NON ACS MORTALITY

CASES
MARCH 2016 .

CASE 1
68 years old female
DOA 19th Feb 2016
DOD 3rd March 2016
Cause Sepsis secondary to HAP

Admitted to private hospital on 11th December 2015

for right sided pleural effusion

Echo : severe TR secondary to dilated RA annulus
: moderate MR secondary to dilated LA
annulus
: LVEF 45%
Pleural fluid aspirate transudate
Pick tail drainage inserted on 24th january 2016.
Refer to HPP for chest tube insertion of right sided
pleural effusion on 19th Feb 2016

Upon admission patient was comfortable, her vital

signs was stable, right large pleural effusion

Refer to CTC for chest tube insertion and pleurodesis

(done on 22nd Feb )

On 24th Feb, patient had respiratory distress with high

grade fever. Lungs finding showed generalized rhonchi.

WCC 20, Hb 9.5 , platlet 179.
She was intubated and started on IV ceftriazone.
On 25th Feb, she was transferred to CCU and IV

antibiotics upgraded to Tazosin

26th Feb she was referred to nephro team for AKI. HD was

initiated.
CTC reviewed the patient daily, her chest tube was kept ;

drained between 80-150cc daily.

On 1st Mac, second HD was done, Chest team was referred for

management of persistent right pleural effusion (chest xray on

28th Feb showed persistent right pleural effusion with chest
tube insitu. Chest tube was still draining about 100cc, serous ).
Chest team continued the current management and KIV
bronchoscopy if tracheal aspirate C+S negative.
On 3rd Mac patient collapsed and develop PEA. CPR

commenced but patient died.

CASE 2
71 years old female
DOA 8th March 2016
DOD 22nd March 2016
Cause Pneumonia

Underlying DM, HPT and on thyroxine replacement

Rx for post thyrodectomy

H/O admission in Dec 2015 for decompensared CCF

and has a NPS appointment

Premorbid : bed bound for past 2 years ( after H/O

fall) and bilateral eyes blindness

c/o progressive dyspnea 2 days and productive

cough 2/52. No h/o fever.

Clinically, alert, not tachypnea, v/s BP 183/91, PR 75
and afebrile. Lungs : bibasal crepitation, pedal
edema
Ix : chest Xray ( cardiomegaly with congested lung
fields and bilateral pleural effusion, wcc : 12.2 Hb 8.6
plt 346, RP normal)
Admitted to C8 with diagnosis of Decompensated
CCF. IV lasix was initiated. She was also transfused 1
PC and plan to refer to OGDS

On 8th March ( at night of admission), GCS dropped

to 5/15. She had a spiking temperature and lungs

finding showed left lower zone crepitation, ABG :
pH 7.4, pCO2 7.5, HCO3 36.5, pO2 15 ). No focal
neurological deficit. Initiated on IV unasyn with
clinical impression of community acquired
pneumonia
On 9th March , IV antiobiotic was escalated to

rocephine . She was refered to gastro team for OGDS

( plan to scope once patient was stable as anemia
likely secondary to IDA and there is no clinical
evidence of active bleeding)

On 10th march, patient had respiratory distressed

and she was then intubated. CT brain revealed no

ICB
IV antibiotic was changed to Tazocin ( 12th march) ,
then to IV meropenam ( 16th march) in view
persistant high spiking temperature.
She was also refered to nephro team for worsening
renal profile but didnt required HD.
on 18th march , transferred to CCU as her BP
dropped . ECG then showed inferior and lateral T
inversion. Bedside echo showed LVEF of 60%,
LA/LV not dilated and LV wall thickness preserved.

Patient had much clinical improvement in ccu

Repeated Chest Xray improved, WCC dropped ( from

15.2 to 9.6), multiple blood C+S NG.
urine
C+S (8th March, on day of admission ) showed
E. Coli
On 22th march, patient was extubated, completed iv
meropenam ( Day 7, by ID team) and tranfered to C8.
However , at night patient was noted unresponsive . ECG
revealed PEA, CPR and IV adrenaline given but
pronounced death after 20 min resuscitation.

CASE 3
72 years old male
DOA 21st March 2016
DOD 22nd March 2016
Cause urosepsis

Underlying DM , HPT, BPH (CBD since Jan 2016)

CAD with stented once in 2000

Earlier in the morning, patient went to k/k where his

CBD was off. But the urinary catheter was reinserted
that evening as patient cant PU; upon reinsertion
noted frank hematuria and refer to casualty
Also c/o mild left sided chest pain at 2pm with SOB at
rest.

O/E confused, v/s ( BP :130/99, PR : 126, Tem : 40.5)

Lungs : bibasal crepitation, SpO2: 100% on NPO2

CBD frank hematuria.

ECG (7pm) : ST elevation inferior leads ( no posterior
wall and right ventricle involvement)
CK 108, AST 151, LDH 261
WBC : 47, plt 151, Hb 13.3
Imp: Acute inferior MI Killip 2
Urosepsis secondary to long standing CBD with
traumatic urinary catheter insertion

Admitted to CCU, was given s/c fondaparinux only

and not for antiplatlet in view of frank hematuria. IV

unasyn started. KIV COROS once no bleeding
Bedside echo: LVEF 30-35%, global hypokinesia

with more pronounced at inferoseptal wall, LV

thickness still preserved

On 22nd march early morning, patients blood pressure

dropped . Fluid resuscitation initiated and later

commenced on inotrope support.
As frank hematuria persist, LMWH off, refer to urology
team where bladder irrigation was started and IV
antiobiotic was continued.
Patient was referred to nephro team for HD support as
developed severe metabolic asidosis with AKI.
On 22nd march night, SLED was initiated but terminated
as blood pressure dropped and patient became
unconscious. Developed PEA , CPR and IV adrenaline
commenced but resuscitation was unsuccessful.

CASE 4
83 years old female
DOA 5th march 2016
DOD 6th March 2016
Cause Aspiration pneumonia

Underlying DM, premorbid status: partially ADL

dependant and dementia

H/O CAD ( admitted for NSTEMI in 11/2015 and
APO secondary to ACS in jan 2016), COROS was
refused . ECHO : LVEF 30 -35%, severe hypokinesia
and severe MR
c/o SOB and unwell for 2 days
h/o choking during feeding
no fever

O/E tachypnea, vital signs: bp 79/44, PR 61, Tem

35.4
SpO2 : 90% HFM, lungs : bilateral crepitation , no
pitting edema
Chest Xray : bilateral lower zone lungs hazziness
Wcc 8.6,Hb 10.2 plt 262 CRP 15.3
RP: 152/5.3/106/13.9/262
ABG: pH 7.088, pO2 4.96,pCO2 3.36, HCO3 6.1
CK 1741, LDH 1294, AST 746
ECG: LBBB
Serum lactate 18 ( 0.5-1.6), reflo : 10.2
UFEME: leucocyte 2+, nitrate neg

Imp: 1. severe metabolic acidosis secondary to

aspiration pneumonia/ urosepsis

2. cover for ACS
started on IV rocephine, inotrope support and fluid ( 2
pints NS). DIL/DNR issued
On 6th march night, patient noted unconscious. ECG
revealed asystole.

CASE 5
60 years old male
DOA 27th march 2016
DOD 27th March 2016
Cause Acute stroke

Electively admitted for COROS

Indication: h/o inferior STEMI (from Hospital

Kepala Batas in august 2015)

Echo : LVEF 45% , hypokinetic segment at mid
inferior posterior wall, LA and LV chambers dilated

Walking with stable condition (according to nursing

note)
Noted patient less responsive,
Vital sign: BP 160/90, PR 86, afebrile
clinically not in respiratory distressed, lungs clear,
reflo : 6.1, ECG: old inferior MI
blood test : FBC/ RP/ LFT normal range
urgent CT Brain ordered
However, patient developed PEA, resuscitation was
done for 30 minutes but unable to revive patient.

CASE 6
84 years old male
DOA 14th Feb 2016
DOD 18th March 2016
Cause Urosepsis

Underlying DM on insulin Rx , IHD ( 3VD and refused

CABG), CKD, BPD on suprapubic catheterization and

COPD
H/O admission for decompensated CCF in 0ctober
2015
c/o progressive dyspnea for 2 days
Associated orthopnea and pedal edema
No fever/urti
0/e hemodynamically stable and afebrile, lungs bibasal
crepitation
ECG: SR, Chest Xray : congested lung field, ABG :
Normal range
Treated with IV lasix

On 15th march morning, clinically improved and

treatment was commenced.

However, at 5.30pm noted acute altered mental status
and persistant vomiting
V/sign: BP 130/70, PR 100, Tem: 39
ECG :SR with no acute dynamic changes
Lungs bibasal crepitation and clinically not tachypnea
Electively intubated in view of unable to protect
airway and drop of GCS
Urgent CT Brain : no ICB
Wcc : 13.6 Hb 11.2 plt 354, UFEME leucocyte 2+,
nitrate +ve

On 17th march, patient still having high spiking

temperature and became hypotensive. IV antibiotic

was upgraded to Tazosin, inotrope support was
initiated , refer to urology team for suprapubic
catheter change and urgent ultrasound KUB was
ordered.
However, on 18th march early morning, patient was
expired.