VCU DEATH AND COMPLICATIONS CONFERENCE

Brief Overview of Case Diagnosis: Procedure: Complication: Right foot cellulitis with PVD Procedure: Superficial femoral to posterior tibial bypass with reverse brachial vein graft Complication: Acute non-oliguric renal failure

Clinical History HPI: 55 yo man with hx DM, PVD s/p femo-pop bypass (1995) and revision 2006 who was admitted to Vascular Surgery service for cellulitis of right foot. Pt had been treated with Keflex/Cipro by PCP for 14 days without improvement. Admitted to Vascular Surgery Service on 1/26 for cellulitis Arterial duplex showed occlusion of SFA Started on Vancomycin and Zosyn

Medical History PMH: SurgHx: Labs: Meds: Physical Exam: Allergies: PVD DM XCHOL HTN SurgHx: Right fem-pop 1995 Right inguinal herniorrhaphy 1997 Revision fem-pop 2006 Labs: CBC: 12.4/13.3/294 BUN 10 / Cr 0.84 Meds: Lisinopril, ASA, plavix, insulin Physical Exam: Vitals: T 36.7 HR 95 BP 137/87 RR 16 O2 100% RA WT 98 kg Gen: NAD Ext: Femoral pulse, no palpable popliteal/DP/PT pulse. Motor and sensation intact. Forefoot extreme TTP Allergies: Latex

Hospital Course Jan 26th: Jan 29th: Jan 30th: Jan 31th: Admitted to Vascular Surgery for cellulitis Started on Vanc/Zosyn Jan 29th: Vancomycin trough 17.1 Jan 30th: Angiogram showed mid SFA occlusion with reconstitution to peroneal and posterior tibial arteries Jan 31th: Infectious disease was consulted for cellulitis who recommended 3 weeks of empiric antibiotic Vanc/Zosyn At once weekly checks of BMP/CBC/Vanc Trough (goal 15 – 20)

Hospital Course Jan 31th: Feb 3rd: Feb 4th: Feb 5th: Infectious disease was consulted for cellulitis who recommended 3 weeks of empiric antibiotic Vanc/Zosyn At once weekly checks of BMP/CBC/Vanc Trough (goal 15 – 20) Feb 3rd: Taken to OR for SFA – PT bypass with reverse brachial vein graft Anesthesia records: SBP 90-150’s. No pressor requirement In: NS 2700 ml and 500 ml albumin Out: EBL 700 ml, UOP 1105 ml Feb 4th: UOP 1990 BUN 20 / Cr 0.81 Feb 5th: UOP 1415, BUN 20 / Cr 3.08, Hemoglobin 7.9 given 1 uPRBC Vanc/Zosyn held. Renal consulted. Vanc trough 54.1

Hospital Course

Analysis of Complication Was the complication potentially avoidable? Perhaps: Vanc trough checked more frequently. Would avoiding the complication change the outcome for the patient? Yes. Possible hemodialysis and may require longer hospitalization What factors contributed the complication? Patient had arteriogram (IV constrast). Questionable intra- operative hypotension

Multi-center prospective observation study: Feb 2008 – June 2010 Primary endpoint: Look at difference in incidence of nephrotoxicity between patients with Vanc trough > 15 mg/L and those < 15 mg/L Secondary endpoint: Look at patient risk factors for nephrotoxicity Define nephrotoxicity as: Increase serum Cr 0.5 mg/L or 50% increase from baseline on 2 consecutive measurements Patients: If you disagree with the management of the case, find data to support your position. If everything was done according to the standard of care, what else could have been done to improve the situation?

If you disagree with the management of the case, find data to support your position. If everything was done according to the standard of care, what else could have been done to improve the situation? Incidence of toxicity with initial trough level > 20 (32%), > 25 (45%), > 30 (50%) 12

Teaching Points No protocol or guideline for the frequency of vancomycin trough level checks Be vigilent and follow trough levels for patients at high risk including recent IV contrast load or recent operations. If you disagree with the management of the case, find data to support your position. If everything was done according to the standard of care, what else could have been done to improve the situation? 13