Morbidity and Mortality Rounds Dr. Shounak Das July 27, 2007

History HPI: 53 y.o. Hispanic female admitted through the ER with fever + hypotension53 y.o. Hispanic female admitted through the ER with fever + hypotension h/o diabetes, morbid obesity, CAD 8 years s/p CABG complicated by CVA with residual hemiplegiah/o diabetes, morbid obesity, CAD 8 years s/p CABG complicated by CVA with residual hemiplegia 1 month PTA admitted with PE1 month PTA admitted with PE PPM placed 3 weeks PTAPPM placed 3 weeks PTA 1 day PTA developed chills, nausea, vomiting1 day PTA developed chills, nausea, vomiting

History PMH: diabetesdiabetes CADCAD CVACVA dyslipidemiadyslipidemia PSH: CABGCABG R knee surgeryR knee surgery lap cholylap choly hypertension hypertension morbid obesity morbid obesity pulmonary embolus pulmonary embolus PPM placement PPM placement IVC filter IVC filter

History meds (home): aspirin 81 mg dailyaspirin 81 mg daily lisinopril 10 mg dailylisinopril 10 mg daily actos 45 mg dailyactos 45 mg daily 70/30 insulin 20 units bid70/30 insulin 20 units bid toprol XL 50 mg dailytoprol XL 50 mg daily allergies: NKDANKDA

History FH: +ve for diabetes + hypertension+ve for diabetes + hypertension SH: marriedmarried non-smoker; no EtOHnon-smoker; no EtOH

History ROS: denies chest pain or palpitationsdenies chest pain or palpitations no coughno cough denies abdominal pain or recent change in bowel habitsdenies abdominal pain or recent change in bowel habits denies dysuriadenies dysuria weight gain is notedweight gain is noted she complains of slight headacheshe complains of slight headache

Physical Exam Vital signs: HR: 88 (reg) RR: 24 HR: 88 (reg) RR: 24 BP: 80/51T°: BP: 80/51T°: HEENT: PERRLA/EOMI/anicteric/oropharynx normal/no lymphadenopathy PERRLA/EOMI/anicteric/oropharynx normal/no lymphadenopathy Chest: clear to auscultation bilaterally/mild inflammation around pacemaker pocket; no fluctuance/drainage clear to auscultation bilaterally/mild inflammation around pacemaker pocket; no fluctuance/drainage General: ill-looking obese patient ill-looking obese patient

Physical Exam CVS: RRR/NL S 1 + S 2 /no extra sounds, rubs, or murmurs RRR/NL S 1 + S 2 /no extra sounds, rubs, or murmurs Abdo: Nl bowel sounds/ soft, non-tender/no hepatosplenomegaly Nl bowel sounds/ soft, non-tender/no hepatosplenomegaly Neuro: CN II-XII intact/R-sided weakness (U>L) CN II-XII intact/R-sided weakness (U>L) Extremities: +1 bilateral ankle edema +1 bilateral ankle edema Skin: no rashes no rashes

Labs Ca 2+ : corr Mg 2+ : 0.8 TP: 5.3 Alb: 2.4 AST: 27 ALT: 13 Alk Phos: 85 T bili: 0.9 INR: 1.3 fibrinogen: 309 CRP: 11 60%N16%L12%M11%B AG = 9

Labs  CXR: low volumes; no infiltrate  u/a: 25 WBC/hpf  blood cultures: 2/2 +ve for MSSA  TEE: RA lead – 2-3 mm mobile vegetation/thrombus

started on IV vancomycin initially, then switched to nafcillin once sensitivities confirmedstarted on IV vancomycin initially, then switched to nafcillin once sensitivities confirmed started on pressorsstarted on pressors intubated hospital day #2intubated hospital day #2 started on CVVHD hospital day #8 for ARFstarted on CVVHD hospital day #8 for ARF pacemaker removed hospital day #11pacemaker removed hospital day #11 MOF; persistent hypotension despite maximal pressorsMOF; persistent hypotension despite maximal pressors withdrawal of care hospital day # 15withdrawal of care hospital day # 15 Course in Hospital

Pacemaker Infections  incidence roughly 5%  90% of these are “pocket infections”  remaining are “deeper infections” i.e. “device – related endocarditis”  risk factors: diabetes, recent manipulation of device, temporary pacers  90% caused by s. epidermis or s. aureus  1/3 rd “early” (3-6 mos.); 2/3rds “late” (after 3-6 mos.)  lead removal recommended for device-related endocarditis