Medical Management

Matthew Crull
February 5th, 2010
 Chief Complaint
• 61 year-old male with COPD, ELSD
and Multiple Myeloma referred to the
Emergency Department by Oncology
with blood cultures growing gram
negative rods.
 Background
• Recent prolonged hospitalization (52days) two
weeks prior to admission:
– Admitted for ARF:
– Cr 6.1 on admission
– Required intermittent HD
– Diagnosed with Multiple Myeloma:
– Light chain MM confirmed by bone marrow bx 6/2009.
– On Velcade/Dexamethasone.
– Hospital Stay complicated by PNA.
– Sputum Cultures negative.
– Treated with Vanc, Ceftaz, flagyl and fluconazole
 History of Present Illness
• 4 days prior to admission patient presented to infusion center for next dose
of velcade/dexamethasone infusion and found to have thrombocytopenia
24K (91K 4 days prior) and a new leukocytosis (7.9 -> 27.1).
• Velcade/Dex held. Blood Cx, UA/Ucx, and CXR obtained.
• CXR with possible new opacification in LLL
• 1 Day prior to admission WBC now 43.4, Velcade/Dex held again.
• Day of admission patient asked to report to ED because of blood cultures
from 4 days ago now growing gram negative rods.
• Patient initially refused to provide additional history. Continually stating,
“I'm feeling fine".
• Eventually endorsed general fatigue, malaise, chills, and cough, which was
occasionally productive of sputum. With the cough, he noted SOB at rest.
Denied subject fevers or nightsweats. Noted increased abdominal
distension, but denied abdominal pain, nausea or vomiting. Noted several
loose stools over the past couple of days. No HA or stiff neck.
 Past Medical History
Past Medical History Medications
• Bumex with KCl supplementation
• Multiple Myeloma • Spironolactone
• Metoprolol
• Cirrhosis/ESLD • Formoterol
• Lactulose
• HCV: Genotype 3. • Allopurinol
Untreated • Acyclovir
• Sevelamer
• Alcohol Dependence • Thiamine and Folic Acid
• PRN:Ativan, Tramadol, Zofran,
• COPD (FEV1 of 1.35)
Compazine, Ambien, Combivent

• Hypertension
• Allergies:NKDA
Social History: Family History:

• 8 brothers and 4 sisters, Limited

contact with family for many
years.
• Prior to admission in June, lived in • Brother who died
Alpine with roommate. Currently
living in a nursing home.
ofcirrhosis and “lymph
• EtOH: Long alcohol history but node cancer”
quit at time of MM diagnosis.
• Unaware of any other
• Tobacco: 30 pack year history;
quit 2 months ago family history.
• Illicit Drug Use: denies
 Physical Exam
• Vitals:
– T:96.1, BP:97/65 (Present to ED:81/55), P:85, Resp:97% on 10L NRB (80% on
RA), breathing 18-22
• GEN: Somnolent but arrousable, NAD on a NRB
• Skin: Warm extremities, No erythema at port site
• HEENT: Anicteric, EOMI, PERRLA, clear posterior oropharynx
• NECK: No adenopahty, full ROM
• CHEST: Wheezes in bilateral lung fields, occasional crackles @ bases
• CV: RRR no murmurs, Flat JVP
• ABD: Distended, BS+, soft, NT, bulging flanks and fluid wave
• EXT: 2+pitting to just distal of knee, sym pulses
• NEURO: A&Ox3,Remainder of neuro exam grosslyintact grossly
 Laboratory Data
127 92 79 11.9
96 39.4 82
4.9 22 2.26 35.3

Ca: 9.1 Mg: 1.8 Phos: 3.8 PMN: 82 Band: 0

• ALB 2.5 L • Coags:
• AST 49 H – INR: 1.5
• ALT 35 – PTT 27.6
• T BIL 1.9 H • UA:
• ALKPHOS 109 – SPG: 1.011
• LDH 283 H – Ph 5.5
• URIC 7.8 H
– LeukNeg

– Nitrate: Neg
• BNP 145
– WBC: 0
• CKMB: 2.1
– RBC: 0
• T: 0.04
• Micro:
• Myo: 61.8
– BCx(7/31): GNR in aerobic bottles
• Lactic Acid: 1.4
– Peritoneal fluid:

– + PMNs
• ABG: 7.46/34/65 on 15L NRB
– WBC: 390 83% PMNs RBC <10000
Questions?
 Initial Management
• ED: Bolused 2 L of NS with transient rise in BP. 2 peripheral blood cultures,
diagnostic paracentesis, started on Vanc/Zosyn and Cipro.
• GNR Sepsis: Suspected lungs as primary source. Diagnostic paracentesis
suggestive of SBP.
– Sputum Cultures & blood cultures from port
– Continued Vanc/Cipro/Zosyn
– IVF to support blood pressure
– Dexamethasone and CortStim test for possible AI
– Cocci and crypto serology sent
– stool studies sent
• Acute on Chronic renal failure: Slight bump increatininefrom time of d/c on 7/22.
Questioned prerenal state from hypotension.
– Supportive IVF
– Diurectics held
– Urine lytes, UUN, and Cr obtained
• DNaR/DNI with Full Care. No advance directive and no Identified DPOA
 Hospital Course: Day 2
• Sepsis/Hypotension:
– Blood cultures still unspeciated
– BP 100’s/60’s
– WBC unchanged
• PNA/Hypoxia: SpO2 90-95% on 6L NRB and desaturated quickly when off NRB.
• ARF:
– GFR unchanged
– Urine studies consistent with prerenal etiology.
• HypoNatremia: 124 -> 127
• Thrombocytopenia: 70-80K
• Refusing Care:
– Questioned patient’s Capacity to make medical decisions.
– Psych eval: Agree with delerium and possible underlying depression
– Ethics consulted
– Attempted to contact surrogate decision maker
 Hospital Course: Day 3
• Over night: Patient elected to continue with treatment

• PNA/Hypoxia:

– Transitioned from NRB to 6L by FM

– CXR: Obtained
 Hospital Course: Day 3
• Over night: Patient elected to continue with treatment
• PNA/Hypoxia:
– Transitioned from NRB to 6L by FM
– CXR: Dense consolidation encapsulating probable right upper lobe cavity. Remaining scattered infiltrates are
unchanged.
– Chest CT: Right upper lobe area of consolidation with cavitation consistent with necrotizing pneumonia.
• Sepsis: Micro: Achromobacter (Alcaligenes) Xylosoxidans:
– Sensitive to:
– Ceftazidime
– Cefepime
– Piperacilln/Tazobactam
– Trimethoprim/Sulfamethoxazole
• ARF: Cr improving
• Consults:
– Psychiatry: evaluated fully and determined to have capacity to make care decisions.
– ID : Suspected lung as source for bacteremia. Discontinued Vancomycin & Cipro. Continued Zosyn and
recultured
– Pulmonary:In agreement with ID. If failing to improve would consider bronchoscopy to obtain samples
– Heme/Onc: Hold treatment for MM and readdress once infectious issues resolved
 Achromobacter (Alcaligenes)
Xylosoxidans
• Aerobic gram negative rod inhabiting aquatic environments.
• Uncommon cause of bacteremia.
• Primarily an opportunistic organism infecting immuncompromised hosts.
• Common sites of infection:
– Catheter related bacteremia
– Endocarditis
– Pneumonia
– GI/GU
• Increasing prevalence in cystic fibrosis patients
• High mortality rate especially in cases of pneumonia and neonates.
• Highly resistant organism
– Sensitive: TMP-SMX, anti-pseudomonal PCNs and carbapenems
– Resistant: fluoroquinolones and aminoglycosides.
 Hospital Course: Day 4-6
• Pneumonia/Hypoxia:
– Continued down titration of Supplemental O2
– Underwent large volume paracentesis with subsequent improvement in oxygenation.
– Imaging: improved opacification surrounding cavitary lesion in RUL
– sputum culture growing pseudomonas aeruginosa resistant to Zosyn and Cipro.
• Sepsis:
– Leukocytosis unchanged
– Blood Cx from port + for achromobacter. Repeated blood Cx.
• ARF: GFR improving
– Bumex restarted
• HypoNa: Continuing to trend toward normal
• ID Consult:
– Bactrim added to double cover achromobactor
– Pseudomonas likely representing colonization continued with Zosyn
– Sputum cultures repeated
• Return of pending studies: AFB negative x3, Influenza negative, Cocci negative, Crypto
negative, GDH/C. Diff negative.
 Hospital Course: Day 7-10
• Pneumonia/Sepsis:
– Repeat sputum culture with pseudomonas of similar sensitivity
– VasCath removed. Catheter tip cultured & eventually negative
– Titrated off O2
• Afib with RVR and hypotension:
– Attempted IV Fluids + Diltiazem but limited by worsening hypotension
– Refused electrical cardioversion (if indicated)
– Started Digoxin and self-converted back to a sinus rhythm
– Bumex held
• Delerium: Intermittent AMS with orientation only to self
– Toxic/metabolic workup unchanged. CT head negative
– Repeat Paracentesis: Unremarkable for evidence of SBP.
– Suspected worsening of hepatic encephalopathy
– Intermittently refusing Lactulose
• Transferred to the floor
 Hospital Course: Day 11-17
• Sepsis:
– Intermittently hypotensive requiring several transfers in and out of DOU.
– Subsequent infectious workup negative except for pseudomonas from sputum.
– Leukocytosis: Continued slow downward trend before leveling at 15K
• Pneumonia/Hypoxia:
– Requiring 0-2L of supplemental O2 by NC.
– repeat imaging showing improving opacification surrounding RUL cavity.
• ARF: Cr continued to improve
• Cirrhosis/ESLD:
– Significant ascities and LE edema. Restarting of diuretics complicated by hypotension.
– Continued intermittent AMS
• Intermittently refusing care: Never requested to have all care withdrawn
 Goals of Care:
• Throughout hospital stay, patient intermittently refused care to varying degree.
– Initially to more invasive studies and procedures,
– Then measurement of vitals, changing site of IVs and oral medications, and
– Eventually refusing IV medications and oral nutrition
• Social work: Attempted to communicate with family throughout hospital stay.
• Multiple discussions held with patient about goals of care.
– Never committed to changing the of focus care to more palliative measures.
– He declined to appoint a DPOA stating “he did not want to be a burden”.
• On hospital day 16, his oldest sister flew from Colorado to see patient.
• With her present, patient decided to pursue palliative care with inpatient hospice.
• On Hospital Day 17, patient transferred to inpatient Hospice.
Hospital Course: Days 18-47
• Patient admitted to palliative unit noted to be alert but
confused.
• Started on morphine 15mg q12 hour & eventually
uptitrated to 30 mg q12hour
• Ativan added for agitation.
• Eventually became lethargic and no longer able to
swallow oral medications.
• Started continuous morphine infusion
• Haldol added for continuing confusion and aggitation
• “Patient died peacefully on Sept 20, 2009 at 14:56. Sister
notified.”
Questions?...Comments?