1. VCU Death and Complications Conference

2. Brief Overview of Case S/p ileostomy takedown, crohn’s disease
Fungemia, sepsis, MI, death

3. Introduction for Every Case
Complication
Fungemia, sepsis, MI, death
Procedure
Ileostomy takedown
Primary Diagnosis
Hx crohn’s disease s/p bowel resection, takedown of EC fistula and end ileostomy
Give a synopsis of each case to start the presentation.

4. Clinical History
HPI
22 yo man with crohn’s disease s/p small bowel resection with ileostomy for SBO, complicated with EC fistula, high output ileostomy, takedown of fistula, multiple hospitalizations for management of dehydration.
During last hospitalization for dehydration 1/27, he was resuscitated and decision made for takedown ileostomy

5. PMHX Past Medical Past Surgical
Crohn’s
HTN
Coronary artery aneursym (right main and LAD) diagnosed 10/2012 no cardiology follow-up
Past Surgical
As stated previously, in addition multiple PICC lines, last placed prior to 1/27 admission for IV hydration and TPN.
Pertinent medications: carvedilol, percocet, dilaudid
Social hx: smoker, marijuana use, occasional ETOH

6. Timeline of Key Events Pod 1 – uneventful, HR high 90s
Pod 2 – HR low 100, febrile in the evening, cultures sent
Pod3
Febrile, tachycardic , low sbp transiently in late morning,
Yeast in blood cx in the afternoon, fluconazole started
Pod4
RRT for hypotension and tachycardia, bolus given, fluconazole continued, TPN and PICC in place
Oxygenation % RA
Team saw patient on rounds, continued resuscitation, ID consulted, micafungin started
Increasing tachycardia, tachypnea, ekg obtained, cardiology cs for st depression, echo performed

7. 2/2/13

8. 2/4/13 36 hours later

11. POD 4 continued Labs sent including enzymes: Troponin 7
ECHO: Left ventricular systolic function is mildly reduced. EF 45%. There is severe apical wall hypokinesis.
Ct PE obtained
Transfer to ICU, on arrival went to PEA, report of 6 second seizure activity by code team
ACLS protocol, pressors started, cardiac arrest x3 thereafter, pronounced at 1:35pm
Privileged & Confidential: Subject to Peer Review and Medical Review Protections, O.C.G.A et seq. and et seq.

12. Analysis of Complication
Was the complication potentially avoidable?
Yes
Would avoiding the complication change the outcome for the patient?
Yes, sepsis from fungemia, ?role of his coronary artery aneurysm and death
What factors contributed the complication?
Timing of initiation of antifungal
Keeping the potential source of infection in place, continuing TPN through it
Inadequate communication and hand-off
Lack of timely escalation of care
Possibly change of line upon recent admission
? Role of coronary artery aneurysm
“The clinical courses of patients with coronary artery aneurysms usually depend on the severity of the associated atherosclerotic stenoses. Even in the absence of stenosis, abnormal flow patterns within the aneurysm may lead to thrombus formation with subsequent vessel occlusion, distal thromboembolization, or myocardial infarction”

13. Fungemia
Eur J Clin Microbiol Infect Dis 2007, retrospective study to ID risk factors
ICU patients 3000 pts, 2 major risk factors recent Abx, central line
Minor: TPN, immunosuppresion, steroid use, pancreatitis, operation in preceeding week.
Timing of therapy
Garey et, al. Clin Infect Dis 2006
Retrospective multicenter study, 230 pts fluconazole
15.4% mortality with same day therapy as blood cx
23.7% if therapy was started on day 1, 36.4% on day 2, and 41.4% if it was started day 3 (P = .0009)
Multivariate analysis revealed increasing mortality with delay in therapy

14. UPDATE Cardiovascular Heart (395 grams)
-Concentric thickening and luminal narrowing of left anterior descending and right coronary arteries.
-Mild left ventricular hypertrophy.
Small and large bowels
-Multiple intact anastomotic sites.
-Focal dusky and congested appearance.
-No evidence of bowel perforation, necrosis.
-Severe diffuse adhesions throughout abdominal cavity.
-Focal right abdominal wall discoloration underlying ileostomy site.
Immediate Cause of Death: 1. Septicemia
2. Pulmonary Edema

15. References
Ostrosky-Zeichner L., Sable C., Sobel J., et al:  Multicenter retrospective development and validation of a clinical prediction rule for nosocomial invasive candidiasis in the intensive care setting.  Eur J Clin Microbiol Infect Dis 26. (4):
Garey K.W., Rege M., Pai M.P., et al:  Time to initiation of fluconazole therapy impacts mortality in patients with candidemia: a multi-institutional study.  Clin Infect Dis 43. (1):
Sellke: Sabiston and Spencer's Surgery of the Chest, 8th ed.