1. Mortality conference
報告人： R2 蕭凱宇
指導者： VS 賴金湖
2012.02.08

2. Case data
 姓名 : 李秀玉
 病歷號 : M200537989
 性別 : 女
 年齡 : 70
 身高 : 159
 體重 : 57.2
 入院日期 : 100/12/06
 主治醫師 : 賴金湖

3. Chief complaint
 Cool and numbness sensation and pain of
both feet for years and worsened in recent
months.

4. Present illness
 The 70 years old female had suffered from
cool and numbness sensation and pain of
both feet in recent months. Claudication was
also noted. She came to our CVS OPD for
help. ABI on 100/10/31 suspected PAOD,
bilateral lower limb. Angiography on
100/11/08 showed severe stenosis of
bilateral lower limb arteries. Then she was
admitted for surgical intervention.

5. History
 Hypertension for 10 years
 ESRD for 10 years with regular H/D.
 Operation history: s/p AV shunt, L’t arm.
 No allergy history.
 Denied cigarette smoking and alcohol
consumption.
 No special family history.
 No travel, cluster or contact history.

6. Physical examination
 Vital sign: BP:162/75 mmHg, BT:36.8 ℃, HR:80 /min,
RR:18 /min. Height = 154.5 cm, BW = 55 kg
 HEENT: no pale conjunctiva, no icteric sclera.
 Heart: RHB, no systolic murmur.
 Chest: Clear breathing sound, wheezing(-)
 Abdomen: soft and ovoid, normoactive bowel sound
 Extremities: A-V shunt over left arm,
 CVS condition: Pulse of PDA : +-/++, bil. pulse of
POP.A.: +/++, bil. Ischemic pain of calf(+), foot ulcer(-).

7. Ankel- brachial
index (1001031)
0.43, R’t/0.36, L’t

8. Angiography - 1001108

9. Angiography - 1001108

10. CXR
1206

11. EKG - 1206

12. Hospital course – 100/12/06
 1000
 Admitted and prepared percutaneous transluminal
angioplasty.
 1600
 Sent patient to CATH room.
 1800
 Sent patient back to ward. Add promostan.
 2130
 Removed sheath and manual compression for 30
minutes.

13. Hospital course – 100/12/06
 2200
 Abdominal hematoma was noted. Hold
promostan. BP 89/35, HR 103. Keep manual
compression and N/S loading 500ml.
 2230
 Hgb 6.9 was noted. Blood transfused PRBC 2u.
 2300
 BP 91/46, HR 95. Shift to sand bag compression
and closely follow up.

14. Hospital course – 100/12/07
 0000
 BP 81/49, HR 101. No oozing was noted over the
wound over left inguinal region. Keep observation.
 0100
 Completed PRBC 2u. BP 88/41, HR 100. Remove
sand bag. No oozing was noted.
 0350
 Conscious change. BP 87/55, HR 78, BS 354
mg/dl, SpO2 80%. On Endo and sent to ICU.

15. Hospital course – 100/12/07
 0400
 BP 95/65, HR 145. ABG showed metabolic acidosis.
 ABG: pH 7.244 ; PaO2 513 ;PaCO2 15 ; HCO3 6.6
 0530
 EKG showed ST depression, suspected ischemic
heart disease.
 0530
 BP 85/53, HR 136. Transfused PRBC 4u. CK 78;
CKMB 40.5; Troponin-I 7.12;

16. Hospital course – 100/12/07
 0700
 CV Dr. arrange echocardiogram which showed
mild LV systolic dysfunction and LVEF < 40%.
 0730
 CAG and angiography revealed 80% stenosis of
LCX-D, 80% stenosis of SMA and active oozing
from puncture site of right distal ext. iliac artery.
 0840
 Sent P’t to OR for operation.

17. Hospital course – 100/12/07
 1100
 Vascular repair of right distal external iliac artery
was done and sent P’t back to ICU. Hypothermia ,
coagulopathy and acidosis persisted. Keep sand
bag compression on the wound.
 1130
 BP 88/54(Levophed 30 mg/min), HR 106, BT 31.6
℃. Transfused PRBC 2u + FFP 4u + whole blood
2u + single donor 2u. Oral bleeding was noted, on
NG with free drainage. Add vit. C, K and
transamin.

18. Hospital course – 100/12/07
 1235
 BP 91/57, HR 97, BT 32.2 ℃. PRBC 2u.
 1345
 BP 85/51, HR 104, BT 32.8 ℃.
 1455
 BP 82/51, HR 105, BT 33.3 ℃
 1600
 BP 83/51, HR 101, BT 33.5 ℃

19. Hospital course – 100/12/07
 1720
 BP 83/47, HR 97, BT 33.9 ℃.
 1850
 BP 72/41, HR 100, BT 34 ℃.
 2100
 BP 99/70, HR 100, BT 34 ℃
 2200
 BP 62/40, HR 99, BT 34.9 ℃
 2216
 Patient expired.

20. PTA - 1206

21. PTA - 1206

22. PTA - 1206

23. Lab Data

24. CXR
1207

25. EKG - 1207

26. EKG - 1207

27. CAG - 1207
 LAD-P: 30-40% stenosis
 LCX-D: 80% stenosis
 RCA-P to M:50%
stenosis

28. Angiography - 1207

29. OP note
 A 0.2x0.2 cm hole over PTA puncture site of
right distal iliac artery with active bleeding.
 After we repaired it , some venous oozing
was still persisted but no active bleeder.

30. TPR chart

31. Diagnosis
 Distal external iliac artery active bleeding,
right with hypovolemic shock, removal of
sheath related.
 Suspect ischemic bowel disease.
 Peripheral artery occlusive disease, bilateral
lower limb.
 Coronary artery disease - one vessel
disease.
 Chronic renal failure under hemodialysis.
 Hypertensive cardiovascular disease.

32. Discussion
Coming Undone: Failure of a Closure Device
Page 184 AORN Journal, January 2011 Vol 93
 How to prevent ?
 Puncture site choice.
 Closure device.
 Stent graft.

33. Punture site choice

34. Closure
device

35. Closure
device

36. Stent graft

37. Thanks for your attending~