIME OF AUTOPSY. THESE DIAGNOSES WILL BE SUPERCEDED BY THE FINAL ANATOMIC DIAGNOSIS
ON PAGE 1 OF THE FINAL AUTOPSY REPORT.
Anatomic Provisional Diagnosis
I. BODY AS A WHOLE:
A. WEIGHT 190 LBS., HEIGHT 170 CM
B. SCLERAL ICTERUS
C. ANASARCA
II. CARDIOVASCULAR:
A HEART WEIGHT 350 G
B. LEFT VENTRICULAR HYPERTROPHY (1.6 CM)
C. MILD CALCIFIC ATHEROSCLEROSIS IN CORONARY ARTERIES AND AORTA
D. PERICARDIAL EFFUSION (20 ML)
46 Department of Medicine |September 19, 2014
Autopsy, cont.
III. RESPIRATORY:
VI. RETICULOENDOTHELIAL SYSTEM:
A. SEVERE PULMONARY EDEMA (RIGHT 1160 A SPLEEN 290 G, UNREMARKABLE
G, LEFT 1110 G)
B. PLEURAL EFFUSION (RIGHT 800 ML, LEFT
VII. ENDOCRINE:
1000 ML)
A. THYROID 18.63 G
C. AIRWAYS PATENT, NO GROSS SIGNS OF
B. ADRENAL GLANDS (RIGHT 10.52 G, LEFT
ASPIRATION
9.48 G)
D. INTERLOBAR PLEURAL ADHESIONS
VIII. CENTRAL NERVOUS SYSTEM:
IV. GASTROINTESTINAL:
A. BRAIN WEIGHT 1310 G
A ESOPHAGEAL VARICES, NON-EROSIVE
B. COMPLETE NEUROPATHOLOGICAL EXAM TO
B. GASTRITIS WITH ATROPHIC GASTRIC
FOLLOW FIXATION
MUCOSA
C. SMALL INTESTINE ISCHEMIA, SEGMENTAL
V. HEPATOBILIARY:
A. CIRRHOTIC, NODULAR LIVER (1810 G)
B. BILIARY SYSTEM PATENT
C. GALL BLADDER FREE OF STONES OR
STRAWBERRY SURFACE
D. PANCREAS UNREMARKABLE
47 Department of Medicine |September 19, 2014
Clinical Manifestations of Acidemia.
Kalantar-Zadeh K et al. N Engl J Med 2013;369:374-382.
48
Key Points
1.
Severe acidosis, regardless of the etiology, affects multiple organ systems
2.
Clinical reasoning errors
• Anchor bias—was the lactic acidosis caused by DKA?
• Confirmation bias—fail to reevaluate differential despite persistent lactic
acidosis after fluid resuscitation
• Attribution error—did his alcohol intoxication interfere with our
assessment
3.
Always think a step ahead—Anticipate problems & implement solutions early
4.
Document (e.g., event note) changes in status, family meetings, and all
procedures even when unsuccessful
49 Department of Medicine |September 19, 2014