MORTALITY MEET

26.07.2019

Presented by : Jyoti Aggarwal

Moderator : Dr Neeraj Singla

Chief complaints and Presenting History
Khema Gupta, 55 years female ; resident of 26 mohinder nagar canal road ,
Jammu and Kashmir; admitted on 3rd may 2019 with cr no : 190502541,
admission no : 201918625 ; presented with c/o :

o Fever * 7 days

o Neck pain * 2 days

o Drowsiness * 2 days

o Altered sensorium * 1 day

• Fever : high grade (not documented), intermittent , Elaborate further

• a/w intermittent headache and chills and rigors.

• 5 days later she developed neck pain (nape??) Occipital headache drowsiness
followed by altered sensorium .
• No h/o vomiting
• No h/o weakness of any body part
• No h/o convulsions/ LOC
• H/o hydrophobia/dysphagia/ aerophobia…………..????

• There is alleged history of rabid (stray) dog bite on 11.04.2019 on face

with a laceration over upper lip extending upto tip of nose and left cheek
(Category III???)
Past history and treatment
history
• No past h/o similar complaints

• No past h/o DM /HTN/EPILEPSY

• No H/o tuberculosis contact in family/no history of ATT in past

• Patient received inj ATS , ARV (Verocell ) at Govt Medical College

,Jammu on day 0 , 3 , 7 ,14 with D28 due on 9th may 2019 and ARS 8.8 ml
given locally into wound and i/m in gluteal region on 11 .04.19

• For the above mentioned complaints patient went to a local pvt hospital
where MRI brain was performed which was found to be normal and
possibilty of ? Viral encephalitis was kept
• Patient took lama and came to PGIMER , Chandigarh where CSF
examination was performed with routine investigations and
sample for Rabies PCR and skin biopsy sent to NIMHANS ;
referred to coc to continue charted treatment ;

• Admitted at GMCH 32 on 03.05.19 to Medicine ICU at 11 :30 pm

Clinical Examination
Vitals Patient conscious but drowsy ( GCS : E3V3M5)
Pulse rate : 92/min
BP : 130/80 mmHg
RR :22 /min (tachypneic)
SPo2 ?????

Temp : Afebrile

• CVS/Resp/Abd exam – WNL

• CNS ----HMF ; Sn :
• Motor :
• B/L plantars : flexors
• Neck rigidity : present
• Signs of meningeal irritation :
• Pupil :
• Vertical Nystagmus ( downbeat)
Course in Hospital
• Patient was intubated same day i/v/o respiratory distress put on
mechanical ventilation (SIMV mode 30/500/2.8/10/0.2/20/40/5/0)
• CSF examination done same day 3rd may night (04.05.19) and CSF sent
for pan viral markers
• CSF at PGI : lymphocytic predominant , protein 101 mg/dl , glucose 58
mg/dl (corresponding blood glucose ????)
• Outside reports (02.05.19 ) were suggestive of hyponatremia sodium
124meq for which 3% Nacl was given over 3-4 hours
• Outside MRI brain films were discussed Reviewed which was grossly
normal study
Serft and Hemogram on 04.05.19 ( 1st Day )

Date 04/05 05/05 06/05 07/05 Date 04/05

Hb 10.4
Na 134 132 130 125
TLC 14.5
K 3.3 2.8 4.2 3.7 DLC 90/07/02/01
Platelet count 1.78 LAC
Cl 99 98 97 91
MCV 61
Urea 18 25 21 31 MCH 20
MCHC 33
Creat 0.6 0.6 0.5 0.6
RDW 16
Date 04/05 ( pre I ) 04/05 (post I ) 05/05 06/05
pH 7.40 7.54 7.53 7.49
paO2 80.2 202 150 137
pCO2 33.3 25.6 24.2 24.5
HCO3 20.3 22.0 20.5 18.6
SpO2 99.4% 99.4% 99.2% 99.0%
Na 134 127 125 126
K 2.3 2.4 3.0 3.5
Cl 99 92 99 99
iCal 2.27 2.95 2.99 3.02
Lactate 1.5 1.0 1.1 1.8
BE - 3.6 0.4 -1.4 -3.5
Glu 97 150 115 133
 3rd – 6TH May
• GCS on day of admission E1VE??TM1………..??????? ( GCS : E3V3M5
• Neurology consult was taken and plan was kept to start Inj Acylovir
i/v/o ? Viral Encephalitis .
• On 6th may (3rd day ) 2am patient’s BP shoot up to 210/110 mmHg for
which Inj midazolam infusion rate was increased to 4mg/hr from
3mg/hr and inj ketamine infusion was planned ( non availability )
• Patient’s BP at 5am : 120/70mm Hg
• Patient was given 10% Ca Gluconate i/v/o iCal 2.9

• K Correction and Na correction given

• Patient was given Inj Interferon alpha 3 lac IU intrathecal OD (As per
Milawaukee Protocol ) 6th may onwards i/v/o rabies encephalitis
• CSF for pan viral markers was collected-Negative
• CSF and Nuchal Skin biopsy report – Negative for Rabies virus RNA
8th May ( 5th Day )
• CEMRI Brain was done :
• T2FLAIR hyperintensities in B/L superior and middle frontal gyri , B/L medial frontal
cortex , b/l insular cortex and b/l medial temporal lobes , right putamen , b/l
thalami , midbrain and upper dorsal pons , b/l dentate nuclei with few of them in b/l
thalami , midbrain and upper dorsal pons showing diffusion restriction as described .
• Subtle sulcal space hyper intensities on post contrast FLAIR images as described.

• F/S/O meningoencephalitis

• (IMAGE) ????
9th to 14th may
GCS : E1VTM1
• BP shooted upto 180/90 mmHg on 10.05.19 ? Autonomic
disturbances
• Tracheostomised on 11.05.19
• K correction given i/v/o potassium = 2.7
• USG Chest on 13.05.19 – no e/o pleural effusion
15th to 22nd May
GCS :E1VTM1 to M3
• Neurology consult was taken and plan was to start Inj Methyl Prednisolone and ATT.
• On 16th may (14th day ) there was increased discharge from stoma site for which Ent
consult was taken and tracheal aspirate sent for c/s
• CXRAY 17th may : White out lung ? VAP ? Mucous plug collapse
• USG Chest done on same day : moderate PLEF
• Full dose ATT was started on 17th MAY
• Tracheal aspirate
• CSF sent for gene Xpert TB -Negative
LP was repeated on 22nd may and CSF sent to NIMHANS for Rabies Virus PCR
23 – 30 may th

GCS : E2VTM3 to E4VTM3

• Hyponatremia : free water restriciton (k/c/o hypothyroid….can lead to chronic hyponatremia) (thyroid profile ????)
• Euvolemic status with urine osmolality 549 mOSM/kgH2O ?SIADH (S osmolarity??? ) urine volume ??? JVP ??
• Thyroxine dose increased from 75 mcg to 150 mcg (TSH - 8.6 )
• Urine Spot Na : 81

Date 23.05 24.05 25.05 26.05

Na 119 130 141 127
K 3.6 3.8 3.9 4.5
Cl 97 98 101 91
Urea 20 23 19 18
Creat 0.6 0.8 0.8 0.5
31st May -2nd JUNE
GCS E4VTM3
Neuro consult taken advised inj sustanone 50 mcg i/m stat and tab
gravitor added (INDications ????)
• Anesthesia consult taken for weaning off ventilatory support
• Patient was put on BIPAP mode on 2ND june due to respiratory distress
patient again put on to SIMV mode
3 - 5th June
GCS : E4VTM3
Weaning attempts done with following ABG records:
Date (Mode ) 04.06 (BIPAP) 05.06 T PIECE 06.06 T PIECE 07.06 CPAP/PS

pH 7.54 7.51 7.49 7.50

Pao2 138 190 154 157

PCO2 26.3 25.5 26.3 22.5

HCO3 22.6 21.2 20.0 17.3

SpO2 98.4% 99.6% 99.3% 99.3%

6th -13th June
GCS : E4VTM3
• K Correction was given K level 2.5mEq/L
• Patient put on T piece and maintained saturation
• ATT was stopped i/v/o ATT induced hepatitis OT/PT 282/824
• USG CHEST : No e/o pleural effusion
• CXRAY (AP) : left homogenous opacity ? Left lung collapse for which
Pulmonary Medicine consult was taken and bronchoscopy was
planned
14th June (43rd day )
• Patient was shifted to EMW on T Piece with BP 150/100 mmHg
,adequate urine output , Na 138 mEq , K 3.3 mEq and GCS E4VTM2
• Patient was shifted to MICU with worsened sensorium GCS E1VTM1
• Inj Piperacillin Tazobactam was started on 14.6.19
15th June
• Patient’s BP was UR AT 8: 15 am and SpO2 85 % on T piece ,
bradycardia – put on SIMV mode and inotropes were started
• Pulmonary medicine consult was taken for ? Left collapsed lung
advised nebulisation with duolin and budecort ( avoid trade names)and to
continue chest physiotherapy.
Date 14.06 ( T Piece @ 8lt) 15.06 (SIMV /VC)
pH 7.48 7.49
pO2 268 165
pCO2 30.3 24.7
HCO3 22.5 18.9
Spo2 99.8% 99.6%
16th June
GCS : E1VTM1
• BP improved and Nor Adr was tapered from 50ml/hr to 30ml/hr ( Give
dose)

• K correction given K level 2.8

• CVP monitoring
Date
started with CVP
15.06.19
1 mmHg17.06.19
16.06.19
– 2.5 -3 litres IV fluids given
18.06.19
Na 153 160 162 170
K 2.8 3.8 2.3 3.9
Cl 115 130 127 137
Urea 13 18 21 18
Creat 0.5 0.5 0.7 0.8
17th June
• GCS E1VTM1 on SIMV/VC MODE
• SBP : 60mmHg and CVP 2mmHg ……..cvp in cm of saline???
• Inj Dobutamine started @ 40ml/hr (dose)
• B/L compression doppler was done – no e/o DVT
Date 10.6.19 13.6.19 17.6.19
Hb 9.3 9.4 7.2
TLC 10.8 12.6 7.6
DLC 88/06/04/02 85/10/03/02 88/08/02/02
PLATELET COUNT 100 101 41
Date 10.6.19 13.6.19 17.6.19

Hb 9.3 9.4 7.2

TLC 10.8 12.6 7.6

DLC 88/06/04/02 85/10/03/02 88/08/02/02

PLATELET COUNT 100 101 41

Date 17.06.19 (11 am ) 17.06.19 (4pm) 18.06.19 (4 am )

pH 7.34 7.26 7.42
pO2 204 260 177
pCO2 28.1 32.8 21.7
HCO3 15.0 14.2 13.8
Spo2 99.4% 99.8% 99.5%
18th June (47th day )
• SBP on dual inotropes 50mmHg
• Patient developed sudden cardiac arrest at 9:45 am and CPR started
immediately
• Patient could not be revived and declared dead at 10 :15 am.
Cause of death
K/c/o Hypothyroidism / Rabies
Encephalitis / Shock ? Septic shock

Terminal event :
o electrolyte imbalance / cardiac
arrythmias ? Cardiopulmonary
arrest
Milwaukee protocol
• Milwaukee Protocol, version 6 (updated November 2018)
Rabies Lab Findings and imaging
Rabies Vaccination
“If a patient has rabies, he will die
in the next few days; if he does not
die, he does not have rabies!”

Thank you
• Change the presentation as
• I sent the presentation on mortality meet as mail
• Correct the highlighted
• Mention indications for treatment given
• Insert mri images outside and your institute
• Arrange content as hospital course or timeline..its confusing