Presentation discussing in-hospital course of critical patients and possible causes of mortality

1. CCU MORTALITY
7.11.2023

2. Patient details Cause of Death Hospital stay
Mr A
23/M
RHD
Severe AR, Severe MR
Severe TR
Severe PAH
Normal BV function
AF with FVR
LRTI with ADHF
Refractory septic shock
MODS
DOA 9/10/2023
DOD 4/11/2023
Mrs S
70/F
Hypertension
CAD – ACS - IW + RVMI (WP 14 hours)
Killip class II
Severe RV dysfunction
Primary PCI to RCA
Intraprocedural hypotension
Refractory cardiogenic shock
Anuric AKI with ischemic liver injury
DOA 3/11/2023
DOD 4/11/2023

3. • Mr A
• 23/M
• DOA 9/10/23
K/C/O RHD with severe MR, severe AR, severe TR, severe PAH
Admitted with worsening SOB (NYHA III  IV) with orthopnea
B/L pedal edema
H/o fever with cough +

4. ECG

5. CXR

6. Managed with IV antibiotics and IV diuretics
Metoprolol f/b addition of diltiazem for rate control
CTVS team informed regarding requirement of early DVR with TV repair
After initial slight improvement in clinical and biochemical markers, the
patient developed further worsening AKI and congestive hepatitis.
In view of persistent severe hypokalemia and ADHF with AF-FVR,
shifted to CCU on 20/10/23

7. In CCU, the patient was put on NIV support with furosemide infusion
and ditiazem infusion for rate control
Antibiotics were upgraded in view of increasing TLC/procalcitonin
Developed HAP – worsening of consolidation and symptoms despite
upgraded antibiotics (Piptaz and teicoplanin).
Despite sequential upgradation Piptaz  Meropenem  Ceftazidime-
Avibactam, sepsis worsened and patient developed septic
encephalopathy and worsening AKI.

8. Investigations
10/10 16/10 20/10 26/10 27/10 30/10 3/11
Hb 11.8 11.2 11.6 11.3 11.1 11.1 12.1
TLC 13700 10920 12990 17300 13000 12330 23440
Platelet 189000 197000 228000 181000 157000 145000 157000
BU/Cr 109/2.3 99/1.5 109/1.7 108/2.1 105/1.8 70/1.4 97/1.1
Na/K 127/4.1 128/2.7 130/2.9 132/3.8 131/3.5 133/4.5 138/4.8
T Bil 10.8 5.7 6.9 4.8 3.7 3.7 3.8
ALT/AST 66/88 46/58 41/62 23/41 22/39 23/41 190/97
INR 1.9 1.3 1.3
Procal 1.45 1.21 0.7

9. From 27/10/23 - On Ceftazidime-Avibactam with Aztreonam, patient
started improving with decreasing TLC, improving KFTs.
CTVS team reminded for early surgery – 1 week waiting period
All peri-operative workup with clearances obtained.
Patient was stable on NIV with NTG infusion and IV diuretics.
Started developing worsening of SOB on 3/11/23.
Developed AF with FVR  ADHF, requiring intubation in view of severe
respiratory distress.

10. CXR – 3/11/23

11. During intubation, he developed hemodynamically unstable VT
DC shock was given  Asystole
CPR was given for 10 minutes and ROSC was achieved.
Post resuscitation, the patient remained anuric and developed
persistent refractory hyperkalemia.
On 4/11/23, the patient went into asystole. Despite CPR as per
protocol, patient could not be resuscitated.

12. CASE 2

13. • Mrs S
• 70/F
• DOA 3/11/23
K/C/O HTN
Presented to the emergency with chest discomfort since 5 days, with
sudden increase in severity since last 14 hours.
Associated SOB +, h/o intermittent presyncope

14. On examination, BP 90/60 mmHg PR 48/min spO2 98% on RA
Bilateral basal crepts +
No appreciable murmur
ECG showed 2:1 AV block with PR prolongation
The patient was taken up for primary PCI in view of ongoing chest pain
and AV block

15. ECG

16. CXR

17. TPI was inserted
CART – Single vessel disease with proximal RCA thrombotic cut-off
Primary PCI to RCA (PE 2.25 x 16mm)
Patient was intubated and started on Noradrenaline in view of
intraprocedural hypotension with severe metabolic acidosis and
respiratory distress.

18. 2D Echo: RCA territory hypokinetic
Severe RV dysfunction, severe TR (28+RAP)
LVEF 50-55%, no PE/VSR/MR
The patient was anuric with refractory hyperkalemia, metabolic acidosis
Hemodynamically stabilised on Norad.
Nephrology team was consulted and bedside dialysis was done on
3/11/23.

19. Investigations
3/11/23 4/11/23
Hb 6.2 8.0
TLC 17220 11660
Platelet 95000 107000
BU/Cr 84/3.7
Na/K 132/6.0  5.0
ALT/AST 1385/2813
INR 1.4
3/11 4/11
(9AM)
4/11
(3PM)
pH 7.35 7.11 7.05
pO2 70 105 130
pCO2 19.8 23 22
HCO3 11.3 7.4 6.2
K+ 5.74 5.4

20. After hemodialysis, hypotension worsened.
BP 86/40 on high dose Noradrenaline and Adrenaline infusion
Despite refractory hyperkalemia and metabolic acidosis, 2nd session of
HD could not be done in view of persistent hypotension.
On 4/11/23 at 6PM, the patient developed asystole. Despite CPR, she
could not be resuscitated.