My pt died, lab results question?

[BinkieRN]

I had an 85 year old pt who I admitted for profound anemia. Blood had been ordered. All of the labs had been draw. I was doing the admission assessment when suddenly she coded and did not make it. Later I looked at her labs. WBC was 230,000. Troponin was 68. Myoglobin was 1141. The doctor said she died of an MI. I have never seen or heard of a WBC that high? Does that go along with an MI? or could she have been septic also? She did not have a temp. When she came in her 02 sat was 76%. She wanted to lie flat with the rebreather on at 100%. I encouraged her to raise the head of her bed and she refused. Can lying flat cause additional respiratory distress? Thank You.

[BinkieRN, BSN, RN]

Here are the labs that were drawn 30 minutes before she passed:

WBC 230,000

RBC 221,100

Hgb 6.7

Hct 20.5

Trop 0.67

Myog 1141

BNP 229

BUN 98

Creat 4.8

ABG's :

pH 7.29

PCO2 19.6

PO2 50

HCO3 9.3

BE -15.8

Diff:

Neut 2

Lymph 28

Atypical Lymphs 69

Mono 1

Platelets Adequate

PT >100.0

INR > 80.9

Whatever is not listed was in the normal range including her UA which was normal and her Blood Cultures were negative also.

I'm trying to figure out this puzzle. INR of >80.9 OMG!!!

[aeauooo]

Here are the labs that were drawn 30 minutes before she passed:

I'm trying to figure out this puzzle. INR of >80.9 OMG!!!

A troponin of 0.67 and Hct of 20.5 is a very different picture than troponin of 68 and Hct of 6.7.

The PT & INR could easily be explained if she was taking warfarin.

She was in metabolic acidosis and renal failure.

With her elevated coags and anemia, she may have had a GI bleed.

I won't comment about her WBCs.

Did you get a chem 7? Na, K, glucose?

The first thing I would have done is correct her acidosis with some bicarb (her CO2 is already low, so you're not going to correct her acidosis by ventilating her), given her some vitamin K, type & cross for FFP and some PRBCs - but this is where you would run into trouble: trying to correct this woman's coags and anemia with blood products is more than likely going to throw her into further heart failure, which we know from her elevated BNP.

Even if you could have quickly corrected her acid/base balance, she probably would have died anyway.

[aeauooo]

Liver failure is another common cause of coagulopathy, but with that degree of coagulopathy, she would have been very jaundiced for hepatic failure to be the cause.

[Tweety, BSN, RN]

Wow the PT/INR is impressive as well. Those labs are so off the chain, I would have ordered a recollect just to confirm.

Septicemia deaths occur with WBCs 20 to 40 range. When they are as high as you state (and I have seen them that high once), along with the anema, I agree with the above person that there was some sort of blood dyscrasia going on.

The troponin levels might be indicative of an MI as well. Not to mention impending renal failure.

Poor dear probably is in a better place, because it sounds like aggressive care would have been futile.

When positioning patients, I don't like the flat position, but let the patients be the judge of how they breathe the best. If she was comfortable, you did the right thing there and I doubt it contributed to her code.

[ddoosier]

Liver failure is another common cause of coagulopathy, but with that degree of coagulopathy, she would have been very jaundiced for hepatic failure to be the cause.

I have never seen an INR that high!

[aeauooo]

I have never seen an INR that high!

Back when I worked neurotrauma we would get these guys in who were on Coumadin but hadn't had their PT/INR checked for who-knows-how-long. They'd fall off of a ladder or have some other relatively minor head trauma and come in with massive intraparenchymal hemorrhages.

Our neurosurgeons, God love 'em, but they should really stick with what they know, would tank these guys up with FFP. The next thing you know their CVP and PA pressures are sky high, SpO2 in the toilet, and we're giving massive doses of Lasix.

[BinkieRN, BSN, RN]

Troponin was 67 not 0.67, sorry type-o.

The glucose was normal, she was not a diabetic. The doctor noted that following her death her D-dimer was found to be positive and it was believed that the cause of death was a PE and/or an MI.

I know I'm a newbie, her death doesn't bother me, her 7 or 8 children said she had a great life and had hoped she would go quickly someday while still mobile and orientated rather than live to be an invalid and/or demented.

All of the labs were redrawn. Repeat values were all basically the same. WBC 221,000 INR >78 , Troponin 67, etc. Labs draw in April were all WNL. She was not taking Coumadin, not even ASA. It was between the two blood draws that she coded and passed. She was admitted directly into the hospital from her physicians office. She walked into the hospital and had driven herself to her doctors appt. She was initially admitted for SOB, fatigue and an abnormal EKG. 02 sat on room air was 86%.

What bothers me is, ok with a INR of >78 her blood would have been extremely thin. How could she die of a PE? She did not have any history of CLL. She was on 3 RX meds. Nothing impressive. Hctz, prescrption iron supplement, Protonix and Multivitamin.

The whole thing just doesn't make alot of sense to me. She obviously must have had undiagnosed CLL which exacerbated quickly. Probably though that didn't kill her? Anemia was not profound enough to kill her? Possibly a slow brain bleed that suddenly ruptured? A massive MI? Resp Failure? Renal Failure? A combination of all? I just can't quite piece it together in my mind. I'm trying to learn from such an interesting case.

[Christie RN2006]

Sounds like she went into multi system organ failure. I had a patient with rhabdo who's labs were that crazy. Did they check a chem 7 or liver enzymes? I would just about put money on it being crazy too!

[GrumpyRN63, ADN, RN]

sounds like sepsis=resp failure=cardiac arrest, no fever needed, pt could be subnormal temp or immunosuppressed/compromised

[rita359]

Agree with the comment that she was to sick to live. For the familys sake it would have been good to have an autopsy on this lady to difinitively answer why she died. In the short term, I agree with them that she was blest to have gone quickly instead of sufferring a long time but they will always wonder what symptoms they missed and whether they could have found this before it got so bad. An autopsy would be the best way to answer all our questions. I think CLL is the best guess.

[BinkieRN, BSN, RN]

Sounds like she went into multi system organ failure. I had a patient with rhabdo who's labs were that crazy.

Christie - Thank you, I researched rhabdomyolysis and it does fit with the patients clinical presentation and labs.

Hyperuricaemia can lead to encephalopathy with depression of respiration with hypoxia and respiratory acidosis. She was hypoxic.

Hypovolaemia due to hemorrhage. She was hypovolemic.

Hyperkalaemia can precipitate severe arrhythmias and cardiac arrest. She had an abnormal EKG with frequent PVC's and long QT interval, she did have a cardiac arrest. I read somewhere that the myoglobin level will be very elevated, which it was.

Acute Renal Failure is the most significant complication of rhabdomyolysis. She was in acute renal failure.

DIC depletes the body of its platelets and coagulation factors resulting in a situation in which there is a high risk for simultaneous catastrophic thrombosis as well as massive hemorrhage. Which would explain the positive D-dimer although her blood was soooooooooo thin.

Thanks for the learning experience!

http://members.tripod.com/~baggas/rhabdo.html#clinical

[FireStarterRN, BSN, RN]

I didn't think of rhabdo, good call!