Anaesthesia & Intensive Care

Morbidity & Mortality

 M.H.
• 27 years old female

• No chronic illnesses

• Gravida 30+6/40 – uneventful

• LSCS 2017 - (twin gestation, HTN in pregnancy)
• G4 P4
 28th Jan 2019
• Presented to SABH
– 1/7 fever, headache, retro-orbital pain, abdominal
pain
– Dry cough, pleuritic chest pain
– °Rash, °muscle pain, °joint pain °bleeding
– BP 102/44 – 115/45, T 101.6, HR >100
• Assessment
– Viral Illness
– ? Dengue fever

• Management
– Supportive care
– Hydration, panadol
– Dengue titres not done due to financial constraints
 Day 5 (1st Feb)
– SOB, desaturation, respiratory distress
• O2sat 80%, RR-36
• Placed on O2 via face mask with reservoir bag at 15L/min
with improvement to 91%
– Productive cough (yellow sputum)
– High fever persisted
– No change in neurological status

• CXR
– BL opacities noted
• Assessment
– Type I Respiratory failure 2°
– Community acquired pneumonia
– r/o pulmonary embolism in pregnancy

• Management
– Rocephin 2G, followed by 1G
– Heparin 19,000u IV and 12,000u sc
 Day 6 (Feb 2nd)
• Resp distress worsened
– Tripod position, tracheal tugging, accessory muscle use
– SpO2 84 – 92% on 15L O2 face mask via reservoir bag
– Remained hemodynamically stable

– ABG revealed

pH pCO2 pO2 HCO3- BE SpO2

7.45 32 68.8 22.3 -0.8 93.2
• Management
– Intubated for transfer to UHWI
• Desaturated to ~40% post intubation
• Frothy yellow fluid suctioned
• Saturation improved with manual ventilation
 28 Jan 1 Feb 2 Feb
Hb 10.7 11.0 10.1
WBC 9.3 (neutrophilia) ? 5.4
Plt 207 167 161
PT 14.2/ 12.1
INR 1.22
PTT 36.6/28.4
 1 Feb 2 Feb
Na 132 141
K 3.0 3.0
Cl 95 103
HCO3- 21 19
Urea 1.1 0.9
Creat 45 40
 2 Feb 2 Feb
T Bili 21.4 PT 13.2/13.5
Prot 52 INR 0.96
Alb 27 PTT 67.2/29.6
ALT 47 -following heparin
AST 100
GGT 156
 Day 7 (3rd Feb)
• Transferred to UHWI – ICU

• O/E (at UHWI)

– CNS
• Agitated, moving x4 limbs, GCS 8T/15 (sedated)
– RESP
• Harsh breath sounds, °creps, °rhonchi
• Yellow frothy sputum noted in ETT
– Blood tinged
• VENT FiO2 1.0, PC 22, PEEP 10, I:E ratio 3:1
– Subsequently commenced on bilevel
• O/E (at UHWI)
– CVS
• BP 105/61 – 148/98 then deteriorated to 88/53
• PR 104 – 121
– ABD
• Gravid uterus, soft, SFH 30cm
• FHR 128 bpm
 28 Jan 1 Feb 2 Feb Feb 3
Hb 10.7 11.0 10.1 11.0
WBC 9.3 ? 5.4 5.98
(neutrophilia)
Plt 207 167 161 92
PT 14.2/ 12.1
INR 1.22
PTT 36.6/28.4
• Assessment
– Type I Respiratory failure 2°
– Acute viral illness – SARI
– EGA 31+/40
– r/o peripartum cardiomyopathy
– Pulmonary embolism – unlikely
• Management
– HOLD anticoagulation
– Obtained FFP / PRBC
– For LSCS 12 hours after last heparin dose
– Viral titres – RSV, CMV, Dengue, Influenza A+B
– Echocardiogram
– Tamiflu (Oseltamivir) 105 mg po bd
– Refer to IM & ID
– Sputum culture
– F/u blood culture done 31 Jan (at SABH)
• Review by Obstetrics consultant
– Delivery at this time would not improve
ventilation

• Management
– Hold LSCS
pH pCO2 pO2 HCO3- BE SpO2
7.45 32 68.8 22.3 -0.8 93.2
7.26 53.9 69.4 21.8 -0.3 90.37
• Internal Medicine Consult
– Assessment
• Severe Acute Respiratory Infection
• Presumed Dengue Fever
• Superimposed hospital acquired pneumonia
– consolidation pneumonia with pleural effusion
• ARDS
• Acute hepatic impairment
• r/o PE, Wells score 4
– Pulmonary embolism with pulmonary infarcts
• Suggestions by IM
– Change ABX to zosyn / levofloxacin
– CTPA
– Suggest continued anticoagulation
 Later on Day 7 (Feb 3rd)
• Condition deteriorated
– Higher ventilator requirements
– I:E ratio of 6:1
– Bilevel 33 / 15 , PS 23

– Pleaural scan:
• Moderate pleural effusion in (L) lung base with collapse
consolidation of left mid and lower lobe. Small pleural
effusion on the right
 • Urine output 0.2 – 0.3 ml/kg/ hour despite boluses
• Lasix infusion commenced
• Renal screen done
• Hemodynamically stable, no inotropes required

1 Feb 2 Feb 3 Feb

Na 132 141 141
K 3.0 3.0 3.6
Cl 95 103 106
HCO3- 21 19 13
Urea 1.1 0.9 4.0
Creat 45 40 102
 Day 8 (4th Feb)
• LSCS
– TIVA
– Desaturation to 34%, manual ventilated to 97%
– Live male infant delivered
– EBL 400ml, hemodynamically stable
 Day 8 (4th Feb)
• Pulmonology consult
– Assessment
• ARDS / Type I respiratory failure
– ? Secondary to pulmonary embolism
• Hospital acquired pneumonia
• Acute viral illness ?H1/N1
• s/p LSCS
– Suggestions
• CTPA
• BL thoracostomy
• Dengue titres / nasal swab
• Hold anticoagulation – post op
 Day 9 (5th Feb)
• Severe ARDS
– High ventilator requirements - Bilevel 35/15, PS35,
FiO2 1.0
– However, respiratory acidosis improved and FiO2
weaned to 0.5
• Remains sedated
pH pCO2 pO2 HCO3- BE SpO2 Lac
7.19 50 92 17.6 -8.2 94.7 0.7
7.35 39 120 21.4 -3.6 97.9 1.0
 • AKI
– Urine output poor
– 0.3 -0.7 ml/kg/hr
– despite lasix infusion
1 Feb 2 Feb 3 Feb 5 Feb
Na 132 141 141 142
K 3.0 3.0 3.6 4.7
Cl 95 103 106 108
HCO3- 21 19 13 19
Urea 1.1 0.9 4.0 10.3
Creat 45 40 102 259
 email: clinicallabs@uwimona.edu.jm web: http://myspot.mona.uwi.edu/fms/

Patient's Name: HAMILTON , MONIQUE Reg. No: 10032933

Date of Birth: 27-May-1991 Age 27 Sex: F Order No.: 62040118
Physician: ADMITTING, - Date Ordered: 04-Feb-2019 09:37
Ward/Clinic: Intensive Care Unit (UHWI) Acct No.: MX0000239657

MICROBIOLOGY
Source: Sputum Trapped Collected: 04-Feb-2019 09:37
Order#: 62040118 Received: 04-Feb-2019 09:37
Antibiotics at coll.: Piperacillin/tazobactam, Levofloxacin

Gram Stain * Final 06/02/19 14:43

++ Pus Cells, No organisms seen
Respiratory Culture * Final 06/02/19 14:43
No Growth at 48 hrs

Reviewed and Authorized by Dr.Thoms Camille-Ann on 06/02/19.

Patient's Name: HAMILTON , MONIQUE Reg. No: 10032933
Date of Birth: 27-May-1991 Age 27 Sex: F Order No.: 62040176
Physician: ADMITTING, - Date Ordered: 04-Feb-2019 10:10
Ward/Clinic: Intensive Care Unit (UHWI) Acct No.: MX0000239657

MICROBIOLOGY
Source: Nasopharynx Collected: 04-Feb-2019 10:10
Order#: 62040176 Received: 04-Feb-2019 10:10
Antibiotics at coll.: Piperacillin/tazobactam, Levofloxacin

Throat/Nasal Culture * Final 06/02/19 14:46

No Pathogens Isolated

Reviewed and Authorized by Dr.Thoms Camille-Ann on 06/02/19.

 Day 11 (7th Feb)
• Accidental extubation
– Desaturated to low of 12%
– Remained hemodynamically stable
– Quickly reintubated
– Neurology during event
• Moving limbs, eyes open
• Distressed / Air hunger

• Noted to have subcutaneous emphysema

Patient's Name: HAMILTON, MONIQUE Reg. No: 10032933
Date of Birth: 27-May-1991 Age 27 Sex: F Order No.: 62040689
Physician: ADMITTING, - Date Ordered: 04-Feb-2019 15:19
Ward/Clinic: Intensive Care Unit (UHWI) Acct No.: MX0000239657

VIROLOGY
SPECIMEN RV1 COLLECTED 04/02/19 00:00 BY ASORD RECEIVED 04/02/19 15:19 BY NBRWN
Viral Hepatitis

Result Flag Units Reference-Range

Anti-HCV NEGATIVE
Hepatitis B Surface Antigen NEGATIVE
Anti-HAV IgM NEGATIVE
Authorized by: Dr. M. Brown, for Consultant Microbiologist. 07/02/2019
 Day 13 (9th Feb)
• Consultation by renal service
– Urine 2.5L on 5th Feb - 287ml on 8th Feb

• Assessment
– Satge III AKI
• 2o to ischemic ATN
• Hypoxia with accidental extubation and hypotension
– No indication for dialysis
– Suggest lasix be discontinued
 Day 14 (10th Feb)
• GCS depressed
– 5T (E3) from 11T

• Subcutaneous emphysema
– Bilateral tension pneumothox
• Desaturation to 30%-40%, hemodynamically stable
• Needle thoracostomy done by anaesthetist
– Right thoracostomy placed by CTH
• 1.2L serous drainage
• O2 saturation improved to 100%
– Left 7F catheter placed by anaesthesia
• USS guided
pH pCO2 pO2 HCO3- BE SpO2 Lac
7.19 50 92 17.6 -8.2 94.7 0.7
7.35 39 120 21.4 -3.6 97.9 1.0
7.39 29.6 57.3 19.4 -6.0 89.3 1.1
Post thoracostomy
7.32 38.2 183 19.7 -5.7 98.6 1.1
 Day 15 (11th Feb)
• However renal indices continued to worsen
 Day 15 (11th Feb)
• Renal review
– Dialysis catheter placed
– Scheduled for dialysis
 Day 16 (12th Feb)
• CTH review
– Large L pleural effusion
• Deviation of heart to R
• Left thoracostomy placed

• Hyperkalemia (noted at 2am)

– Refractory to medical treatment

pH pCO2 pO2 HCO3- BE SpO2 Lac K Hb

6.954 98.6 20.3 15.5 -10 16.2 3.4 7.7 5.5
 Day 16 (12th Feb)
Later that day
• R thorocostomy tube replaced
• Sentinel node not in chest

• During procedure (2:40pm)

– Hypoxia, bradycardia & hypotension noted
– Followed by CP arrest
• ROSC 26 mins
• Adrenaline 1mg x3
• Defibrillated x2 (125 and 200J)
• Hyperkalemia cocktail
 Day 16 (12th Feb)
• Arrested again within a hour
– CPR again commenced
– No return of spontaneous circulation

• Pronounced dead at 3:11pm

Physician: ADMITTING, - Date Ordered: 12-Feb-2019 10:06
Ward/Clinic: Intensive Care Unit (UHWI) Acct No.: MX0000240506

VIROLOGY
SPECIMEN RV1 COLLECTED 12/02/19 BY ADMIT RECEIVED 12/02/19 10:14 BY MIVBA
Fever and Rash

Result Flag Units Reference-Range

Dengue NS1 Antigen (Rapid) NEGATIVE
Authorized by: Dr. Joshua Anzinger, Consultant Virologist. 14/02/2019
Dengue IgG (Rapid) NEGATIVE
Authorized by: Dr. Joshua Anzinger, Consultant Virologist. 14/02/2019
Dengue IgM (Rapid) NEGATIVE
Authorized by: Dr. Joshua Anzinger, Consultant Virologist. 14/02/2019
Dengue NS1 Antigen NEGATIVE
Other Viral Illness

Result Flag Units Reference-Range

Cytomegalovirus IgM NEGATIVE
Respiratory Virus

Result Flag Units Reference-Range

Influenza A (H1N1) pdm - Acute Titre see below
@CONVAL
Inflluenza A (H3N2) - Acute Titre see below
@CONVAL
Influenza B Victoria - Acute Titre see below
@CONVAL
Influenza B Yamagata - Acute Titre see below
@CONVAL
 Faculty of Medical Sciences, Mona
Ph: (876) 927-1620-9 Fax: (876) 977-1811
email: clinicallabs@uwimona.edu.jm web: http://myspot.mona.uwi.edu/fms/

Patient's Name:
Date of Birth:
HAMILTON, MONIQUE
27-May-1991
15th Feb
Age 27 Sex: F
Reg. No:
Order No.:
10032933
62040710
Physician: ADMITTING, - Date Ordered: 04-Feb-2019 15:29
Ward/Clinic: Intensive Care Unit (UHWI) Acct No.: MX0000239657

VIROLOGY
SPECIMEN XST COLLECTED 04/02/19 00:00 BY ASORD RECEIVED 04/02/19 15:30 BY NBRWN
Respiratory Virus

Result Flag Units Reference-Range

Influenza A see below
Authorized by: Dr. S. Jackson, Consultant Microbiologist. 15/02/2019
Influenza A (H1N1)pdm09
Influenza B NEGATIVE
Respiratory Viruses (DFA) NEGATIVE
Authorized by: Dr. Joshua Anzinger, Consultant Virologist. 05/03/2019
Patient's Name: HAMILTON , MONIQUE Reg. No: 10032933
Date of Birth: 27-May-1991 Age 27 Sex: F Order No.: 62110431
Physician: ADMITTING, - Date Ordered: 11-Feb-2019 12:00
Ward/Clinic: Intensive Care Unit (UHWI) Acct No.: MX0000240506

MICROBIOLOGY
Source: Blood Collected: 11-Feb-2019 12:01
Order#: 62110431 Received: 11-Feb-2019 12:01
Antibiotics at coll.: Levofloxacin, Piperacillin/tazobactam

Blood Culture Manual * Final 20/02/19 12:09

Blood Culture Remains Sterile After 7 Days Incubation

Reviewed and Authorized by Dr.Reynolds-Campbel Glendee on 20/02/19.