Albert Chmielewski

Morbidity & Mortality

• 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.

Patient Information / Chief Complaint

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

• 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

• 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?