Morbidity & Mortality
Albert Chmielewski
Patient Information / Chief
Complaint
• 44 y/o Male with profound
mental retardation, a resident of
Country View Care center,
brought in to the Emergency
Department for acute
respiratory distress.
HPI
• Admitted on the 7th of August for dyspnea
and hypoxia.
• According to nursing home records, patient
had problems with oral intake of food, and
was a high risk for aspiration.
• Before admission to the ED, patient’s Oxygen
saturation was 78%, with an elevated temp.
of 100.4. Patient was also reportedly
coughing frequently and in moderate
respiratory distress.
HPI cont.
• Upon admission to ED, patient’s Vitals were:
– temperature 99.6, RR 34, Pulse 116, Bp 126/72,
PulseOx 95% @ 5L NC.
• Significant Labs:
– WBC:19.9, HgB:15.1, Na:134, Glu:128.
SGOT/SGPT:55/74. ABG’s:WNL. BUN:9, Cr:0.4
• Chest X-ray showed small left lower lobe
retro-cardiac opacity suspicious for
pneumonia. Blood cultures taken x2.
• Patient received 1L NS bolus and 1 dose of
Zosyn in ED and was transferred to Medical
Floor.
PMH
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Cerebral Palsy
Mental Retardation
GERD
Seizure Disorder (last seizure in 2006)
– Dr. Shah managing
Family Hx
• Both parents deceased from
malignancies of unknown origin.
Social Hx
• Lives at Country View, has been
institutionalized most of his life to due
aggressive behavior as a child.
• Legal guardian is a cousin who provided
much of the patient’s Family and
Social Hx.
ROS
• Could not be obtained other than
the HPI above.
Medications
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Benztropine 0.5mg BID
Gabapentin 300mg TID
Risperidone 0.5mg QAM 1mg QHS
Valproic Acid 325mg TID 500mg QHS
Ranitidine Oral Liquid 120mg QD
Cetirizine 10mg QHS
Fish Oil
MV QD
Medications PRN
• Tylenol 650mg
• Metamucil
• Milk of Magnesia 30ml
Allergies
• NKDA
Physical Exam
• GENERAL : NAD
• HEENT : NC/AT. PERRLA, EOMI. No
cervical LAD, no thyromegaly, no bruit,
oropharynx WNL, neck soft/supple, no LAD.
• Resp: No wheezes, crackles, or pleural rubs.
Fremitus WNL, no dullness to percussion.
• CVS : Systolic Murmur 2+, Tachycardic in the
~100’s, No rubs.
Physical Exam cont.
• Abd : Soft, non-tender, non-distended. NABS.
• Ext : No clubbing, cyanosis, edema. Pulses
intact +2.
• MSK : Generalized muscular atrophy.
• Neuro : Not alert or oriented. Resting tremor
present L side > R side. Moderate Spasticity
of Lower Limbs. Unable to assess CN and
Gait.
• Psych : Unable to assess.
Indication for Intervention
• Acute Respiratory Failure
Labs and Imaging Studies
Labs and Imaging Studies
Labs and Imaging Studies
Labs and Imaging Studies
Labs and Imaging Studies
Labs and Imaging Studies
Labs and Imaging Studies
• Xray from 7th showing small retro-cardiac
opacity.
Labs and Imaging Studies
Labs and Imaging Studies
Labs and Imaging Studies
• Chest Xray from 10th, showing a right
basilar opacity. No significant changes
since prior. Probable small left pleural
effusion.
Labs and Imaging Studies
Labs and Imaging Studies
Labs and Imaging Studies
• Chest Xray from 12th, showing increased
infiltrates in the lung bases, especially in
the right, and small pleural effusions.
Labs and Imaging Studies
Labs and Imaging Studies
Labs and Imaging Studies
• Chest Xrays from 15th, PICC line present.
Stable BL pleural effusions with
associated atelectasis or infiltrate, left
greater than right, with costophrenic
blunting BL.
Procedural Details
• Foley Catheter placement to monitor
I/O’s closely
• Kidney USG to assess any abnormalities
in kidney structure.
• PICC line due to problems with peripheral
IV access.
Brief Hospital Course
Labs and Imaging Studies
Labs and Imaging Studies
Labs and Imaging Studies
Labs and Imaging Studies
Recognition of the Complication
• On the 9th patient developed ARF due to
acute kidney injury of unknown etiology.
• Subsequently the next day the patient
developed hypernatremia which reached
its apex on the 13th.
Management of Complication
• Consulting Nephrology.
• Changing IV fluids to D5W ¼ NS and
monitoring electrolyte imbalance and
kidney function closely.
• USG of Kidney
• Strict I/O’s (cath’d on 10th but emphasized
importance of documenting with nurses)
Assessment and Analysis
• ERROR analysis
– No hemodynamic instability, no
compromise of urologic integrity,
and no obvious reasons for acute
kidney injury were identified.
Difficult to assess the events that
led to this adverse outcome.
Adverse Events and/or Outcomes
During Patients Hospitalization
• Unexpected Death - NO
• Medical/Surgical complications – YES
– AKF secondary to AKI of unknown
etiology, meds the prime suspect???
• Delay in care – NO
• Delay in Diagnosis – Perhaps
– Although a cause/diagnosis of the initial
kidney insult eluded the team/specialists.
Decisive and swift changes to medical
management lead to a positive outcome.
• Prolonged Medical Care in setting of
poor prognosis – NO
Factors Contributing to Adverse
Patient Outcome
• Communication – YES
– Difficulty at times to communicate with Nephrology,
as chart notes and dictated notes differ greatly and
contain different information
• Coordination of Care – NO
• Volume of activity/workload – NO
• Escalation of Care – YES
– On the 10th BUN and Cr were increased to 34 and 3.7
respectively from his admission values of 8 and 0.4.
Nephrology did not see patient till the 12th.
• Recognition of change in clinical status – NO
Root Cause analysis
Questions or comments?