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