MORTALITY REPORT

CASE- AKI( Acute Kidney Injury)

Department- Nephrology
Other Departments Involved-GE and Critical
Care.
SR Incharge- Dr. Hilal A Malla SR Nephrology
Moderator- Dr. B A Laway Prof & Head
Endocrinology.
Presenter- Dr. Qazi Mohammad Iqbal SR
Community Medicine.
CASE- AKI( Acute Kidney Injury)
Department- Nephrology
Other Departments Involved-GE and Critical
Care.
SR Incharge- Dr. Hilal A Malla SR Nephrology
Moderator- Dr. B A Laway Prof & Head
Endocrinology.
Presenter- Dr. Qazi Mohammad Iqbal SR
Community Medicine.
7/3/2014 1
Name of Deceased Bhat Abdul Rahim
S/O Bhat Gh. Mohammad
R/O Narain Bagh Ganderbal
Age- 50 Yrs Sex-Male
Under MRD No. 00802892 Under MRD No. 00802892
Date of Admission-18-05-2014 Date of Death- 18-05-2014
Total Stay at SKIMS 22 hours
7/3/2014 2
Reception note in AE At 12.15 am
50 yr male NT/ND admitted with
Complaints of
BLN
Pain abdomen
With h/o of fever, cough and vomiting
O/E Conc. Oriented
Tachypnic -40/min
BP -111/50 mmHg
SaO
2
-75% on Room air
Chest-Rt. ISA Crepts +
CVS-S1 S2 +
P/A- Tender RHC
CXR- Rt. LZ CAP with effusion
Impression- Rt CAP with
effusion.
PLAN
Base Line Investigations
ECG
ABG with elect.
Sicu consult.
Treatment received(12.45
am)
Inj. Levoflox 750mg iv
Inj. Hydrocort 100mg iv
Inj Lasix 20mg iv
Salbair Nebul.
50 yr male NT/ND admitted with
Complaints of
BLN
Pain abdomen
With h/o of fever, cough and vomiting
O/E Conc. Oriented
Tachypnic -40/min
BP -111/50 mmHg
SaO
2
-75% on Room air
Chest-Rt. ISA Crepts +
CVS-S1 S2 +
P/A- Tender RHC
CXR- Rt. LZ CAP with effusion
Impression- Rt CAP with
effusion.
PLAN
Base Line Investigations
ECG
ABG with elect.
Sicu consult.
Treatment received(12.45
am)
Inj. Levoflox 750mg iv
Inj. Hydrocort 100mg iv
Inj Lasix 20mg iv
Salbair Nebul.
7/3/2014 3
At 1 am-Case seen by
resident AE
Pt restless tachypnic
BP 100/40 mmHg ; SO
2
80% on FM
PLAN- Repeat ABG
SICU consultation
At 1.50 am
Pt conc. , In distress
RR 42/min- BP
100/50mmHg
SO
2
70% on FM
IMPRESSION OF CAP
with severe Met acidosis
? AKI
Treatment received-
Inj Pip.+Tazo 4.5 gm iv(time 1.30am)
Inj NaHCO3 100meq in 200 ml DNS over 40 min( 2 am)
At 1 am-Case seen by
resident AE
Pt restless tachypnic
BP 100/40 mmHg ; SO
2
80% on FM
PLAN- Repeat ABG
SICU consultation
At 1.50 am
Pt conc. , In distress
RR 42/min- BP
100/50mmHg
SO
2
70% on FM
IMPRESSION OF CAP
with severe Met acidosis
? AKI
ABG
Revealed
Na
+
-118 K
+
- 5.4 PO
2
139
PCO
2
15 HCO
3
3.0
pH
6.89
7/3/2014 4
Case discussed with SR Nephro. 2.10 am
Shift patient for Peritoneal dialysis
Repeat
ABG
Revealed
Na
+
-117 K
+
- 5.5 PO
2
124
PCO
2
16 HCO
3
3.0
pH
6.87
Shift patient for Peritoneal dialysis
7/3/2014 5
Patient seen by SR nephro
Time not mentioned
Pt. had visited A/E 3 days back on 15-5-2014 with similar
complaints.
Pt was investigated in A/E which revealed;
Hb-11.8; TLC-6.23 ; DLC-N 64 L 21; Plt- 76
Urea-69; Cr.- 1.7 Bl. Sugar(R)- 99
Bil-1.18; ALT-29; ALP-54
U/E- Pus cell 3-5; Alb & Sugar Nil
USG Abd.- B/L mod. Pleural effusion R>L with mild ascites with
prominent hepatic vein.
Received Monocef-O; Azithromycin & Torsemide.
Patient was advised for follow up in General Medicine/
Nephrology OPD
Pt. had visited A/E 3 days back on 15-5-2014 with similar
complaints.
Pt was investigated in A/E which revealed;
Hb-11.8; TLC-6.23 ; DLC-N 64 L 21; Plt- 76
Urea-69; Cr.- 1.7 Bl. Sugar(R)- 99
Bil-1.18; ALT-29; ALP-54
U/E- Pus cell 3-5; Alb & Sugar Nil
USG Abd.- B/L mod. Pleural effusion R>L with mild ascites with
prominent hepatic vein.
Received Monocef-O; Azithromycin & Torsemide.
Patient was advised for follow up in General Medicine/
Nephrology OPD
7/3/2014 6
Pt was admitted with
BLN & Drowsiness 1 day
duration
Diffuse pain abd.
Vomiting
H/O decreased urine output
Exam revealed-
Pt. Conc, Drowsy, Tachypnic
BP- 100/50 mm Hg
Chest- Decreased RS Rt. LZ
CVS- S
1
S
2
+
P/A- Soft, Diffuse tenderness +
CNS- moving all four limbs.
CBC/ KFT-awaited
CXR- Rt Lower zone
consolidation/effusion
Impression- CAP with
Severe met. Acidosis
R/O- DKA ( do Urgent
Blood sugar)
PLAN
Shift to ward 4A for urgent
PD as pt condition not
well
Inj Pip+tazo 4.5 gm iv BD
Inj Levofloxacin 500mg iv
Alt day
Collect CBC/KFT
Pt was admitted with
BLN & Drowsiness 1 day
duration
Diffuse pain abd.
Vomiting
H/O decreased urine output
Exam revealed-
Pt. Conc, Drowsy, Tachypnic
BP- 100/50 mm Hg
Chest- Decreased RS Rt. LZ
CVS- S
1
S
2
+
P/A- Soft, Diffuse tenderness +
CNS- moving all four limbs.
CBC/ KFT-awaited
CXR- Rt Lower zone
consolidation/effusion
Impression- CAP with
Severe met. Acidosis
R/O- DKA ( do Urgent
Blood sugar)
PLAN
Shift to ward 4A for urgent
PD as pt condition not
well
Inj Pip+tazo 4.5 gm iv BD
Inj Levofloxacin 500mg iv
Alt day
Collect CBC/KFT
7/3/2014 7
Ward 4A reception note- 2.30 am
50 yr male NT,ND presented with
Cough without expectoration &
Fever(high gr assoc. with rigor &
chills) -10 days
Vomiting ( Mult. Episodes) & Abd
Pain-2days.
Doub ul H/O sed urine output.
O/E- Afebrile; BP-96/60 mmHg; RR-
30/min; Pulse-96/min
Pallor+; Cyanosis+; Edema-Neg.; JVP-not
raised
CHEST-b/l decreased air entry, rt basal
crepts
CVS- S1 S2 + Tachycardia
CNS- Drowsy ; GCS-13/15
P/A- Tense; Tenderness Neg
No Organomegaly
IMPRESSION
1) CAP with severe met.
Acidosis with
hyponatremia with
hyperkalemia AKI? (Sepsis
related?)
2) Abd pain with Acute
Pancreatitis, vomiting
induced AKI.
PLAN
1) Base line
2) Start PD
3) Inj NaHCO
3
4) GE call
5) SICU Call
6) Sr. Amylase
50 yr male NT,ND presented with
Cough without expectoration &
Fever(high gr assoc. with rigor &
chills) -10 days
Vomiting ( Mult. Episodes) & Abd
Pain-2days.
Doub ul H/O sed urine output.
O/E- Afebrile; BP-96/60 mmHg; RR-
30/min; Pulse-96/min
Pallor+; Cyanosis+; Edema-Neg.; JVP-not
raised
CHEST-b/l decreased air entry, rt basal
crepts
CVS- S1 S2 + Tachycardia
CNS- Drowsy ; GCS-13/15
P/A- Tense; Tenderness Neg
No Organomegaly
IMPRESSION
1) CAP with severe met.
Acidosis with
hyponatremia with
hyperkalemia AKI? (Sepsis
related?)
2) Abd pain with Acute
Pancreatitis, vomiting
induced AKI.
PLAN
1) Base line
2) Start PD
3) Inj NaHCO
3
4) GE call
5) SICU Call
6) Sr. Amylase
7/3/2014 8
GE call for Sev. Abd. Pain with vomiting
with Sev. Met. Acidosis(?? Ac. Pancreatitis)
5.15 am
C/S by SR GE
Exam revealed- Acidotic
breathing; Talking irrelevant
PR-96 b/m ;BP-96/60
PA- PD catheter in place,
soft, ND, NT, NO
organomegaly
Chest- B/L occ wheeze Rt
sed air entry at base
Cr- NA; USG Abd- NA ;
Amylase- NA
IMP- Rt CAP with rt effusion
with ARF with severe
metabolic acidosis
R/O Post- strep GN.
No feature of acute Abd
clinically
Pain Abd/ Vomiting can be
explained by Rt LZ
consolidation and AKI
respectively.
Continue PD
Will be reviewed.
Exam revealed- Acidotic
breathing; Talking irrelevant
PR-96 b/m ;BP-96/60
PA- PD catheter in place,
soft, ND, NT, NO
organomegaly
Chest- B/L occ wheeze Rt
sed air entry at base
Cr- NA; USG Abd- NA ;
Amylase- NA
IMP- Rt CAP with rt effusion
with ARF with severe
metabolic acidosis
R/O Post- strep GN.
No feature of acute Abd
clinically
Pain Abd/ Vomiting can be
explained by Rt LZ
consolidation and AKI
respectively.
Continue PD
Will be reviewed.
7/3/2014 9
Reassessed by SR Nephro at 7 am
Pt persisted with tachypnia with shock
BP-90/40 mmHg
CBC- Hb-12.1; TLC-11.2 ; Plt- 114
KFT- 131/3.8 Glu-110 Repeat BS (R)- 206
Bil-5.26; ALT-1849; ALP-66; Ca- 10.8; Amylase-134
VBG-;pH -6.90; Na
+
- 120; K
+
-4.8 & HCO
3
- 4.5
Suggested Urgent SICU consultation
Start Inotropic Support
Pt persisted with tachypnia with shock
BP-90/40 mmHg
CBC- Hb-12.1; TLC-11.2 ; Plt- 114
KFT- 131/3.8 Glu-110 Repeat BS (R)- 206
Bil-5.26; ALT-1849; ALP-66; Ca- 10.8; Amylase-134
VBG-;pH -6.90; Na
+
- 120; K
+
-4.8 & HCO
3
- 4.5
Suggested Urgent SICU consultation
Start Inotropic Support
7/3/2014 10
Case seen by SR Critical care 9.25 am
50 yr male case of AKI with Sev.
Met Acidosis on PD.
O/E- Consc. Oriented breathing
spontaneously on O
2
mask
HR-96bpm; BP- 80/40mmHg;
RR- 16 pm
GCS- E4 V5 M6 15/15
Chest-b/l basal crepts +; AE
Rt base
CVS- S1 S2 +
Input- on PD
Output- Nil
Advise;
Propped up position
High Conc NRM
breathing Mask
Start NA infusion so
as to maintain
MAP75
Repeat ABG
Central line
Effective HD/PD
50 yr male case of AKI with Sev.
Met Acidosis on PD.
O/E- Consc. Oriented breathing
spontaneously on O
2
mask
HR-96bpm; BP- 80/40mmHg;
RR- 16 pm
GCS- E4 V5 M6 15/15
Chest-b/l basal crepts +; AE
Rt base
CVS- S1 S2 +
Input- on PD
Output- Nil
Advise;
Propped up position
High Conc NRM
breathing Mask
Start NA infusion so
as to maintain
MAP75
Repeat ABG
Central line
Effective HD/PD
ABG pH-6.90 pCO
2
-23 pO
2
-88 HCO
3
-4.5
7/3/2014 11
Pt. Shifted to SICU at 11.15 am
Conc.; Oriented
Pulse-100/min; BP- 60/30 mmHg on NA and
Dopamine support from ward 4A.
RR-36/min; Central line Rt Jugular ooze ++.
Chest- Rt. Basal crepts; CVS- S
1
S
2
+
PA-Soft PD catheter in place.
Dobutamine drip started & increased to max. pt not
maintaining BP60/30 mmHg.
HCO
3
of 400 meq(200 & 200) given.
Conc.; Oriented
Pulse-100/min; BP- 60/30 mmHg on NA and
Dopamine support from ward 4A.
RR-36/min; Central line Rt Jugular ooze ++.
Chest- Rt. Basal crepts; CVS- S
1
S
2
+
PA-Soft PD catheter in place.
Dobutamine drip started & increased to max. pt not
maintaining BP60/30 mmHg.
HCO
3
of 400 meq(200 & 200) given.
Repeat
ABG
Na
+
-128 K
+
- 4.28 PO
2
54
PCO
2
36 HCO
3
17.0
pH
7.28
7/3/2014 12
Added dopamine max &
started vasopressin.
BP not improving
beyond 70/30mmHg on
four support.
CVP-20mmHg
Trop T Neg; ECG- N
SO
2
-95 %
Amylase-N; CBC-N;
Widal (outside)-Neg
Coag, Repeat LFT, KFT &
Amylase-Sent.
Received 4 Bags of FFP
IMPRESSION-VIRAL SYNDROME with
strong possibility of Myocarditis
Added dopamine max &
started vasopressin.
BP not improving
beyond 70/30mmHg on
four support.
CVP-20mmHg
Trop T Neg; ECG- N
SO
2
-95 %
Amylase-N; CBC-N;
Widal (outside)-Neg
Coag, Repeat LFT, KFT &
Amylase-Sent.
Received 4 Bags of FFP
Repeat
ABG
Na
+
-
129
K
+
-
4.84
PO
2
91
PCO
2
29
HCO
3
12.0
pH
7.23
7/3/2014 13
Review Notes by SR SICU time??
Pt very sick.
Needs echo and Cardiology opinion.
If not possible should consider Immunosuppression and
Steroid therapy empirically.
KFT-125/4; Bil-5.6; ALT-2837; ALP-68
Hb-11.9;TLC-16.35 N90; Plt-107; PT-30;aPTT-84; INR-2.55
Adv/Treatment-
Cont Dobutamine, dopamine, NA and vasopressin;
Guarded fluids
O2 inhalahion via F Mask; CVP monitoing;
PD continue; Hourly ABG.
Cadiology consultation
GM consultation for Rt Pl effusion
Pt very sick.
Needs echo and Cardiology opinion.
If not possible should consider Immunosuppression and
Steroid therapy empirically.
KFT-125/4; Bil-5.6; ALT-2837; ALP-68
Hb-11.9;TLC-16.35 N90; Plt-107; PT-30;aPTT-84; INR-2.55
Adv/Treatment-
Cont Dobutamine, dopamine, NA and vasopressin;
Guarded fluids
O2 inhalahion via F Mask; CVP monitoing;
PD continue; Hourly ABG.
Cadiology consultation
GM consultation for Rt Pl effusion
7/3/2014 14
Around 7pm Cardiology
consultation Sought
Advised;(after discussing case
with Consult. On Call)
Continue pressor support titrate
with BP
Monitor input /output and CVP
Continue dialysis and resp.
support
Continue antibiotics
Septic screen
GM consultation
Start steroids after lasix 20mg iv
sos (BP> 90).
Milrinone.
Call seen by SR GM/Geriatrics
8pm
Pt on 4 inotropic support-Vaso
4ml/hr, Milrinone 16ml/hr,
Dobutamine 70ml/hr and NA
98 ml/hr.
BP-59/28mmHg; HR-135/min,
reg; O
2
sat-87% on 15 L 60%
venturi
GCS-E4V5M6-15/15 no focal
neurological deficit
ABG-pH-7.27; pCO
2
-28; pO
2
-68;
HCO
3
-12.9; Na
+
-140 & K
+
-4.05
IMPRESSION-Viral Myocarditis
with MOF with ?DIC
PLAN/ADV
Tamiflu 75mg PO BD
Cont current mgt
Septic screen-throat swab; Bl.
Culture; urine culture
Advised;(after discussing case
with Consult. On Call)
Continue pressor support titrate
with BP
Monitor input /output and CVP
Continue dialysis and resp.
support
Continue antibiotics
Septic screen
GM consultation
Start steroids after lasix 20mg iv
sos (BP> 90).
Milrinone.
Pt on 4 inotropic support-Vaso
4ml/hr, Milrinone 16ml/hr,
Dobutamine 70ml/hr and NA
98 ml/hr.
BP-59/28mmHg; HR-135/min,
reg; O
2
sat-87% on 15 L 60%
venturi
GCS-E4V5M6-15/15 no focal
neurological deficit
ABG-pH-7.27; pCO
2
-28; pO
2
-68;
HCO
3
-12.9; Na
+
-140 & K
+
-4.05
IMPRESSION-Viral Myocarditis
with MOF with ?DIC
PLAN/ADV
Tamiflu 75mg PO BD
Cont current mgt
Septic screen-throat swab; Bl.
Culture; urine culture
7/3/2014 15
Evening Note 8.15 PM
C/O- Viral Syndrome with AKI
GCS-15/15; Pupils-B/l-NSRTL
CVS-Pt hemodynamically unstable
on 4 supports-NA-100Ug/min;
Dobutamine@15Ug/min;
Vasopressin runing in chamber
set; Inj Milrinone@50Ug/min
BP-60/30; HR-100/min
Pt breathing spontaneously on F/M
with O2 flow @15 L/min, b/l Air
enry+; b/l crepts++; b/l wheeze
++; SPO2-80%
PLAN- Continue inotropic support,
Salbair nebulization hrly; CST
At around 9.30pm pt developed
cardiopulmonary arrest
CPR started immediately. Pt
intubated with ETT.
Inj adrenaline given as per
ACLS guidelines.
CPR continued for 30 min.
However pt could not be
reverted back.
Pt declared dead at 10.00
pm.
C/O- Viral Syndrome with AKI
GCS-15/15; Pupils-B/l-NSRTL
CVS-Pt hemodynamically unstable
on 4 supports-NA-100Ug/min;
Dobutamine@15Ug/min;
Vasopressin runing in chamber
set; Inj Milrinone@50Ug/min
BP-60/30; HR-100/min
Pt breathing spontaneously on F/M
with O2 flow @15 L/min, b/l Air
enry+; b/l crepts++; b/l wheeze
++; SPO2-80%
PLAN- Continue inotropic support,
Salbair nebulization hrly; CST
CPR started immediately. Pt
intubated with ETT.
Inj adrenaline given as per
ACLS guidelines.
CPR continued for 30 min.
However pt could not be
reverted back.
Pt declared dead at 10.00
pm.
7/3/2014 16
Critical evaluation
Missed opportunity- Pt. Should have been admitted of
15-05-2014.
Better history taking- History of drug abuse ; History
of any drug intake; Sexual behavior (HIV).
Missed opportunity- Pt. Should have been admitted of
15-05-2014.
Better history taking- History of drug abuse ; History
of any drug intake; Sexual behavior (HIV).
7/3/2014 17