Death Round Death Round

MICU CaseMICU Case

By Maruf AberraBy Maruf Aberra

Jan 23/2007Jan 23/2007

Identification Late F..T.Late F..T. Age -14 yearsAge -14 years FemaleFemale Addis AbabaAddis Ababa Date of admission- 27/04/99 E.cDate of admission- 27/04/99 E.c Date of death - 01/05/99 E.cDate of death - 01/05/99 E.c

Referral Paper (Referral Paper (Private ClinicPrivate Clinic))27/04/9927/04/99 Known Diabetic on InsulinKnown Diabetic on Insulin Cough productive of on and off blood mixed Cough productive of on and off blood mixed

sputumsputum Fast & deep breathingFast & deep breathing Failure to communicate.Failure to communicate. BP =unrecordable Pulse=Feeble, fast T=35 BP =unrecordable Pulse=Feeble, fast T=35 Decreased air entry & crept over the left lungDecreased air entry & crept over the left lung RBS 260 mg/dlRBS 260 mg/dl DX= DKA, Pneumonia R/O PTBDX= DKA, Pneumonia R/O PTB MGT= (N/S +R/L) 2500ml, Ampicillin 500mgIVMGT= (N/S +R/L) 2500ml, Ampicillin 500mgIV

History at presentationHistory at presentation

Vomiting and diarrhea / 04 daysVomiting and diarrhea / 04 daysChange in mentation/08 hoursChange in mentation/08 hours

Known type-1 DM for five years, at the time taking Known type-1 DM for five years, at the time taking Humulin N 10+10 /dayHumulin N 10+10 /day

Since 4-days prior had reported to have watery Since 4-days prior had reported to have watery diarrhea and Vomiting of ingested matter diarrhea and Vomiting of ingested matter associated with abdominal cramp. Followed by associated with abdominal cramp. Followed by change in mention for 8 hours before presentation.change in mention for 8 hours before presentation.

Preceding polyuria and polydypsia.Preceding polyuria and polydypsia. No fever No fever No cough/ chest painNo cough/ chest pain No nuchal pain/rigidityNo nuchal pain/rigidity

ExaminationExamination

Vital signs Vital signs BP= unrecordableBP= unrecordable 100/60 mmHg after 3 bags of fluid100/60 mmHg after 3 bags of fluid PR= 114/m RR=32 deep and PR= 114/m RR=32 deep and

laboredlabored T= 36T= 36 Pink conjunctiva, no icturusPink conjunctiva, no icturus Dry mucosaDry mucosa No sLAPNo sLAP Fine crackles on bilateral lower lungsFine crackles on bilateral lower lungs No murmur or gallopNo murmur or gallop

Examination contd…Examination contd…

Full abdomen, moves with respirationFull abdomen, moves with respiration No organomegally, No shifting dullness or fluid No organomegally, No shifting dullness or fluid

thrillthrill

Urinary catheter in place draining clear urineUrinary catheter in place draining clear urine Skin turgor goes back slowlySkin turgor goes back slowly No edemaNo edema No active skin lesionsNo active skin lesions Non communicating with GCS=11/15Non communicating with GCS=11/15 No cranial nerve or motor deficit appreciatedNo cranial nerve or motor deficit appreciated Funduscopy= Clear disc margins, No Funduscopy= Clear disc margins, No

Background changesBackground changes Meningeal irritation signs- negativeMeningeal irritation signs- negative

InvestigationsInvestigations 27/04/9927/04/99 CBC WBC 26,400 N= 74% L=19.3%CBC WBC 26,400 N= 74% L=19.3% Hgb 11.6g/dlHgb 11.6g/dl HCT 34.30%HCT 34.30% Plt 138,000Plt 138,000 BF NEGBF NEG RBS 254 RBS 254 U/A Ketone 4+U/A Ketone 4+ Sugar 2+Sugar 2+ WBC 1—2/ HpFWBC 1—2/ HpF RBC 8—12/HpFRBC 8—12/HpF ALB TraceALB Trace

DiagnosisDiagnosis & & Mgt.Mgt.

Asst=DKA Asst=DKA

Type 1 DMType 1 DM

R/O Sepsis of GI onsetR/O Sepsis of GI onset

Management Management (27/04/99 5:30 PM)(27/04/99 5:30 PM) DKA MgtDKA Mgt

Fluid - N/S 2000cc over 3 hours then 1000cc Fluid - N/S 2000cc over 3 hours then 1000cc 8 hourly8 hourly

Insulin- Bolus & Infusion Insulin- Bolus & Infusion

KCLKCL Ceftriaxone 1gm BIDCeftriaxone 1gm BID

MICU mgt and courseMICU mgt and course 28/04/99 8:30AM28/04/99 8:30AM On Insulin Infusion 10 units/Hour , took ~80 unitsOn Insulin Infusion 10 units/Hour , took ~80 units Fluid 3 litres given , KCL givenFluid 3 litres given , KCL given Urine output =3200ml/12 hrsUrine output =3200ml/12 hrs Ketone= +3Ketone= +3 RBS= 201RBS= 201 Agonizing pain ? Abdominal Agonizing pain ? Abdominal BP 60/40 mmHGBP 60/40 mmHG PR-88 RR - 28 T <35 C Spo2=88% PR-88 RR - 28 T <35 C Spo2=88%

with room airwith room air Chest- bilateral basal cracklesChest- bilateral basal crackles ABD=Tenderness on right lower quadrantABD=Tenderness on right lower quadrant RestlessRestless

Course & mgt contd…Course & mgt contd…

Impression= Acute abdomen, SepsisImpression= Acute abdomen, Sepsis Plan workups CXR, plain ABD X-Plan workups CXR, plain ABD X-

RAYRAY

OFT, Lipase OFT, Lipase

Dopamine 5 mic /minDopamine 5 mic /min

Hydrocortisone 100mg QIDHydrocortisone 100mg QID

Surgical consultationSurgical consultation

InvestigationsInvestigations

LAB LAB 27/04/9927/04/99 28/04/9928/04/99 BUN ………….48 BUN ………….48 Creatinine……..0.9 Creatinine……..0.9 AST……………77AST……………77 ALT…………...52ALT…………...52 ALP…………...309ALP…………...309 Bilirubin……….0.8Bilirubin……….0.8 Total protein…...6.5Total protein…...6.5 HBsAg……….........................NEGHBsAg……….........................NEG HEP C Ab…………………NEGHEP C Ab…………………NEG PT…………….. …………….15PT…………….. …………….15 PTT………………………….30.8PTT………………………….30.8 INR………………………….1.24 INR………………………….1.24 Amylase……….. ………….....102Amylase……….. ………….....102 K+…………………………...3.5K+…………………………...3.5 Na+…………............................135Na+…………............................135 Cl-…………………………....119 Cl-…………………………....119

MGT & course contd…MGT & course contd…

Surgical Resident Note(28/04/99)Surgical Resident Note(28/04/99)

ABD= moves with respiration, soft , ABD= moves with respiration, soft , Active Active

bowel soundsbowel sounds

PR= formed normal colored stool on PR= formed normal colored stool on examining finger, No massexamining finger, No mass

IMP= severe pneumonia + DKAIMP= severe pneumonia + DKA

Doesn’t seem to have acute Doesn’t seem to have acute abdomenabdomen

Mgt & course contd… 28/04/99 11:00 AMMgt & course contd… 28/04/99 11:00 AM

Restless pointing to her abdomen and shoutingRestless pointing to her abdomen and shouting BP= 90/60 mm Hg PR=114 T= 37.4 spo2=90%BP= 90/60 mm Hg PR=114 T= 37.4 spo2=90% ABD- Not distendedABD- Not distended Diffuse abdominal tenderness, more over the Diffuse abdominal tenderness, more over the

epigastria areaepigastria area No sign of fluid collection, Normoactive bowel soundsNo sign of fluid collection, Normoactive bowel sounds

CNS -Disoriented, GCS 13/15CNS -Disoriented, GCS 13/15 ASS’t -Severe CAP with sepsis ASS’t -Severe CAP with sepsis Acute abdomen R/O Acute pancreatitisAcute abdomen R/O Acute pancreatitis

Analgesics GivenAnalgesics GivenLP doneLP doneOpening pressure….normalOpening pressure….normalAppearance ……… Crystal clearAppearance ……… Crystal clear WBC……….5 cellsWBC……….5 cells

Mgt. & course contd…Mgt. & course contd…29/04/99, 9:00 AM29/04/99, 9:00 AM Grunting, in pain, not communicating wellGrunting, in pain, not communicating well B/P=100/60 mmHgB/P=100/60 mmHg Tachypnoeic RR=40/minTachypnoeic RR=40/min Bilateral lower lung BBS and decreased air Bilateral lower lung BBS and decreased air

entryentry Soft abdomen with differential tenderness Soft abdomen with differential tenderness

in the RLQ, normoactive bowel soundsin the RLQ, normoactive bowel sounds Non communicating, a bit obeys Non communicating, a bit obeys

commands to some extentcommands to some extent Ketones= negativeKetones= negative RBS= 264 mg/dlRBS= 264 mg/dl

Mgt & course contd…Mgt & course contd…

Ass’t - Multi focal pneumonia + Ass’t - Multi focal pneumonia + R/O Acute abdomenR/O Acute abdomen

Plan - Re Consultation (surgical/ Plan - Re Consultation (surgical/ Gyn)Gyn)

Rx= Cloxacillin Rx= Cloxacillin

CimetidineCimetidine

Mgt & course Contd…Mgt & course Contd…

GYN- resident Noted(29/04/99)GYN- resident Noted(29/04/99) RLQ tenderness, No guarding or rebound RLQ tenderness, No guarding or rebound

tendernesstenderness PR=No adnexial mass , free cul de sacPR=No adnexial mass , free cul de sac R/o appendicitisR/o appendicitis Suggested- Consult surgical side, can plan joint Suggested- Consult surgical side, can plan joint

operation if they plan explorationoperation if they plan exploration

SURGICAL-resident noteSURGICAL-resident note ABD- Flat moves with respirationABD- Flat moves with respiration No area of tendernessNo area of tenderness Active bowel soundsActive bowel sounds NO sign of acute abdomenNO sign of acute abdomen

ABDOMINAL + PELVIC ULTRASOUND (30-ABDOMINAL + PELVIC ULTRASOUND (30-04-99)04-99)

Liver =11.0 CM, Blunt edge, mildly Liver =11.0 CM, Blunt edge, mildly heterogeneous, no focal lesionsheterogeneous, no focal lesions

PV and CBD have normal caliber, GB freePV and CBD have normal caliber, GB free Spleen= 9 CMs, normal echo patternSpleen= 9 CMs, normal echo pattern Kidneys= NormalKidneys= Normal Minimal free fluid collection within the Minimal free fluid collection within the

pelvispelvis Pancreas, par aortic and RLQ= difficult to Pancreas, par aortic and RLQ= difficult to

comment because of increased bowel gas. comment because of increased bowel gas.

Mgt & Course contd…Mgt & Course contd…30/04/99 (430/04/99 (4thth day admission) day admission) BP-100/55 mmHg PR-140/m RR-52 T-35.8 BP-100/55 mmHg PR-140/m RR-52 T-35.8

SPo2-80%SPo2-80% Distended abdomenDistended abdomen Hypoactive bowel soundsHypoactive bowel sounds GCS=6/15GCS=6/15 UOP=200 ml/8 hrUOP=200 ml/8 hr Ass’t - DeterioratingAss’t - Deteriorating ACTIONACTION Antibiotics revisedAntibiotics revised Vancomycin + Ceftazidime + Vancomycin + Ceftazidime +

GentamycinGentamycin Sliding ScaleSliding Scale HydrocortisoneHydrocortisone CimetidineCimetidine

Course at 4Course at 4thth day MICU day MICU30/04/99 4:45 PM30/04/99 4:45 PM Mechanical ventilation StartedMechanical ventilation Started

01/05/9901/05/99 MV IppV modeMV IppV mode B/P 85/50 mmHg- Dopamine initiatedB/P 85/50 mmHg- Dopamine initiated UOP < 50ml/16 hours. Gentamycin heldUOP < 50ml/16 hours. Gentamycin held Flaccid extremities Flaccid extremities Bilateral dilated fixed pupilsBilateral dilated fixed pupils Brain stem reflexes- intact initiallyBrain stem reflexes- intact initially

02/05/99 9:15AM Died02/05/99 9:15AM Died

DiscussionDiscussion DiagnosisDiagnosisDKADKASEPTIC SHOCK Focus GISEPTIC SHOCK Focus GI ChestChest PresentationPresentation DKA can mimic acute abdomenDKA can mimic acute abdomen ManagementManagement AntibioticAntibiotic CorticosteroidCorticosteroid Blood Glucose levelBlood Glucose level SURGICAL INTERVENTION ?SURGICAL INTERVENTION ?

Discussion… Mgt of septic shockDiscussion… Mgt of septic shock ANTIMICROBIAL AGENTSANTIMICROBIAL AGENTS Pending culture results Empirical RxPending culture results Empirical Rx Maximal dose and IVMaximal dose and IV Delayed, inadequate, or inappropriate Delayed, inadequate, or inappropriate

antimicrobial therapy is associated with poor antimicrobial therapy is associated with poor outcome.outcome.

In Patients with septic shock the time to In Patients with septic shock the time to initiation of appropriate antimicrobial therapy initiation of appropriate antimicrobial therapy was the strongest predictor of mortality. was the strongest predictor of mortality.

Severely ill patients presenting with sepsis of Severely ill patients presenting with sepsis of unclear etiology should be treated with unclear etiology should be treated with intravenous vancomycin (adjusted for renal intravenous vancomycin (adjusted for renal function) until the possibility of MRSA sepsis function) until the possibility of MRSA sepsis has been excluded.has been excluded.

Discussion… Mgt of septic shockDiscussion… Mgt of septic shock Acceptable regimensAcceptable regimens Combining vancomycin with: Combining vancomycin with: Cephalosporin, 3rd or 4th Cephalosporin, 3rd or 4th

generation generation Or Beta-lactam/ beta- lactamase Or Beta-lactam/ beta- lactamase

inhibitor inhibitor Or Carbapenem Or Carbapenem Alternatively, if Pseudomonas is a possible pathogenAlternatively, if Pseudomonas is a possible pathogen Combine vancomycin withCombine vancomycin with Antipseudomonal cephalosporin Antipseudomonal cephalosporin Or Antipseudomonal carbapenemOr Antipseudomonal carbapenem Or Antipseudomonal Or Antipseudomonal

beta-lactam/beta-lactamase inhibitor beta-lactam/beta-lactamase inhibitor Or Fluoroquinolone with good anti-Or Fluoroquinolone with good anti-

pseudomonas activity pseudomonas activity Or AminoglycosideOr Aminoglycoside Or Monobactam Or Monobactam

Discussion… Mgt of septic shockDiscussion… Mgt of septic shock CORTICOSTEROIDSCORTICOSTEROIDS many septic patients have a relative adrenal many septic patients have a relative adrenal

insufficiencyinsufficiency may benefit from low dose corticosteroidsmay benefit from low dose corticosteroids

REMOVAL OF THE SOURCE OF INFECTIONREMOVAL OF THE SOURCE OF INFECTION

HEMODYNAMIC, RESPIRATORY, AND HEMODYNAMIC, RESPIRATORY, AND METABOLIC SUPPORTMETABOLIC SUPPORT

blood glucose should be aggressively blood glucose should be aggressively controlled with an insulin infusion aiming for controlled with an insulin infusion aiming for a blood level of 80 to 110 mg/dL.a blood level of 80 to 110 mg/dL.