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Kardasheva m&m 02.05.2019
- 1. Morbidity and Mortality Case February 5, 2019 Aleksandra Kardasheva, DO
- 2. Agenda 1. History of M&M 2. Case presentation 3. Group discussion 4. Teaching points
- 3. M&M History • Originated in early 1900s with Ernest Codman • Born in 1869 in Boston, MA and matriculated at Harvard and MGH • One of his main recognitions was the idea of “End Result Cards” • Every patient should have such card: diagnosis, treatment and outcome. Followed up for at least one year to identify opportunities for improvement
- 4. M&M Goals • Organized case reviews to identify adverse outcomes with a goal of raising awareness and seeking opportunities for improvement. • The M&M conference is a component of a culture of safety. • It is a confidential communication under Washington State Quality Assurance laws.
- 5. Case Presentation • ID/CC: 74 yo Vietnamese speaking woman with history of RCC on nivolumab who presents to oncology clinic for a follow up. Aside from feeling more fatigued she denies any other symptoms. • PMH: CKD Stage 5, DMT2, HTN, HLD, gout, hospitalized x 1 • PSHx: AVF in place • Social: Married, has 5 sons and 5 daughters
- 6. Case Presentation • VSS • Labs 12.2 8.9 212 28 140 4.2 4.53 109 22 40 131 4.1 7.25 101 17 70 9.0 9.3 271 28 AlkP 1537 ALT 349 AST 740 TB 2 AlkP 88 ALT 12 AST 18 TB 0.3
- 7. Feb April May Aug Aug - Oct • Diagnosed with RCC of R kidney • Not resectable because of concern for HD after nephrectomy • Started 1st line tx for RCC: Pazopanib (TKI) • Discontinued Pazopanib 2/2 worsening proteinuria and progression of CKD • Started 2nd line treatment with Nivolumab • Finished 6 cycles of Nivolumab
- 8. Hospital Day 1 -Viral hep.panel negative, INR 1 -U/S: diffuse echogenic & heterogeneous liver w/ no masses -GI consulted -MRCP: no biliary dilation -Possibly side effect of nivolumab: can cause elevation of liver enzymes: alkaline phosphatase (10%-33%), AST (24- 33%), ALT (16%-31%), and TB (11%-13%)
- 9. Hospital Day 2 • Oncologist: -Oncologist: • GI: • GI • Hospitalist: Transjugular or percutaneous liver bx?
- 10. Hospital Day 3
- 11. Hospital Day 3-4 -Hgb 3.8. MTP initiated -To IR suite for embolization -Arrived to ICU, tenuous condition despite 3 pressors -CT bleeding scan, IR x2 -> venous oozing -Abd comp. syndrome -> Gen surgery consulted -To OR for hemoperitoneum, 5-6L blood removed -Upon closure, worsening coagulopathy -> ? DIC -> ICU -MTP initiated x 2, K-centra on its way
- 12. Case Summary Elderly woman w RCC on 2nd line treatment and multiple chronic diseases presenting to onc clinic w/ worsening fatigue and found to have elevated LFTs admitted for further work up. Hosp course c/b hemorrhagic shock post liver bx progressing to abd compartment syndrome 2/2 hemoperitoneum further c/b DIC and MOF. In the setting of this, family transitioned her code status to DNR and patient expired within less than 4 days of admission.
- 13. Biopsy result
- 14. Questions for Discussion 1.Did the patient have to be admitted for a liver biopsy? Would you have pushed for a liver biopsy? Inpatient vs outpatient procedure? Authority gradient? 2. Does the patient meet indications for a biopsy? Were there C/Is to the biopsy? Was that the right approach? Diagnosis momentum 3. How can we improve post biopsy/procedure care? 4. What would you have done differently?
- 15. Diagnosis Momentum • Once on a diagnostic path, it can be hard to “undo” what has already taken place • What might have started as possibilities has gained so much momentum that by the time we reach a certain milestone, it is too late to undo the consequences
- 17. Approach to liver biopsy • Indications: ▪ Diagnostic evaluation of: • Focal/diffuse abnormalities on imaging • Parenchymal liver disease • Chronically abnormal liver tests (>6mo) • FOU origin ▪ Staging of known parenchymal liver disease ▪ Development of tx plan
- 18. Choosing a route • Percutaneous: preferred, less invasive and less costly • Transjugular: coagulopathy, ascites or vascular tumor • FNA: focal liver lesion with cells for cytology (not a true tissue bx) • Laparoscopic: for staging in pts with intra-abdominal malignancy
- 20. Medications and coagulation status • Meds prolonging bleeding time should be d/c’ed a week before • For pts at high risk for thromboembolic events who must remain on AC, a transjugular liver bx is an alternative • INR < 1.5 • Plts > 50,000
- 21. Special patient populations • CKD: HD, desmopressin • Inherited disorders of hemostasis • Sickle cell disease • Amyloidosis
- 22. Post-biopsy care • Position • Frequency of vitals monitoring • Total duration of observation
- 23. Complications • Bleeding: 0.01-0.5% ▪ Intraperitoneal hemorrhage ▪ Hematoma: intrahepatic/subcapsular ▪ Hemobilia • Transient bacteremia • Bile peritonitis • Organ injury
Editor's Notes
- Also keep in mind as we do this that we are all subject to hindsight bias right now!
- Morbidity and Mortality conferences have long been part of the practice of medicine, having originated in the early 1900s with Ernest Codman at Massachusetts General Hospital in Boston. Codman was the first American doctor to follow the progress of patients through their recoveries in a systematic manner.[3] He kept track of his patients via "End Result Cards" which contained basic demographic data on every patient treated, along with the diagnosis, the treatment he rendered, and the outcome of each case. Each patient was followed up on for at least one year to observe long-term outcomes. It was his lifelong pursuit to establish an "end results system" to track the outcomes of patient treatments as an opportunity to identify clinical misadventures that serve as the foundation for improving the care of future patients. Codman triangle (previously referred to as Codman's triangle) is the triangular area of new subperiosteal bone that is created when a lesion, often a tumour, raises the periosteum away from the bone.
- Codman triangle (previously referred to as Codman's triangle) is the triangular area of new subperiosteal bone that is created when a lesion, often a tumour, raises the periosteum away from the bone.
- As I present this case to you, I want you to have a healthy level of curiosity. If something is bothering you and not truly adding up, I want you to make a mental note of it because it will likely come up when we break up in small groups and this will be an opportunity to discuss further.
- The top labs are the ones from the day of admission The bottom ones are from 10/30, last time she was seen by her oncologist
- A type of a bias Once we have committed ourselves to a path, it is hard to undo
- The same idea was explored in the field of medicine
- For most patients, percutaneous liver biopsy is the preferred approach because it is less invasive and less costly compared with other approaches A transjugular liver biopsy is preferred for patients with coagulopathy, large-volume ascites, or a suspected vascular tumor. Fine needle aspiration (FNA) of the liver with image guidance is used to sample a focal liver lesion and provides a small number of cells for cytological examination; thus, it is not a complete tissue biopsy Laparoscopic liver biopsy is used for staging disease in patients with intra-abdominal malignancy and is likely to have a higher diagnostic yield in patients with cirrhosis compared with percutaneous liver biopsy. However, it requires general anesthesia, which is associated with increased risk of complications and cost
- Plavix, asa, warfarin, NSAIDs, Ginkgo biloba and fish oil AASLD American Association for the Study of Liver Diseases Society of Interventional Radiology
- Sickle cell: Serious complications, including bleeding and death, have been described in patients with acute hepatic disease, complicating sickle cell anemia, and suggesting that a percutaneous biopsy should be avoided in such patients Amyloidosis: Amyloidosis is associated with an increased risk of bleeding. Several factors may contribute, including factor X deficiency, due to binding to amyloid fibrils; decreased synthesis of coagulation proteins in patients with advanced liver disease; and amyloid infiltration of blood vessel walls.
- While the optimal post-procedure position has not been studied, the AASLD suggests positioning the patient in the right decubitus position for two hours followed by a supine position for an additional hour. We monitor the patient's vital signs every 15 minutes for the first hour, every 30 minutes for two hours, and then hourly until discharge at four hours after biopsy. The minimal duration of observation that is safe has not been clearly established; an observation period as short as one hour has been described [20,21]. An observation period of two to four hours has been recommended in a guideline from the AASLD
- Curiosity is the wick in the candle of learning