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Morbidity and Mortality

Transcript: Dispo Patient admitted to floor for blood transfusion and GI consulted for endoscopy and colonoscopy Rapid Response TOD Esophageal Varices Major complication of portal hypertension Detected in 50% or more of cirrhotic patients MDM SOS Course Continued yo u got this! Code 2.. and 3.. and 4.. With each code, more melanotic stools, more blood noted coming around ETT more pressors added. Art line and cordis placed. More blood ordered Variceal Bleeding 70% of cases of UGI bleeding in cirrhotics due to variceal bleeding Mortality during first episode 15-20% Labs Patient brady'd down then pulseless. CPR started. Patient intubated. Airway difficult with bright red blood in airway. Central line placed. During CPR patient found to have large volume melanotic stool. ROSC achieved Crash femoral central line placed. Started on levophed and IVF Blood ordered Varices + = Blakemore? Rapid Response 20:30 Patient hypotensive and somnolent. BP 60/40. Patient started on IVF. Labs drawn Patient transferred to ICU for further care Patient Course - Due to ordering errors, patient received 2 U PRBC in 2 hours and went into respiratory distress and flash pulmonary edema - Admitted to ICU for NIPPV and diuresis - GI consulted. Scope to be done when patient stabilized Patient Course cont. ER HPI Patient eventually weaned from BIPAP and transferred to floor Patient still awaiting endoscopy and colonoscopy Patient is a 50 yo M admitted to floor for anemia. Patient is a frequent flyer, chronic alcoholic. - Anemic with Hb 6.5. - Admitted to floor for transfusion and GI consult fo colonoscopy and endoscopy. References Physical Exam Morbidity and Mortality Christy Kwon PGY3 Code Blue

MORTALITY AND MORBIDITY

Transcript: CHMC FAMILY MEDICINE MORTALITY AND MORBIDITY EVIDENCE BASED MEDICINE EBM DISCUSSION DISCUSSION TO UNDERSTAND THE EFFECTS OF HYPERGLYCEMIA ON THE FETUS, IT SHOULD BE REMEMBERED THAT GLUCOSE CROSSES THE PLACENTA FREELY BUT MATERNAL INSULIN DOES NOT, THUS, MATERNAL HYPERGLYCEMIA IMPORTANT FACTS IMPORTANT FACTS EFFECTS OF HYPERGLYCEMIA ON THE FETUS GLUCOSE CROSSES THE PLACENTA FREELY BUT MATERNAL INSULIN DOES NOT PREGNANCY STATE OF INSULIN RESISTANCE IMPT BEC EACH DIAGNOSIS IMPARTS DIFFERENT CLINICAL SIGNIFICANCE DIFFERENCE OF PREGESTATIONAL AND GESTATIONAL DM DIFFERENCE OF PREGESTATIONAL AND GESTATION... CLINICAL COURSE CLINICAL COURSE AT THE ER > VS every four hours > Diet small but frequent feedings > Labs Serum K: 4.03 > IVF PNSS 1L, fast drip 200 cc then regulate to 6 hours > IVF to ff: PNSS 1l x 8 S> 9 hospital days Persistent vomiting HOSPITAL STAY HOSPITAL STAY S > vomiting of more than 10 episodes (+) vaginal spotting this morning O> VITAL SIGNS : BP 120-130/70-80, PR 102-112, RR 21-26, T 36.5- 37.2, O2 SAT 99% FIRST HOSPITAL DAY FIRST HOSPITAL DAY LABORATORY LABORATORY hyponatremia hyponatremia IVF : PNSS 1l x 8 hours Medications: Nacl one tab 3x a day Duvadilan 1 tab 3x a day THERAPUETICS THERAPUETICS S> persistence of vomiting more than 10 episodes O)> BP 100-110/60-70 PR 90-104 RR 20-21 T 36.6 2ND HOSPITAL DAY 2ND HOSPITAL DAY No New Diagnostics No New Diagnostics CONTINUE MEDICATIONS CONTINUE MEDICATIONS 3RD HOSPITAL DAY 3RD HOSPITAL DAY S> persistence of vomiting more than 10 episodes O)> BP 110/80 PR 105 RR 20 T 36.6 No new laboratory work ups done No new laboratory work ups done IVF PNSS 1L x 8 Maintain on CBR without bathroom privilege Therapuetics Therapuetics 10:00 am S> Vomiting of 4 episodes with no vaginal spotting, able to tolerate the food O> BP 100/60 PR 118 RR 20 T 36.0 MGH ORDERS THM: Vitamin B complex OD FOLLOW UP AFTER ONE WEEK 4th HOSPITAL DAY 4th HOSPITAL DAY S> patient complained of chest pain, palpitation, DOB one hour after patient had vomiting O> BP 110/70 rr 30s cr 140s O2 sat 99-100 (+) tachycardia 6:00 PM 6:00 PM DIAGNOSTICS DIAGNOSTICS IVF: PNSS 1L x 8 Oxygen inhalation via nasal cannula 2-3 lpm Moderate back rest Monitor Vital signs hourly un til stable THERAPUETICS THERAPUETICS S> still with shortness of breath O> awake, coherent dry skin, cold clammy extremeties BP 100/60 PR 1 RR 31 T 36.5 O2 sat 99 8:20 PM 8:20 PM Diagnostics Diagnostics REGULAR INSULIN 5 units UIV Refer to diabetologist and secure Consent Therapeutics Therapeutics S> STILL DYSPNEIC O> BP 90/7- CR 138 9:00 PM 9:00 PM DIAGNOSTICS DIAGNOSTICS IVF PNSS 1l x 125 cc/hr Regular insulin 5 units SC now Lanoxin 0. 25 IV now Repeat ABG after 6 hours Therapuetics Therapuetics O> awake, acidotic breathing ph 6.9, PCO2 8.6, PO2 148 HCO32.0 10:00 PM 10:00 PM CBG stat- 378 then CBG monitoring q2 Diagnostics Diagnostics NPO temporarily Monitor urine output hourly NaHCO3 50 meq SIV 1st dose then after 15 mins NaHCO3 50 meqs Incorporate 100 meq HCO3 to present IVF x 12 Therapeutics Therapeutics s> O> 11:59 PM 11:59 PM CBG- now and increase CBG monitoring to hourly HBA1c- now Diagnostics Diagnostics Another NaHCO3 50 meqs SIV was given Apidra drip started 100 units Apidra + 100 cc of PNSS to run at 10 units/hour Therapuetics Therapuetics 5TH HOSPITAL STAY 5TH HOSPITAL STAY S> decrease SOB by 50 % as aclaimed O> BP 110/70 CR 140a RR 30 Input and Output (-) 634 Urine ketone and urinalysis monitoring Repeat ABG, Na, K, BUN, Crea Diagnostics Diagnostics Repeat ABG Repeat ABG > Sliding scale Apidra >Anothere dose Lanoxin 0.25IV >NaHCO3 drip decrease to 60 cc/hr then dc > Amsulvex 750 mg IV q8 as drip (8am)OB then was shifted to Ceftriaxone 1 gram IV q8 (11:50 am) ENDO > Digoxin 0.25 half amp now then 1 tab OD PO > Dulcolax 2 supp per rectum Therapuetics Therapuetics Transfer to private room > revise DIet to 18- cal diabetic diet 3 meals/ 3 snacks, no salt restriction, increase oral fluid intake Transfer to private room > revise DIet to 18- c... 40 meqs KCL incorporated to present IVF to run the same rate, if tolerated, may titrate and start KCL drip 90 ml D5NSS + 20 meqs KCL run for 5 hours x 2 cycles, repeat Na, K after 2nd cycle 40 meqs KCL incorporated to present IVF to run t... S> Persistent episode of vomiting more than 10 O> CR 119 BP 100/70 6th HOSPITAL STAY 6th HOSPITAL STAY urine ketone monitoring Diagnostics Diagnostics hyponatremia and hypokalemia hyponatremia and hypokalemia ICeftriaxone was increased to 2 gram IV OD Apidra drip was maintained 1 cc/hr KCL drip was discontinued, KCL tab one tab PO TID stated Therapuetics Therapuetics S> decrease episod of vomiting to one episode, with vaginal spotting O> CR 120 min 7th Hospital Day 7th Hospital Day CBG monitoring every six hours CBG monitoring every six hours IV Ceftriaxone was shfted to Tergecef 200 mg one cap twice a day Maintain on CBR Polynerve one tab OD PO Another KCL drip (PNSS 90 ml+ 20 meqsKCL) x 5 for 2 cycles but dc, Mixtard 20 units/16 units SQ pre meals

Morbidity and Mortality

Transcript: - Serial swabbing? -Collodion baby: A parchmentlike membrane at birth is associated with two other clinical forms of autosomal recessive congenital ichthyosis: lamellar ichthyosis and congenital ichthyosiform erythroderma. Another other cause for collodion baby is self-healing lamellar ichthyosis of the newborn. -Restrictive dermopathy -Conradi disease -Trichothiodystrophy -Gaucher syndrome -Neu–Laxova syndrome -Dorfman-Chanarin syndrome By: Rachael Luciano - ~1 in 300,000 births - Autosomal recessive inheritance - Mutation at chromosome 2q25 - Offered to parents who had a previous child with HI - Fetal genomic DNA is collected from amniotic fluid from an amniocentesis or chorionic villus sampling Epidemiology & Pathophysiology - Narcotics - Prenatally via fetal DNA analysis Harlequin Ichthyosis - Not detectable until the second trimester - Facial expression - Extremity tone - Respiratory rate July 5th, 2017 Clinical Characteristics Neonatal Management - Most severe phenotype of the autosomal recessive congenital ichthyoses - Cause by mutations in the lipid transporter adenosine triphosphate binding cassette A12 (ABCA12) Diagnosis Differential Diagnosis Skin care Grand Rounds ~ Function is to facilitate the delivery of lipid glucosylceramides into lamellar granules, and deliver them to the extracellular space Pain Control - Compromised skin barrier is a portal - Possible cellular basis for decreased immune function - Antimicrobial Prophylaxis? Nutrition Infection* - Once to twice daily cleansing - A bland emollient should be applied to entire body - Handle infant with sterile, latex-free gloves coated in emollient - Application of daily retinoid vs oral retinoid - Management of digital necrosis - Three-dimensional ultrasound for analysis of features - Application of nitropaste - Surgical release - Increased caloric demand - Restrictions for oral feeding - Thickened "armorlike" yellow, scales/plaques covering skin - Psuedocontractures - Digital necrosis - Ectropion - Eclabium - Tube feeds Otologic Management Respiratory Management* - Normal signs may be skewed - The compromised skin barrier is likely related to abnormal lamellar granule maturation and secretion resulting in inadequate delivery of lipids, antimicrobial peptides, and enzymes necessary for desquamation - Monitor serum protein, albumin and electrolytes - Increased risk for Vitamin D deficiency and rickets

Morbidity and Mortality

Transcript: Guidewire is then withdrawn The trocar is withdrawn. What happened next? 8/8 Started on azithromycin, DuoNebs every 6 hours Solu-Medrol 40 mg every 12 hours, supp O2 as needed NW is a 68 yo female Medical Hx: COPD, GERD, HTN Family Hx: DM and HF in mother Surgical Hx: Tubal ligation (1984) Social Hx: Married, lives at home with husband who takes care of her medications. Tobacco: Former smoker 1 ppd for 50 years, quit in 2005 Allergies: none Medications: Xanax, Paxil, zocor Daliresp (PDE4), Tudorza (LAMA), Pulmicort (steroid), Brovana (LABA), Albuterol (SABA) 8/19 - Nurse Navigator phone encounter Reports that patient will NOT use NIV. Informed that Apria has ordered Nasal Aire NIV appliance that is more like a nasal cannula than a mask which is being shipped directly to patient's home Prior Hospitalizations 4/13/15 - COPD 7/6/15 - COPD 4/22/16 - GI BLEED 5/9/16 - COPD 7/10/16 - COPD Transfer After central line and intubation in ED Pt was transferred to the ICU ABG 8/21 showed acidosis pH 7.22, pCO2 79.5, pO2 302, HCO3 32. Levophed through CVC Titrate per target MAP>65 The Seldinger technique - Sven Ivar Seldinger, was a radiologist from Mora Municipality, Sweden. In 1953, he introduced the Seldinger technique to obtain safe access to blood vessels and other hollow organs. Attempted extubation on 8/26 and reintubated for respiratory distress several hours later despite BIPAP On and off bipap for days Finally extubated on 8/30, placed on bipap A "sheath" or blunt cannula can now be passed over the guidewire into the cavity or vessel. Line was then sutured and dressing applied. It was noted that blood returned from white port, all 3 flush easily. Pressures remained hypotensive during this integral period Pulmonology appointment on 7/20/16 Noted to have advanced COPD and recent admissions for chronic Hypoxemic respiratory failure due to COPD Baseline FEV1 around 26% of predicted. Uses four liter/min oxygen all the time. Patient uses Tudorza , and takes Albuterol as necessary.Patient also uses Advair one inhalation twice a day. Today, she thinks her breathing is back to baseline. Plan Discussed importance of compliance. Continue Tudorza, Pulmicort, Brovana inhalations twice daily Albuterol inhaler six times daily Daliresp once daily Having been in use for a few hours, the patient had received ativan and approx 200cc of Levophed directly into the mediastinum Had some new HF, frequent multifocal PVC's and at one point went to A-FIB for short period of time then went back to SR on her own. Was followed by cardiology 8/11 through 8/17 MSSA growing on sputum cx Remained weak while working with PT Waxing and waning respiratory course Pt continued to refuse BIPAP at night 8/18 - Discharged home w/ home health Prednisone 40 qam x 7 days Pulmicort, Brovana, Turdorza daily Continue round the clock O2 A round-tipped guidewire is then advanced through the lumen of the trocar. A sheath can be used to introduce catheters or other devices to perform endoluminal procedures A case presentation by Mark Haggerty, DO PGY3 Portsmouth Family Medicine The desired vessel or cavity is punctured with a sharp hollow needle called a trocar, with ultrasound guidance if necessary. CT surgery reviewed the images and recommended that it was safe to pull the line Potential areas of improvement and remaining questions Barriers to care Financial - high co-pay on inhalers Unable to tolerate NIV therapy Unwilling to address advanced directives Apparent low motivation, discouraged. Let's get some more background on our patient NW SBT failed on 8/23, 8/24, 8/25 Agitated, pulled out OGT Diarrhea required fecal management system Radiologist talked to ICU regarding CT finding of misplaced CVL Post insertion: All the lumens of the line are aspirated (to ensure that they are all positioned inside the vein) and flushed with either saline or heparin. A chest X-ray may be performed afterwards to confirm that the line is positioned inside the superior vena cava and no pneumothorax was caused inadvertently. Electromagnetic tracking can be used to verify tip placement and provide guidance during insertion, obviating the need for the X-ray afterwards. Sunny day Per pallitaive who had been following; Patient verbalized wanting to shift gears from aggressive measures and focus on comfort. Patient was aware of risk that should she eat by mouth, that it may hasten her death, yet she opted to eat. Comfort care measures initiated by Palliative 9/2 - on prn ativan, fentanyl, robinul, morphine for comfort NW passed away on 9/8/2016 It was noted by nursing that no blood could be aspirated from the ports, and that when the CT finding was noted, the levophed was stopped and no change in blood pressure resulted ED 8/21 Per Medic: alert initially, given solumedrol 125 mg IV, duoneb. Enroute to hospital, patient became more unresponsive, on CPAP Per Husband: She has been SOB since being discharged on 8/18. Per ED nurse: Grayish discoloration of the skin, agonal breathing

Mortality and Morbidity

Transcript: Suicide Mental Health Mortality & Morbidity Evidence has consistently shown that patients with mental illness have greater physical health morbidity and mortality compared to the general population. Many factors have been implicated and include a generally unhealthy lifestyle, side effects of medication, and inadequate physical healthcare. Introduction Diabetes Patients suffering from depression are twice as likely to develop type 2 diabetes mellitus, and the prevalence of stroke and myocardial infarction is three- and five-fold respectively higher than people without depression. Diabetes Mellitus Type 2 There is a significant higher prevalence of cigarette smoking in those with mental illness. 56-88% of those with a mental disorder smoke cigarettes. The overall U.S. prevalence is only 25%. 44% of all cigarettes in US are smoked by persons with mental illness Smoking Respiratory Disease The rate of suicides in those with mental illness is stagering; 1,365 people in 2014. Men had a suicide rate four times greater than that of women. The suicide rates among adults were similar across age groups, although the highest rates were among those age 45 to 64. American Indian and Alaska Native youth and middle-aged persons have the highest rate of suicide, followed by non-Hispanic White middle-aged and older adult males. African Americans have the lowest suicide rate, while Hispanics have the second lowest rate. Suicide Those with mental disorders have a significant higher chance of developing eating disorders. Eating disorders are associated with a high mortality because of the physical disorders caused by anorexia/bulimia nervosa affecting other organ systems. Eating Disorders Eating Disorders Cardiovascular disease is yet another risk factor for those with poor mental health. Out of the 88,241 Medicare patients that were hospitalized for MI, their mortality increased by 19% with any mental disorder and 34% with schizophrenia. Psychotropic medication is associated with impaired glucose tolerance and diabetes, metabolic syndrome, dyslipidemia, cardiovascular complications, extrapyramidal side effects and sexual dysfunction. Cardiovascular Disease Cardiovacular Disease To make matters worse, those with mental illness are less likely to be screened or treated for dyslipidemia, hyperglycemia, and hypertension. They are less likely to receive an angioplasty or CABG or to receive drug therapies of proven benefit (thrombolytics, aspirin, beta-blockers, ACE inhibitors) post myocardial infarction. Even Bigger Problems Prpoper Health Care There is a great need for a more active role of healthcare providers to not only treat those with mental illness equaily but to treat the whole person and not just the mind. Information. (2019). Retrieved from https:// dmh.mo.gov/mental-illness/help/facts. Physical morbidity and mortality in people with mental illness. (2014). Retrieved from https://www.bjmp.org/content/physical-morbidity-and-mortality-people-mental-illness. Suicide in America: Frequently Asked Questions. (2019). Retrieved from https://www.nimh.nih.gov/health/publications/suicide-faq/index.shtml. References References

Morbidity & Mortality

Transcript: Morbidity & Mortality Emergency Medicine Ariel Hawley, MD November 2022 Initial presentation Initial Presentation 72 yo M presents with abdominal pain, vomiting, anorexia for 5 days. Pain described as cramping, worse in the LUQ. Pain is worse with movements, especially anything that engages his abdominal muscles. He has had intermittent diarrrhea x 2 weeks but now no bowel movement for several days. Denies fever or malaise. Similar symptoms after diaphragmatic hernia surgey. He cannot keep down some fluids and applesauce but cannot seem to tolerate solid foods. PCP sent him in for evaluation. Past Medical History Past Medical History Diabetes Mellitus Hypertension Hyperlipidemia Appendectomy Robotic Inguinal Hernia Repair Diaphragmatic Hernia Repair Physical Exam Physical Exam MDM MDM Return to the Emergency Department Second topic Subtopic 1 Subtopic 1 Management of Mesenteric Ischemia Here's a place for the third part of your presentation. And to the right, there are subsections for more specific detail. Third topic Fourth topic Fourth topic Here's a place for the fourth part of your presentation. And to the right, there are subsections for more specific detail. Here's a place for the fourth part of your presentation. And to the right, there are subsections for more specific detail. Subtopic 1 Subtopic 1 Subtopic 2 Subtopic 2

Morbidity and Mortality

Transcript: How to Fight Obesity What is Added Sugar? Sugar increases ones likely hood of contracting and keeping certain diseases such as type 1&2 Diabetes 1 affects the pancreas's production of insulin and 2 affects how the body processes blood sugar, and Fatty Liver Disease , Osteoporosis, and many others. Another term for illness or close to death. What is Mortality? What is the recommended amount of added sugar? Morbidity and Mortality of Sugar in America There are many ways that the U.S. is currently using to fight obesity, one of which is to go on a 2,000 calorie protein diet, which may seem like it's very small, but it is actually a very good way to lose weight. As sen in this diagram. When something leads to someone being in the state of, or being subject to death. As little as possible, you can still eat it, but it is recommended that you eat as little as you can. But the recommended daily in take is about 5% of the calories you eat witch can range from 25 to 40 grams. What is Morbidity? Why is Added Sugar Morbid? 65% of people in America are Obese or considered overweight. That would be an estimate of 210,069,498. Americans also consume over 130lbs of sugar per person per year Added sugars are sugars and syrups that are added to foods or beverages when they are processed or prepared. How many people are obese?

MORBIDITY AND MORTALITY

Transcript: Left MCA infarct (2011) CAD s/p CABG X 3 (2004) Ischemic cardiomyopathy Hypertension Hyperlipidemia PAST MEDICAL HISTORY LABS CASE PRESENTATION VITAL SIGNS Nursing High patient to physician ratio High patient to pharmacist BY sOWMYA KORAPATI Aggrenox 25-200 mg BID Atorvastatin 80 mg daily Carvedilol 6.25 mg BID Lasix 40 mg daily Lisinopril 10 mg daily Potassium chloride 20 mEq daily No headache No fever, chills No palpitations, chest pain or shortness of breath PLACE PHYSICAL EXAM MORBIDITY AND MORTALITY ROOT CAUSE ANALYSIS SOCIAL HISTORY POLICY REVIEW OF SYSTEMS Day 1 - Keppra Day 2 - A Flutter with HR 60 - 85 Day 3 - Coumadin Day 4 - Discharge Lives at home with his wife 30 pack year smoking history quit 20 years ago No history of alcohol or substance abuse PEOPLE No apparent distress CVS - regular rhythm. S1 S2 heard. No murmurs, rubs or gallops Neuro - Alert and oriented to self and place. Expressive aphasia. Increased tone in right upper and lower extremity. Positive babinski on the right. Medication reconciliation Ordering Warfarin DAY OF DISCHARGE HOSPITAL COURSE DISCHARGED WITHOUT COUMADIN PROCEDURE BMP - with in normal limits CBC - witn in normal limits Glucose - 124 CT head - Large area of encephalomalacia in the left frontal parietal region. Chronic infarction in left cerebellum. Small vessel ischemic changes. CIPs - negative Carotid dopplers - less than 50% diameter stenosis in bilateral carotid arteries. Suspected seizure T - 97.3 BP - 148/85 Pulse - 71 RR - 18 O2 Sat - 98% RA REASON FOR ADMISSION Provider Physician - missed warfarin order - patient/family education Pharmacist - medication reconciliation did not include warfarin 14:39 - DISCHARGE INSTRUCTIONS 14:47 - PHARMACY MEDICATION RECONCILIATION NOTE 15:10 - PATIENT LEAVES 16:21 - PATIENT WAS DISCHARGED WITHOUT WARFARIN ORDER. MEDICATIONS

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