morbidity and mortality conference

MORBIDITY AND MORBIDITY AND MORTALITY MORTALITY

CONFERENCECONFERENCE

Zalveen A. Chua MDZalveen A. Chua MD

Teresita Aquino MDTeresita Aquino MD

Marivic Punzalan MDMarivic Punzalan MD

General DataGeneral Data

• J.A. J.A. • 23 years old 23 years old • MaleMale• Single Single • FilipinoFilipino

Chief ComplaintChief Complaint

Decrease sensoriumDecrease sensorium

History of Present IllnessHistory of Present Illness

One Month PTAOne Month PTA• Undocumented feverUndocumented fever• ToothacheToothache• Underwent dental extraction (3 Underwent dental extraction (3

molars) molars) • Given Mefenamic Acid 500mg for Given Mefenamic Acid 500mg for

pain reliefpain relief


20 days PTA (10 days post extraction)20 days PTA (10 days post extraction)• Undocumented fever relieved with Undocumented fever relieved with

ParacetamolParacetamol• (+)generalized body malaise, (+)chills(+)generalized body malaise, (+)chills• No cough, no colds, No dysuria notedNo cough, no colds, No dysuria noted• Consult was done given an unrecalled Consult was done given an unrecalled

antibioticantibiotic


Two weeks PTA (16 days post tooth Two weeks PTA (16 days post tooth extraction)extraction)

• Persistence of feverPersistence of fever• (+) headache (+) vomiting (+)nape (+) headache (+) vomiting (+)nape

painpain• Consult done at and was advised Consult done at and was advised

admissionadmission• Admission was refused due to financial Admission was refused due to financial

constraintsconstraints


11 days PTA (19 days post extraction)11 days PTA (19 days post extraction)• Persistence of SymptomsPersistence of Symptoms• Right sided body weaknessRight sided body weakness• Decrease sensorium with incoherent Decrease sensorium with incoherent

speechspeech• Consult was done and patient was Consult was done and patient was

admittedadmitted• Cranial CT scan done revealing a left Cranial CT scan done revealing a left

temporal lobe abscess with mass effecttemporal lobe abscess with mass effect

Past Medical HistoryPast Medical History

• (-) HPN(-) HPN• (-) DM(-) DM• (-) Asthma(-) Asthma

Family HistoryFamily History

UnremarkableUnremarkable

Personal and Social Personal and Social HistoryHistory

• Occasional smokerOccasional smoker• Occasional alcoholic beverage Occasional alcoholic beverage

drinkerdrinker• Fond of playing basketball (hx of Fond of playing basketball (hx of

trauma?)trauma?)• Works as a “griller”Works as a “griller”

Physical ExaminationPhysical Examination

Patient is drowsy, oriented to 3 spheres not in respiratory Patient is drowsy, oriented to 3 spheres not in respiratory distressdistress

Vital signs: BP: 110/70 HR 58 RR 22 T: 36.8Vital signs: BP: 110/70 HR 58 RR 22 T: 36.8Skin: Good skin turgor, No visible lesions seenSkin: Good skin turgor, No visible lesions seenHead: Symmetrical, no palpable masses, no visible Head: Symmetrical, no palpable masses, no visible

woundswoundsEye: Pink palpebral conjunctiva, anicteric scleraeEye: Pink palpebral conjunctiva, anicteric scleraeEar: No lesions, No discharge, Ear: No lesions, No discharge, ruptured tympanic ruptured tympanic membrane ASmembrane AS, hyperemic tympanic membrane AD, hyperemic tympanic membrane ADNose: No discharge, No alar flaringNose: No discharge, No alar flaringThroat: dry lips and buccal mucosa, no tonsillo-Throat: dry lips and buccal mucosa, no tonsillo-

pharyngeal pharyngeal congestioncongestion


Chest and LungsChest and Lungs

Symmetrical chest expansion, clear Symmetrical chest expansion, clear breath soundsbreath sounds

CVSCVS

Adynamic precordium, No thrills, Adynamic precordium, No thrills, bradycardic, bradycardic,

no murmursno murmurs


AbdomenAbdomen

Flat, Hypoactive bowel sounds, soft Flat, Hypoactive bowel sounds, soft no tendernessno tenderness

ExtremitiesExtremities

Symmetrical, Full and equal pulsesSymmetrical, Full and equal pulses


Neurologic examinationNeurologic examination Patient is drowsy, with spontaneous eye Patient is drowsy, with spontaneous eye

movement, follows commandsmovement, follows commandsCranial NervesCranial NervesI: n/aI: n/a VIII: intact VIII: intactII, III: pupils reactive IX,X (+) gagII, III: pupils reactive IX,X (+) gagIII, IV, VI: Full EOMs III, IV, VI: Full EOMs XII: tongue midline XII: tongue midlineVII: shallow Right NLF VII: shallow Right NLF


MOTORMOTOR

RUL, RLL : 4/5RUL, RLL : 4/5

LUL, LLL:5/5LUL, LLL:5/5

SensorySensory

No sensory deficitsNo sensory deficits


• DTR’s: ++DTR’s: ++

• (+) Brudzinski (+) Kernig’s sign(+) Brudzinski (+) Kernig’s sign

Salient FeaturesSalient Features

• 23 year old 23 year old • MaleMale• s/p dental extractions/p dental extraction• Undocumented feverUndocumented fever• HeadacheHeadache• VomitingVomiting• Nape PainNape Pain• Ruptured TM ASRuptured TM AS• Decrease sensoriumDecrease sensorium• Right sided body weaknessRight sided body weakness

ImpressionImpression

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

Course in the WardsCourse in the WardsUpon admissionUpon admission

Patient referred to medicine for ID consult and clearancePatient referred to medicine for ID consult and clearance

DiagnosticsDiagnosticsCBCCBCSerum Na, KSerum Na, KChest X-rayChest X-rayPT, PTTPT, PTTRepeat cranial CT scan with IV contrast was suggestedRepeat cranial CT scan with IV contrast was suggested12L ECG sinus bradycardia 54bpm NSSTWC12L ECG sinus bradycardia 54bpm NSSTWC

Initial ManagementInitial Management

Therapeutics Therapeutics

Penicillin G 4 million units IV q 4 Penicillin G 4 million units IV q 4 hourshours

Metronidazole 500mg/tab q6 to be Metronidazole 500mg/tab q6 to be shifted to shifted to

IV once on NPOIV once on NPO

Mannitol 100cc q 4 hoursMannitol 100cc q 4 hours

PNSS1L x 100cc/hr PNSS1L x 100cc/hr

Course in the WardsCourse in the Wards

11stst HD HD • CBCCBC Hgb 12.1 Hct 36 Hgb 12.1 Hct 36 WBC 13240WBC 13240 seg 75 lym seg 75 lym

1111• Na 134 Na 134 K 2.6K 2.6• PT, PTT: NormalPT, PTT: Normal• Chest X-ray: No Significant Chest FindingsChest X-ray: No Significant Chest Findings• 12L ECG 12L ECG sinus bradycardia 37bpm with sinus bradycardia 37bpm with

anteroseptal wall ischemia LVH by anteroseptal wall ischemia LVH by voltagevoltage


11stst HD HD• Patient remained drowsy but coherentPatient remained drowsy but coherent• Vital signs BP 110/80 HR 45 RR 20 T Vital signs BP 110/80 HR 45 RR 20 T

36.6C36.6C• DATDAT• Seen by ID service with the ff Seen by ID service with the ff

suggestionssuggestions– Referral to Cardiology Referral to Cardiology – Referral to Dental ServicesReferral to Dental Services


11stst HD HD• K+ correction was startedK+ correction was started

Kalium durule 4 durules x 2 doses Kalium durule 4 durules x 2 doses

KCL 30meq + PNSS 100cc x 8 hoursKCL 30meq + PNSS 100cc x 8 hours• Acetylcysteine 600mg OD startedAcetylcysteine 600mg OD started• Repeat K and 12L ECG in AMRepeat K and 12L ECG in AM


22ndnd HD HD• Patient seen by cardiology service Patient seen by cardiology service

with the ff assessmentwith the ff assessmentNo evidence of active cardiac disease, No evidence of active cardiac disease, hypokalemia probably nutritional with hypokalemia probably nutritional with ongoing correction.ongoing correction.Recommendation: No objection to Recommendation: No objection to contemplated surgery with low to contemplated surgery with low to intermediate risk if repeat K results intermediate risk if repeat K results are already acceptableare already acceptable

Course in then WardsCourse in then Wards

22ndnd HD HD • Noted to be more drowsy but arousableNoted to be more drowsy but arousable• Pupils 3 mm dilated ERTL Pupils 3 mm dilated ERTL • Mannitol 50 cc IV extra dose was givenMannitol 50 cc IV extra dose was given• Bricanyl drip 1 amp in D5W 250cc x Bricanyl drip 1 amp in D5W 250cc x

10cc/hr to attain a heart rate of at least 10cc/hr to attain a heart rate of at least 80bpm80bpm

• Need for immediate surgery was Need for immediate surgery was contemplated pending CP clearancecontemplated pending CP clearance


33rdrd HD HD• Patient noted to be unresponsive and Patient noted to be unresponsive and

cyanoticcyanotic• BP 0 CR 34 bpm BP 0 CR 34 bpm • CPR started, Epinephrine 1 amp x 2 CPR started, Epinephrine 1 amp x 2

doses and NaHCO3 1amp x 1 dose doses and NaHCO3 1amp x 1 dose givengiven

• Intubation doneIntubation done• Patient was revivedPatient was revived


33rdrd HD HD• Due to poor prognosis and Due to poor prognosis and

worsening condition, his father worsening condition, his father opted DNAR in case of another opted DNAR in case of another arrestarrest


44thth HD HD• Patient subsequently expired Patient subsequently expired

General Approach to the General Approach to the PatientPatient

• The consultant must bear in mind that the The consultant must bear in mind that the perioperative evaluation may be the ideal perioperative evaluation may be the ideal opportunity to affect long-term treatment of opportunity to affect long-term treatment of a patient with significant cardiac diseasea patient with significant cardiac disease

• The referring physician and patient should The referring physician and patient should be informed of the results of the evaluation be informed of the results of the evaluation and implications for the patient’s prognosisand implications for the patient’s prognosis

• The consultant can assist in planning for The consultant can assist in planning for follow-upfollow-up

Preoperative Clinical Preoperative Clinical EvaluationEvaluation

• The initial history, physical examination and The initial history, physical examination and ECG should focus on identification of ECG should focus on identification of potentially serious cardiac disorders such as:potentially serious cardiac disorders such as:

coronary artery disease (prior MI and angina)coronary artery disease (prior MI and angina)

heart failureheart failure

symptomatic arrhythmiassymptomatic arrhythmias

presence of pacemaker or implantable presence of pacemaker or implantable cardioverter defibrillator (ICD)cardioverter defibrillator (ICD)

history of orthostatic intolerancehistory of orthostatic intolerance


• Define disease severity, stability and prior Define disease severity, stability and prior treatmenttreatment

• Factors that help determine cardiac risk:Factors that help determine cardiac risk:

functional capacity functional capacity ageage comorbid conditions (diabetes mellitus, peripheral comorbid conditions (diabetes mellitus, peripheral

vascular disease, renal dysfunction, and chronic vascular disease, renal dysfunction, and chronic pulmonary disease) pulmonary disease)

Type of surgery Type of surgery (vascular procedures and prolonged (vascular procedures and prolonged complicated thoracic, abdominal, head and neck complicated thoracic, abdominal, head and neck procedures)procedures)


• Other risk indices:Other risk indices:

history of cerebrovascular diseasehistory of cerebrovascular disease

preoperative elevated creatinine, preoperative elevated creatinine, >2mg/dl>2mg/dl

insulin treatment for diabetes mellitusinsulin treatment for diabetes mellitus

high-risk surgery high-risk surgery

Clinical Predictors of Clinical Predictors of Increased Perioperative Increased Perioperative

Cardiovascular RiskCardiovascular Risk

Functional CapacityFunctional Capacity

• Expressed in metabolic equivalent (MET) Expressed in metabolic equivalent (MET) levelslevels

• Perioperative cardiac and long-term risks Perioperative cardiac and long-term risks are are increased in patients unable to meet a increased in patients unable to meet a 4-MET demand4-MET demand during most normal daily during most normal daily activitiesactivities

Surgery-Specific RiskSurgery-Specific Risk

• 2 Important factors:2 Important factors:

1. the type of surgery1. the type of surgery

2. the degree of hemodynamic stress 2. the degree of hemodynamic stress associated with the procedureassociated with the procedure

Management of Specific Management of Specific Preoperative Preoperative Cardiovascular Cardiovascular

ConditionsConditions

Clinical Predictors of Clinical Predictors of Increased Perioperative Increased Perioperative

Cardiovascular RiskCardiovascular Risk

Further Preoperative Further Preoperative Testing to Assess Testing to Assess

Coronary RiskCoronary Risk


• Expressed in metabolic equivalent (MET) Expressed in metabolic equivalent (MET) levelslevels

• Perioperative cardiac and long-term risks Perioperative cardiac and long-term risks are are increased in patients unable to meet a increased in patients unable to meet a 4-MET demand4-MET demand during most normal daily during most normal daily activitiesactivities

Surgery-Specific RiskSurgery-Specific Risk

• 2 Important factors:2 Important factors:

1. the type of surgery1. the type of surgery

2. the degree of hemodynamic stress 2. the degree of hemodynamic stress associated with the procedureassociated with the procedure

Cardiac Risk Cardiac Risk Stratification for Stratification for

Noncardiac Surgical Noncardiac Surgical ProceduresProcedures

Management of Specific Management of Specific Preoperative Preoperative Cardiovascular Cardiovascular

ConditionsConditions

HypertensionHypertension• Stage 3 hypertension (SBP greater than or equal to Stage 3 hypertension (SBP greater than or equal to

180 mmHg and DBP greater than or equal to 110 180 mmHg and DBP greater than or equal to 110 mmHg mmHg should be controlled before surgery)should be controlled before surgery)

• Establishment of an effective regimen can be Establishment of an effective regimen can be achieved over several days to weeks of preoperative achieved over several days to weeks of preoperative outpatient treatmentoutpatient treatment

• If surgery is more urgent, rapid acting agents can be If surgery is more urgent, rapid acting agents can be administeredadministered

• Continuation of preoperative antiypertensive Continuation of preoperative antiypertensive treatment through the perioperative period is critical treatment through the perioperative period is critical

Valvular Heart Disease Valvular Heart Disease

• Symptomatic stenotic lesions are Symptomatic stenotic lesions are associated with risk of perioperative heart associated with risk of perioperative heart failure or shock failure or shock

• Symptomatic regurgitant valve disease is Symptomatic regurgitant valve disease is usually better tolerated perioperatively usually better tolerated perioperatively and maybe stabilized preoperatively with and maybe stabilized preoperatively with intensive medical therapy and monitoringintensive medical therapy and monitoring

Valvular Heart DiseaseValvular Heart Disease

• Regurgitant valve disease can be treated Regurgitant valve disease can be treated definitively with valve repair or definitively with valve repair or replacement after noncardiac surgeryreplacement after noncardiac surgery

• Exceptions include severe valvular Exceptions include severe valvular regurgitation with reduced left ventricular regurgitation with reduced left ventricular function function

Myocardial DiseaseMyocardial Disease

• Dilated and hypertrophic cardiomyopathy Dilated and hypertrophic cardiomyopathy are associated with an increased are associated with an increased incidence of perioperative heart failureincidence of perioperative heart failure

• Management is aimed at maximizing Management is aimed at maximizing preoperative hemodynamic status and preoperative hemodynamic status and providing intensive postoperative medical providing intensive postoperative medical therapy and surveillance therapy and surveillance

Arrhythmias and Arrhythmias and Conduction AbnormalitiesConduction Abnormalities

• Therapy should be initiated for Therapy should be initiated for symptomatic or hemodynamically symptomatic or hemodynamically significant arrhythmiassignificant arrhythmias

• Indications for antiarrhythmic therapy Indications for antiarrhythmic therapy and cardiac pacing are identical to the and cardiac pacing are identical to the nonoperative settingnonoperative setting

Arrhythmias and Arrhythmias and Conduction AbnormalitiesConduction Abnormalities

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

• Aggressive monitoring or treatment in the Aggressive monitoring or treatment in the perioperative period generally is not perioperative period generally is not necessarynecessary

Implantable Implantable Pacemakers or ICDsPacemakers or ICDs

• The type and extent of evaluation of a The type and extent of evaluation of a pacemaker or ICD depend on:pacemaker or ICD depend on:

the urgency of the surgery the urgency of the surgery whether a pacemaker has unipolar or bipolar whether a pacemaker has unipolar or bipolar

leads leads whether electrocautery is bipolar or unipolarwhether electrocautery is bipolar or unipolar the distance between electrocautery and the distance between electrocautery and

pacemakerpacemaker pacemaker dependency pacemaker dependency

ICD devices should be programmed off ICD devices should be programmed off immediately before surgery and then on again immediately before surgery and then on again postoperativelypostoperatively

Supplemental Supplemental Preoperative EvaluationPreoperative Evaluation

• Assessment of left ventricular functionAssessment of left ventricular function• Exercise stress testingExercise stress testing• Pharmacological stress testingPharmacological stress testing• Ambulatory ECG monitoringAmbulatory ECG monitoring• Coronary angiography Coronary angiography

Supplemental Supplemental Preoperative EvaluationPreoperative Evaluation

• In most ambulatory patients, the test of In most ambulatory patients, the test of choice is choice is exercise ECG testing exercise ECG testing which :which :

1. provides an estimate of functional capacity1. provides an estimate of functional capacity

2. detects myocardial ischemia 2. detects myocardial ischemia

In patients with important abnormalities In patients with important abnormalities on resting ECG (LBBB, LVH with strain on resting ECG (LBBB, LVH with strain pattern, or digitalis effect), exercise ECG pattern, or digitalis effect), exercise ECG or exercise myocardial perfusion imaging or exercise myocardial perfusion imaging should be consideredshould be considered

Recommendations for Recommendations for Preoperative Noninvasive Preoperative Noninvasive

Evaluation of Left Ventricular Evaluation of Left Ventricular FunctionFunction• Class I Class I Patients with current or poorly Patients with current or poorly

controlled heart failure (If previous evaluation controlled heart failure (If previous evaluation has documented severe left ventricular has documented severe left ventricular dysfunction, repeat preoperative testing may dysfunction, repeat preoperative testing may not be necessary)not be necessary)

• Class IIa Class IIa Patients withPatients with prior heart failure prior heart failure and patients with dyspnea of unknown originand patients with dyspnea of unknown origin

• Class III Class III As a routine test of left ventricular As a routine test of left ventricular function in patients without prior heart failurefunction in patients without prior heart failure

Recommendations forRecommendations for Preoperative 12-Lead Preoperative 12-Lead

Rest ECGRest ECG

• Class IClass I Recent episode of chest pain or Recent episode of chest pain or ischemic equivalent in clinically ischemic equivalent in clinically intermediate- or high-risk patients intermediate- or high-risk patients scheduled for an intermediate- or high-scheduled for an intermediate- or high-risk operative procedure risk operative procedure

• Class IIaClass IIa Asymtomatic persons with Asymtomatic persons with diabetes mellitusdiabetes mellitus

Recommendations forRecommendations for Preoperative 12-Lead Preoperative 12-Lead

Rest ECGRest ECG• Class IIbClass IIb 1. Patients with prior coronary revascularization1. Patients with prior coronary revascularization

2. 2. AsymptomaticAsymptomatic male >45 years old or female male >45 years old or female >55 years old>55 years old with 2 or more atherosclerotic risk with 2 or more atherosclerotic risk factorsfactors

3. Prior hospital admission for cardiac causes3. Prior hospital admission for cardiac causes

Class III Class III As a routine test in asymptomatic As a routine test in asymptomatic subjects undergoing low-risk operative subjects undergoing low-risk operative proceduresprocedures

Recommendations for Recommendations for Exercise or Exercise or

Pharmacological Stress Pharmacological Stress TestingTesting• Class IClass I

1. Diagnosis of adult patients with 1. Diagnosis of adult patients with intermediate pretest probability of CADintermediate pretest probability of CAD

2. Prognostic assessment of patients 2. Prognostic assessment of patients undergoing initial evaluation for suspected undergoing initial evaluation for suspected or proven CADor proven CAD

3. Demonstration of proof of myocardial 3. Demonstration of proof of myocardial ischemia before coronary revascularizationischemia before coronary revascularization

4. Evaluation of adequacy of medical 4. Evaluation of adequacy of medical therapy therapy


Pharmacological Stress Pharmacological Stress TestingTesting• Class IIa Class IIa Evaluation of exercise capacity when Evaluation of exercise capacity when

subjective assessment is unreliablesubjective assessment is unreliable

• Class IIb Class IIb 1. Diagnosis of CAD patients with high or low 1. Diagnosis of CAD patients with high or low

pretest probability :pretest probability :

those with resting ST depression less than 1 those with resting ST depression less than 1 mmmm

those taking digitalisthose taking digitalis

those with ECG criteria for LVH those with ECG criteria for LVH


Pharmacological Stress Pharmacological Stress TestingTesting• Class IIb Class IIb

2. Detection of restenosis in high-risk 2. Detection of restenosis in high-risk asymptomatic subjects within the initial months asymptomatic subjects within the initial months after percutaneous coronary interventionafter percutaneous coronary intervention

• Class IIIClass III 1. For exercise stress testing, diagnosis of patients 1. For exercise stress testing, diagnosis of patients

with resting ECG abnormalities that preclude with resting ECG abnormalities that preclude adequate assessment (pre-excitation syndrome, adequate assessment (pre-excitation syndrome, electronically paced ventricular rhythm, rest ST electronically paced ventricular rhythm, rest ST depression >1 mm or left bundle branch block) depression >1 mm or left bundle branch block)


Pharmacological Stress Pharmacological Stress TestingTesting

• Class IIIClass III

2. Severe comorbidity likely to limit life 2. Severe comorbidity likely to limit life expectancy or candidacy for expectancy or candidacy for revascularizationrevascularization

3. Routine screening of asymptomatic 3. Routine screening of asymptomatic men or womenmen or women

4. Investigation of isolated ectopic beats 4. Investigation of isolated ectopic beats in young patientsin young patients

morbidity and mortality conference

Documents

units iv q

left temporal lobe abscess

visible lesions seenhead

admittedcranial ct scan

pttrepeat cranial ct

visible woundseye

x gagiii

mass effect secondary