Post from Kurt Pfeifer from SPAQI
Here's the October Case of the Month from Maria Barsky, MD (UC Irvine)
HPI: 67-year-old woman with PMH of DM2, HTN and CABG 7 weeks ago for 3 vessel disease noted on cath done for stable angina is scheduled for closure of chest wound tomorrow morning. Three weeks after CABG developed fevers, found to be septic, and admitted to the ICU. She improved after 2 weeks of IV antibiotics. The source of infection was thought to be chest wound from CABG dehiscence. Her course was complicated by hypoxic respiratory failure thought to be secondary to COPD. She has been on 4L of supplemental oxygen at time of evaluation, which she has been on for one week (decreased from 6L two weeks ago). This oxygen requirement has been stable for the past 7 days. She denies chest pain, shortness of breath, and feels well overall. Denies orthopnea. Feels deconditioned and cannot take more than a few steps without assistance. Prior to hospitalization was independent with ADLs. The primary team believes that delaying wound closure in this patient will put her at further risk for infection, thus they want to perform it prior to discharge to SNF.
Medications:
-clopidogrel 75mg
-Aspirin 81mg
-Lasix 20mg PO
-duonebs prn
Social hx:
-No smoking, etoh, drugs.
Vitals:
-Afebrile for over 7 days; BPs 120-140/60-90; HR 60-100; SPO2 90-100% on 4L
Physical exam:
On exam, she had
JVD ~10cm, Decreased breath sounds, no wheezes
normal cardiac exam and no peripheral edema
Relevant labs:
-CMP: Cr 1.6(stable since septic episode but previously 1.0-1.3), BUN 30-40;
-BNP: 230(no previous measurements performed)
Relevant imaging:
-CXR (day prior): small pleural effusions and mild vascular congestion vs. atelectasis
-Echocardiogram: EF 47%; no significant valvular abnormalities, no wall motion abnormalities
Discussion Questions:
-In general, how long would you delay nonemergent, noncardiac surgery after CABG?
-For this patient, would you delay the surgery? If yes, what would you want accomplished prior to surgery?