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Mortality Review

Medical Dept 2016


Hospital Miri

ID and Biodata
Age: 52
Sex: Female
Occupation: Receiptionist
Address: Bandar Baru, Permyjaya, Miri
Date of Admission: 27/12/2015
Date of Death: 19/1/2016
Cause of Death: ischaemic heart disease with
decompensated CCF

Clinical Presentation
Referred by ENT team in ED TRO respiratory
illness
52 years old lady, underlying hypertension, OSA
and post total thyroidectomy for MNG complicated
with hypocalcemia.
Presented with SOB and fever for 1 day.
SOB progressively worsening at 5 am on the day
of admission
No cough, nausea, vomitting or abd pain
Had history of orthopnea and PND
Snore during sleep
3

Examination on admission

Drowsy but arousable, tacypnic, obese, stridor


BP:115/94mmHg
PR:94
RR:32
T:37.7c
Spo2: 84% on BiPAP
HEART: DRNM
LUNGS: bibasal crepitation
ABDOMEN: Soft and non tender
Pedal oedema present
4

Investigations on admission
ABG (on
neb)

ABG (on
BiPAP)

pH

7.15

pH

7.12

pCO2

104.4

pCO2

131.5

pO2

55.7

pO2

59.9

HCO3 28.5
BE

5.3

SO2

79.4
%

RP

FBC
WCC

15.6

urea

10.9

Hb

13.9

creat

123

Plt

354

Na

136

Hct

48.9

4.0

Cl

91

CX
R

Cardiomegaly,
Bilateral lower zone haziness

EC
G

Sinus rhythm, P pulmonale

Initial management
Suggest for intubation in view of
impending respiratory collapse due to
worsening CO2 retention/ respiratory
acidosis-intubated by anaest team
IV augmentin 1.2g TDS
IV frusemide 40mg TDS
Sent blood C+S, sputum AFB, sputum
C+S, urine C+S, urine FEME

Progress in ward
Date

Progress

medication

27/12/1
5
(day 1
intubat
ion)

- intubated, ventilated in ward due to no ICU bed available,


sedated on iv mida/morphine, febrile (T:39c)
-Initially started on ivi frusemide. Subsequently noted BP low at
8pm and ivi frusemide was withold
-Due to persistant hypotension, started on iv noradrenaline

IV Augmentin 1.2g TDS


Iv calcium gluconate 1g over
1h
T calcium lactate 1.2g TDS
T rocaltriol 0.25mg BD
T CaCO3 2g TDS
T L-thyroxine 100 mcg OD
FR 500cc/day
IVD 1 pint/day DS

-Serum ca: 1.39


-ABG @ 8pm=pH 7.55, pCO2 45, PO2 99, lac1.4, HCO3 36.7, BE
15.1, SO2 98%
-Blood c+S: NG
28/12/1
5

GCS E1VTM1 on IV mida/morphine, BP


noradrenaline
Febrile and required high setting ventilor

supported

with

iv

Noted ETT deep, reanchored at 19cm


Had oropharyngeal bleeding (fresh blood)
Reviewed by ENT team: mild bleeding from nasopharynx, packing
was done.
No further bleeding noted
WCC : 15.6 -> 20.5
Plt: 354 -> 296
Hb: 13.9 ->12.6
PT/APTT/INR: 15.2/ 31.9/ 1.25
Corrected Ca : 1.68
Echo done: left atrium moderately dilated, RA& RV dilated,
moderate AR, mild TR, mild MR, poor LV systolic fraction, severe

*IV Rocephine 2g OD
*IV Ca Gluconate 1g stat
*s/c clexane 60mg OD
*IV tranexamic acid 500mg
TDS
T calcium lactate 1.2g TDS
T rocaltriol 0.25mg BD
T CaCO3 2g TDS
T L-thyroxine 100 mcg OD

29/12/15
Day 1 ICU
admission
TRO
leptospiro
sis
AKI
NSTEMI in
failure

Transfer in to ICU for ICU care and stabilization


GCS E1VTM1, sedated, on iv noradrenaline
Started feeding
ECG(27/12/15): T inversion over II, III, aVF
CK inc trend: 263-> 4340
CKMB: 95
RP = Na 141, K 3.9, Cl 95, Urea 21.7, Creat 250
Lepto rapid test and lepto serology taken: rejected (wrong
form)

*IV cefepime 1g BD
Withold s/c clexane
T calcium lactate 1.2g TDS
T rocaltriol 0.25mg BD
T CaCO3 2g TDS
T L-thyroxine 100 mcg OD
IV tranexamic acid 500mg
TDS
Iv omeprazole 40mg BD

CXR reporting: cardiomegaly, bilateral pleural effusion with


adjacent collapse consolidation, apparent widening of
mediastinum could be due to poor inspiration
DNA CPR was issued in view of poor heart function, AKI and
ongoing infection
Urine c+s: NG
ETT c+s: NG
30/12/15
Day 4
intubation
Decompen
sated CCF
2 CAP
Unstable
angina

Spiking fever,
Bp supported by iv noradrenlaine, adrenaline and dobutamine
Poor urine output (20-30cc/h)
Feeding withold
Off sedation
Reviewed by ENT: bilateral nasal packing removed
Flexible scope: no active bleeding at nasopharnyx or other area of
nasal cavity. Slight raw area at nasopharynx and nasal cavity

IV cefepime 1g BD (D2)
Iv frusemide 5 mgSTAT
T calcium lactate 1.2g TDS
T rocaltriol 0.25mg BD
T CaCO3 2g TDS
T L-thyroxine 100 mcg OD
IV tranexamic acid 500mg TDS
Iv omeprazole 40mg BD
IVD 60cc/h

Blood c+s: NG

Date

Progress

Medication

31/12/1
5

Patient febrile, intubated, not sedated, GCS E1VTM1, on 3


ionotrope

IV cefepime 1g BD (D3)
IV lasix 5mg STAT
T calcium lactate 1.2g TDS
T rocaltriol 0.25mg BD
T CaCO3 2g TDS
T L-thyroxine 100 mcg OD
IV tranexamic acid 500mg TDS
Iv omeprazole 40mg BD

Tracheostomy done: cuffed ETT size 7.5. post op was


uneventful.
RP = Na 148, K 4.8, Cl 109, Urea 24, Creat 303
Restarted feeding
Urine output reducing trend (30-40cc/h)
1/1/16
POD1
tracheo
stomy

Noted urea, cretine worsening


-urea 24->44.6
-creatinine 303->562
-K 5.4-> 4.9
-insulin chase done x4
u/o= 5-20cc/h
-ionotrope was tapered down( adrenaline was off)

2/1/16

GCS improving E2VTM1, not sedated


On noradrenaline, able to off dobutamine
HD done 2 hour heparin free, extract 600cc
ABG= pH 7.41, pC02 50, pO2 85, HCo3 29.6, BE 6.0, K
4.8, lac 1.2, SO2 98%
RP preHD = Na 141, K 5.5, Cl 102, Urea 46.5, Creat 584
RP postHD(post 24 h) = Na 139, K 4.9, Cl 100, Urea 37.5,
Creat 485

Iv lasix 5mg stat


*Ivi lasix 1ml/h
*Oral kalimate 10g TDS
Iv cefepime D4
T calcium lactate 1.2g TDS
T rocaltriol 0.25mg BD
T CaCO3 2g TDS
T L-thyroxine 100 mcg OD
IV tranexamic acid 500mg TDS
T omeprazole 40mg BD
IV cefepime D5
Ivi lasix
Oral kalimate 10g TDS
T calcium lactate 1.2g TDS
T rocaltriol 0.25mg BD
T CaCO3 2g TDS
T L-thyroxine 100 mcg OD
IV tranexamic acid 500mg TDS
T omeprazole 40mg BD

Date

Progress

Remark

3/1/16

GCS E3VTM4 not sedated, BP not supported


Patient afebrile
Pt was off ventilation and shifted to TM 50%

IV cefepime 1g BD D6
Ivi lasix
Oral kalimate 10g TDS
T calcium lactate 1.2g TDS
T rocaltriol 0.25mg BD
T CaCO3 2g TDS
T L-thyroxine 100 mcg OD
IV tranexamic acid 500mg TDS
T omeprazole 40mg BD

RP=K 5.6, Urea 40.3, Creat 501


Post Insulin chase K 4.9

4/1/16

Transfer back to FMW


Had episode of desaturation spo2 88% and connected
back to ventilator, restart on sedation and
noradrenaline
Respi: rhonchi
ABG= pH 7.12, pCO2 84, pO2 78, HCO3 21.9, BE -3.7,
SO2 90%
HD was done. Unable to complete 3 hour due to
venous and TMP pressure > 400mmHg. Terminated 15
minute earlier. Extract 400ml under tight heparin
ABG on CPAP= pH 7.36, pCO2 53, pO2 234, lac 1.2,
HCO3 27.6 BE 3.3, SO2 100%
Urea: 46.9-> 35.9
Creatinie: 507-> 459
K: 4.9-> 5.6
u/o; 50-70cc/h
Blood c+s: NG

Iv mida morphine
Iv noradrenaline
Iv cefepime D7
Neb AVN 6 hrly
Oral kalimate 10g TDS
T calcium lactate 1.2g TDS
T rocaltriol 0.25mg BD
T CaCO3 2g TDS
T L-thyroxine 100 mcg OD

Date

Progress

Remark

5/1/16

GCS E3VTM4, ventilated


Sedation was off
Patient febrile

Ivi lasix
Iv noradrenaline
*Iv EES 250mg BD
Ravin enema II/II OD
Syrup lactulose 15 mls TDS
IVD 1 pint/day all NS

Noted NBO since 29/12/2015, abd distended, bowel sound


sluggish, AXR dilated large bowel, refer to surgical.imp
subacute I/O. keep NPO.
K: 5.6 -> 5.5 (post insulin chase)
6/1/16

GCS E4VTM6, BP not supported


Started on TPN, febrile
HD done completed 2 hour heparin free. Extract 1900ml
Urea: 34.4-> 45.1
Creatinie: 634-> 633
K: 5.5-> 5.5
u/o=90cc/24h
i/o=-573cc
blood c+s: NG

7/1/16

GCS E4VTM6, not sedated


off ventilation shifted to TM 50%
ETT suction: blood stained (1 episode)

8/1/16

HD done. Planned for 4 hour however completed about 3


hour HD. Extract 1400cc
ABG= pH 7.32, pCO2 42.9, po2 116.7, HCo3 21.3, BE -3.7,
So2 98%
RP [pre HD]= urea 62.3, creatinine 732, K 5.3

Iv cefazoline 2g EOD
x2/52(during HD)
Ivi lasix
Iv glymine
T calcium lactate 1.2g TDS
T rocaltriol 0.25mg BD
T CaCO3 2g TDS
T L-thyroxine 100 mcg OD

IV cefazolin
IV EES
*Ivi lasix off
T calcium lactate 1.2g TDS
T rocaltriol 0.25mg BD
T CaCO3 2g TDS
T L-thyroxine 100 mcg OD
IV cefazolin
IV EES
Oral kalimate 10g TDS
Iv omeprazole 40mg OD
Iv EES 250mg BD
Iv lasix 40mg TDS

Date

Progress

Medication

9/1/16

Reviewed by ENT team and planned to changed to


double lumen ETT

IV cefazolin
Oral kalimate 10g TDS
Iv omeprazole 40mg OD
Iv EES 250mg BD
Iv lasix 40mg TDS

10/1/1
6

Was allow orally and TPN was off

*Off EES

11/1/1
6

Had episode of desaturation


Spo2 65% on TM 35%
Lung: transmitted sound
Suction: noted blood clot , ? blocked
BG= pH6.95, pco2 89, po2 35, HCO3 12.9, BE -13.5,
SO2 33

Iv cefazolin
T calcium lactate 1.2g TDS
T rocaltriol 0.25mg BD
T CaCO3 2g TDS
T L-thyroxine 100 mcg OD
T tranexamic acid 500mg OD
Iv lasix 40mg TDS

Put on TM 50%
HD done,completed 4 hour under tight heparin. Extract
2L
Urea: 66.4-> 50.7
Creatinine: 815-> 683
K: 6.1-> 4.0
VBG: ph 7.27,PCO2 43, PO2 43, HCO3 19, BE -6.9, SO2
71%
13/1/1
6

Noted Hb 7.8. HD done and was transfused 1 pint


packed cell during HD.. completed for 4 hour extract
2L
Post-transfusion hb 8.3
ABG= pH 7.23, pCO2 45, HCo3 18.8

* s/c clexane 60mg OD


*Iv lasix 40mg OD

Date

Progress

Medication

15/1/16

USG abd: both kidney inc in size, ? Acute renal failure

IV cefazolin
*T haematinics
T CaCO3 1g TDS
T frusemide 40mg OD
T omeprazole 40mg OD
Syr lactulose 15ml ON
T calcitriol 0.25mcg OD

16/1/16

HD done completed 4 hour heparin free. Extract 1000ml


Urea: 38.9-> 10.7
Creatinie: 681-> 396
K: 3.9-> 3.4
u/o=200cc, pm shift

IV cefazolin
T haematinics
T CaCO3 1g TDS
T frusemide 40mg OD
T omeprazole 40mg OD
Syr lactulose 15ml ON
T calcitriol 0.25mcg OD

ABG= pH 7.49, pCO2 39, po2 88, HCo3 29.5, BE -5.9, So2
97%

1718/1/16

GCS E4VTM6, low grade fever 37.8

19/1/16

Noted spo2 40% on TM 35% during straining.


Upon attended, no pulse palpable , no spontaneous
breathing, BP unrecordable, no heart sound, cardiac
minotor show asystole.
DNA CPR issued earlier
Death pronounced at 0745h
Cause of death: ischaemic heart disease with
decompensated CCF

IV cefazolin
T spironolactone 25mg OD
T haematinics
T CaCO3 1g TDS
T frusemide 40mg OD
T omeprazole 40mg OD
Syr lactulose 15ml ON

Date

Specimen

Antibiotic

27/12/15

Blood c+s: NG

IV augmentin
(2728/12/2015)

28/12/2015

Blood c+s:
staph
coagulase ve,
MRO +ve
S-linezolid,
vancomycin

Iv rocephine 1g
BD

29/12/15

Urine c+s: NG
ETT c+s: NG

Iv cefepime 1g
BD (29/12/154/1/16)

30/12/15

Blood c+s:NG
ETT c+s: NG
Urine c+s: NG

Iv cefepime 1g
BD (29/12/154/1/16)

4/1/16

Blood c+s: NG

Iv cefepime 1g
BD (29/12/154/1/16)

THANK YOU

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