1. Morbidity & Mortality Presentation Nikita VanDenBosch Wayne State University M&M presentation July 2013

2. Demographics Name: JS (female) Age: 17 years Admitting Diagnosis: Atrial septal defect Discharge Diagnosis: ASD status post closure PMH:ASD, hyperthyroidism, depression PSH: thyroidectomy and wisdom teeth Social Hx: lives at home with parents. Just finished HS and plan to attend college in Colorado in the fall. Family Hx: no family history of congenital heart disease Allergies: NKDA Medications: (prior to admission): levothyroxine thyroid supplement, Celexa, Wellbutrin, Yasmin birth control. 3. History HPI as of 5/31: 17 year old female who was found to have a murmur in the fall of 2012 after a workup for thyroid dysfunction. Her echocardiogram showed a large secundum ASD. Concurrently being evaluated for increased work of breathing during exercise and abnormal pulmonary function testing. Multidisciplinary team Review Options for closure: 0 percutaneous device surgical closure Families choice was surgery 4. The murmur Grade 2/6 systolic ejection murmur with a Fixed split S2 Left upper sternal border 5. Pre-Operative Testing ECHO REPORTS: 9/19/12= THE STUDY WAS TECHNICALLY DIFFICULT. Echo images compromised by body habitus. Mild-moderate right ventricular enlargement. Moderate secundum ASD. Moderate left to right atrial shunt. Mild tricuspid regurgitation. 11/21/12= TEE; Moderate sized ASD. Defect measures 11 mm 6. September 18th EEG 7. The determining ECHO 8. The ECHO with flow 9. In the operating room Intubated Right IJ was placed Left Radial Arterial Line was placed Urinary Catheter was placed Preoperative TEE was consistent with ASD Right mammary incision is made 10. Intraoperative (6/3) surgery- Right Heart enlargement is noted Once on bypass the heart was open, inspection of the intra-atrial septum did not reveal the typical findings of ASD. The fossa ovalis membrane was redundant and thin-walled. Postoperative TEE did not reveal any intra-atrial level shunting. cardiopulmonary bypass was 80 minutes. aortic cross clamp time was 52 minutes. 11. Intraoperative Continued Right pleural catheter was placed for pain management Right pleural and medistinal chest tube OR transfer to PICU, stable condition. 12. Post-Operative Out of OR 1645 Remains stable, intubated, lines in place, no inotropes Cefazolin Labs: PT:11 INR:1.1 PTT:25 Fibrinogen: 358 13. June 3rd EEG 14. POD #1: Medications: Cefazolin: 2,000 mg IV every 8 hours Lasix 10mg IV BID Fentanyl drip: 0.5 mcg/kg/hr On Q pain pump: 6ml/hr to 8ml/hr 15. Labs LABS: Lactate: 1.7 Hgb: 11.1 Hct: 33.5 Plts: 235 ABG: pH 7.4 41/112/25 Na:141 K: 3.8 Cl:108, Hco3: 24, BUN: 7, Cr: 0.67 Glucose 158, Mg 2, Phos 3.9 WBC: 12.7, CRP: 41.2 6/4/13=post-op ECHO: no residual ASD s/p suture closure, normal left ventricular systolic function, no pericardial effusion Chest x-ray obtained 16. Vitals and P.E. Physical Exam: General: awake and appropriate for age CV: Normal S1S2, no murmur, clicks or rubs, radial & pedal pulses +2, no edema, cap refill less than 2 sec. Resp: CTAB, CTx2 in place GI: Soft NT/ND, hypoactive bowel sounds, no organomegally MSK: moves all extremities, 4/5 strength Skin: Incision sites are clean, dry, approximated without redness or drainage. Neuro: no focal deficits HR RR BP SpO2 Temp 94 17 120/71 art. 94% RA 37.8 oral 17. POD #1 (6/4) Extubated at 0255 chest tube out-pulled at 1600, D/C art line, D/C foley, D/C CVL Cefazolin day 2 Tmax 38.2 oral Fluid restriction 1500ml/day-clears were began after extubation Fentanyl drip-0.5 mcq/kg/hr. Ropivacaine(on Qpain pump) 6ml/hr. to 8ml.hr 18. POD #2 Medications: Lasix 20 mg PO daily Cefazolin 2,000 mg IV every 8 hours HOME MEDICATIONS RESTARTED: wellbutrin 100mg PO daily Celexa 20mg PO hs Synthroid 0.137 mg PO daily PRN MEDICATIONS: Lortab 325mg-5mg, 2 tabs PO every 6 hr. moderate pain 19. LABS LABS: Hgb: 10 Hct: 29.9 Plts: 201 Na:138 K: 3.7 Cl:103, Hco3: 27, BUN:6, Cr: 0.49 Glucose 152, Mg 2, Phos 1.7 WBC: 17.01, CRP: 50.7 Chest x-ray: improved. Right diaphragm remains high 20. POD #2: Vitals and P.E. Physical Exam: General: awake and appropriate for age CV: Normal S1S2, no murmur, clicks or rubs, radial & pedal pulses +2, no edema, cap refill less than 2 sec. Resp: CTAB, no retractions or difficulty breathing, on and off hiccups GI: Soft NT/ND, active bowel sounds, flatulent, no stools, no organomegally MSK: moves all extremities, 5/5 strength Skin: Incision sites are clean, dry, approximated without redness or drainage. Neuro: no focal deficits HR RR BP SpO2 Temp 93 27 134/83 RA 95% RA 37 oral 21. POD #2 Day 3:(6/5)able to go home, hiccups, not sure pain meds will hold Full fluids-tolerating general diet Last dose of Cefazolin 22. POD #3 Vitals and P.E. Physical Exam: General: alert and oriented. Calm and interactive. HEENT: normocephalic, PEERLA, Nares patent bilaterally, mucus membranes moist and intact. No jugular vein distention. CV: Normal S1S2, no murmur, clicks or rubs, radial & pedal pulses +2, no edema, cap refill less than 2 sec. Resp: CTAB, no wheezing, no retractions or difficulty breathing, on and off hiccups GI: Soft NT/ND, active bowel sounds, flatulent, no stools, no organomegally MSK: moves all extremities, 5/5 strength Skin: right submammary Incision sites are clean, dry, well approximated without tenderness, redness or drainage. Chest tube sites are clean, dry, well approximated without tenderness, redness or drainage. Neuro: no focal deficits HR RR BP SpO2 Temp 98 15 142/79 RA 99% RA 35.6 oral 23. POD #3 (6/6) Discharge home Discharge ECHO= small pericardial effusion, good biventricular function No stool Chest x-ray: continued improvement with bilateral lung aeration. 24. Things that were learned J snores likes the hospital for 2 things, Morphine and Oxygen Wore oxygen for a brief time after her chest tube were removed. 25. Discharge Medications Continue with home medications Lasix 20 mg PO daily Miralax 17grams PO daily Motrin 600mg po take q 6 hours for mild pain Lortab 325mg-5mg tab, 2 tab q6 hours for moderate to severe pain 26. Discharge Instructions Follow up June 13, 2013 with surgeon Activity restriction: nothing that will force her arms to be pushed or have her arms above her head. Showering restrictions: 1 week post-op okay to shower and to wipe wounds clean and dried off with towel. Wait 4 weeks prior to submersion. Incision sites: watch for redness, swelling, discharge. Watch for signs of infection Bowel regimen: Use Miralax until regular bowel regimen has returned 27. Post-Operative Follow Up 6/13/13=no pericardial effusion 1 week post-op apt: no murmur, effusion is decreased in size Discontinue daily Lasix 28. Discussion What were the main complications? There was NO ASD Who was involved in the complication? The entire Cardiac team 29. Discussion What steps were missed that lead to complication? How could it have been prevented? Interventions for the APN 30. A different choice A different scenario Had JS chosen to have a 0 percutaneous procedure(cath lab) Longest hospital stay would have been 1 day Shortest hospital stay would have been 6 hours from when the sheath was removed No additional medications