Case Study I1 SJ

Author: TLL

Kementerian Kesihatan Malaysia Pusat Perubatan Universiti Malaya 2006

Female 52y Malay, BWt 90 kg 13 April

Known hypertensive X 10 years Atenolol 50mg OD Nifedipine 10mg BD

KKM PPUM 2006

Female 52y Malay, BWt 90 kg (2)

13 April

Went to OPD for feeling unwell.

BP 220/180 mmHg, PR 80/min Sent to A&E for high BP.

16:55, in A&E

BP 130/61 mmHg, PR 111/min.

No available info whether anti-HPT was given in OPD

Remainder of clinical examination unremarkable. Diagnosis: Poorly controlled hypertension.
KKM PPUM 2006

Female 52y Malay, BWt 90 kg (3) 13 April, 18:10, Day 3

Admitted to medical ward, clerked by HO Fever Headache Abdominal pain Myalgia 3 days Arthralgia Sorethroat Nausea and loss of appetite
KKM PPUM 2006

Female 52y Malay, BWt 90 kg (4) Past medical history

Open cholecystectomy 5 y previously 1 previous admission for uncontrolled hypertension.

KKM PPUM 2006

Female 52y Malay, BWt 90 kg (5)

Clinical examination on admission

Alert, conscious Mildly dehydrated BP 117/95 mmHg PR 104/min T 37oC Lungs clear Abdomen soft

KKM PPUM 2006

Female 52y Malay, BWt 90 kg (6) Diagnosis

Uncontrolled hypertension Upper respiratory tract infection

KKM PPUM 2006

Female 52y Malay, BWt 90 kg

Discussion
1.

(7)

Comment on the diagnosis

BP no longer high. In fact, SBP has dropped from 220 to 117 mmHg and at the same time HR has increased from 80 to 104/min. In addition to URTI symptoms, patient also has GIT symptoms and her haemodynamic status can not be explained solely by the diagnosis of URTI.

KKM PPUM 2006

Female 52y Malay, BWt 90 kg

13 April, 19:35

(8)

Reviewed by Medical MO c/o epigastric pain Noted patient in shock Cold and clammy peripheries BP 90/70 mmHg, PR 100/min Radial pulse barely palpable Tachypnoeic, RR not recorded Abdominal distension, epigastric tenderness, ascites
KKM PPUM 2006

Female 52y Malay, BWt 90 kg

Diagnosis
Intra-abdominal sepsis (to rule out perforated gastric ulcer). Investigations: Blood C&S ABG Chest (erect) and abdominal X-Ray ECG

(9)

KKM PPUM 2006

Female 52y Malay, BWt 90 kg

Discussion
2.

(10)

What is the physiologic status?

3.

Analyse the diagnosis of perforated gastric ulcer with intrabdominal sepsis in relation to the clinical progress.

Patient is in decompensated shock Her SBP has dropped from 220 to 90 mmHg!

The haemodynamic instability preceded the onset of abdominal pain. Fever preceded the onset of abdominal pain. At the time of haemodynamic instability, the patient is actually afebrile.

KKM PPUM 2006

Female 52y Malay, BWt 90 kg (11)

Treatment

IVI Gelofusine 500mL rapid bolus IV NS 500mL rapid bolus then 500mL/1 h followed by IV NS 7 pints/24 h IV Ceftriaxone 2g stat then 1g q 24 h IV Metronidazole 500mg stat then q 8 h

KKM PPUM 2006

Female 52y Malay, BWt 90 kg (12)

BP, HR, RR monitoring by nurse
13/4 Time 18:30 19:30 BP 117/95 90/70 HR 104 100 RR 25 20 IVI given Maintenance 2.5 L/day Maintenance 2.5 L/day Gelafundin 500 mL fast + NS 500 mL fast + NS 500 mL / 1 h Maintenance 3.5L/day Maintenance 3.5L/day Total fluids so far = Colloids 500mL + Crystalloids 1,500mL

20:40 22:30 23:40

133/96 108/90 129/99

93 109 108

20 24 24

KKM PPUM 2006

Female 52y Malay, BWt 90 kg (13) 13 April, 22:45, 3h post-resuscitation

Reviewed by HO and informed to MO BP 108/90 (auto) mmHg, 104/94 (manual) HR 104/min SpO2 97%

Management

BP, PR hourly Insert central venous catheter Trace investigations

KKM PPUM 2006

Female 52y Malay, BWt 90 kg (14) 14 April, 00:15

Review of investigations sent @16:30 Hb 17.9 Hct 55 Plt 20,000 WBC 5,200 Neutrophil 74% Lymphocytes 22%
KKM PPUM 2006

Female 52y Malay, BWt 90 kg (15)

Discussion
4.

What is the diagnosis?

DSS decompensated Hct of 55%, thrombocytopenia, relative leucopenia are in keeping with DHF with significant plasma leakage that has led to DSS.

KKM PPUM 2006

Female 52y Malay, BWt 90 kg (16)

Investigations
@16:30 Urea Na K Cl Creat ABG:

15.7 mmol/L 130 mmol/L 4.7 mmol/L 98 mmol/L 188 mol/L

ABG @19:30 (on nasal prongs O2 3L/min) pH 7.209 pCO2 2.54kPa pO2 21.25kPa HCO3 7.4 mmol/L BE 18mmol/L SaO2 98.7%

KKM PPUM 2006

Female 52y Malay, BWt 90 kg (17)

Other investigations

Total Protein Albumin Total bilirubin ALP ALT AST (not sent) Serum amylase

63 g/L 35 g/L 54 mol/L 213 U/L 1,707 U/L 206 U/L

KKM PPUM 2006

Female 52y Malay, BWt 90 kg (18)

Discussion
5.

Comment on the lab results.

Patient has developed multi-organ impairment
Renal impairment (caution: can not exclude pre-existing renal impairment secondary to HPT) Liver dysfunction Metabolic acidosis

KKM PPUM 2006

Female 52y Malay, BWt 90 kg (19)

Diagnosis

Dengue shock syndrome Referred for intensive care management

KKM PPUM 2006

Female 52y Malay, BWt 90 kg (20) 14 April 00:40

Seen by intensive care MO in general ward RR Respiratory rate >30/min with use of accessory muscles, Speaking in short sentences, Lethargic, sweating, cold and clammy peripheries, BP 80/60mmHg, PR 140/min On IVI dopamine 20g/kg/min.
KKM PPUM 2006

Female 52y Malay, BWt 90 kg (21) 14 April 00:40

Seen by Intensive Care medical officer Lungs reduced air entry bibasally Abdomen distended but soft Epigastric tenderness PV bleed but not excessive

KKM PPUM 2006

Female 52y Malay, BWt 90 kg (22) 14 April 00:40 Discussion

6.

Comment on the physiologic state

Patient is still in shock.

7.

Comment on the use of inotropic support.

Fluid resuscitation is still not adequate, only ~20ml/kg has been given (based on estimated ideal BW of 70 kg) so far, More fluid should be given instead of inotropes at this juncture, If after 60 ml/kg of fluid resuscitation and patient remains hypotensive, inotropic support can be considered while getting blood for transfusion.

KKM PPUM 2006

Female 52y Malay, BWt 90 kg (23) 14 April 00:40 Discussion

8.

What parameters should be looked at to assess the adequacy of fluid resuscitation

BP, PR, Pulse pressure/volume Urine output, urine SG HCT ABG (particularly the lactate & base excess)

KKM PPUM 2006

Female 52y Malay, BWt 90 kg (24)

Impression : Dengue Shock Syndrome with bilateral pleural effusion, ascites, hepatitis and renal impairment Patient admitted to ICU Patient accompanied to ICU with
Venturi mask O2 40% IVI Dopamine 20g/kg/min

KKM PPUM 2006

Female 52y Malay, BWt 90 kg (25) 14 April, 01:13, Admission to ICU

GCS 15/15 BP 80/46 mmHg, HR 151/min RR 32/min, SpO2 100% 2 peripheral venous access Attempted to insert femoral CVL x3, both sides unsuccessful IVI Gelofusine 500ml stat Started IVI noradrenaline 5 g/min
KKM PPUM 2006

Female 52y Malay, BWt 90 kg (26) Discussion

9.

Comment on femoral CVL cannulation

There are 2 venous access available, can be use for fluid resuscitation, CVL insertion is not indicated at this juncture, Repeated attempts of CVL cannulation increase risks of infection and bleeding.

10.

Comment on the sequence of steps of resuscitation.

Fluid resuscitation should be the priority rather than trying to get femoral CVL access.

KKM PPUM 2006

Female 52y Malay, BWt 90 kg (27) 14 April, 01:40

Intubated for impending respiratory arrest IV fentanyl 50 g IV midazolam 2mg Ventilator settings : FiO21.0, SIMV + PS RR 20/min, PEEP 10 cm H2O, IP 15 cm H2O, PS 14 cm H2O Achieved TV 450-560ml.s
KKM PPUM 2006

Female 52y Malay, BWt 90 kg (28) Discussion

11.

Comment on the choice of induction agents

Fentanyl is preferred in adults if available as it is more cardiostable; if fentanyl is not available morphine, carefully titrated, is acceptable. Ketamine is preferred in children with hypotension, it can be used for adults as well.

KKM PPUM 2006

Female 52y Malay, BWt 90 kg (29) 14 April, 02:00

Further fluid resuscitation 1.5L Gelofusine Dopamine 20 cg/kg/min and noradrenaline 20g/min. BP 83/44 mmHg, PR 144/min. Urinary catheterisation 600ml urine No urine from admission to ward.

KKM PPUM 2006

Female 52y Malay, BWt 90 kg (30) 14 April, 02:35

Attended by ICU specialist on call. Central venous catheterisation via left external jugular vein. Inotropes infused via CVL. CVP not documented. Urine output 20ml/hr.

KKM PPUM 2006

Female 52y Malay, BWt 90 kg (31) Discussion

12.

Why is the patients haemodynamic still unstable?

Inadequate fluid resuscitation High possibility of bleeding

13.

What should be done?

Look for sites of bleeding especially the femoral puncture site Transfuse blood ASAP

KKM PPUM 2006

Female 52y Malay, BWt 90 kg (32) 14 April, 03:00

Noted massive haematoma both groins Ordered blood products : platelets, fresh frozen plasma, cryoprecipitate. Skin mottled. Another 250mL IV Gelofusine given. Started IV dobutamine 5 g/kg/min. BP 97/91 mmHg, PR 141/min.

KKM PPUM 2006

Female 52y Malay, BWt 90 kg (33)

Central venous blood gas
Time pH pCO2 pO2 BE SaO2 Na Cl K Hb mmHg mmHg mmol/L % mmol/L mmol/L mmol/L g/dL 02:45 7.044 34.4 34.7 19.5 03:30 7.064 23.4 37.6 -21.9

HCO3 mmol/L

8.9
43.1 133 114 5.4 10.9 16
KKM PPUM 2006

7.5
49.8 137 115 5.1 5 18

Lactate mmol/L

Female 52y Malay, BWt 90 kg (34) Discussion

14.

Comment on the serial central venous blood gas, Hb and lactate.

Worsening metabolic acidosis due to prolonged shock. Rapid drop in Hb indicating massive bleeding as a result of prolonged shock and contributed by femoral punctures.

KKM PPUM 2006

Female 52y Malay, BWt 90 kg (35) 14 April, 04:00

BP 43/26 mmHg, PR 141/min IV Gelofusine another 250 ml Started IVI adrenaline 10g/min Transfused

FFP 2 units, Cryoprecipitate 6 units, Platelets 4 units

Pupils 8mm sluggish bilaterally Transfused packed cells Urine output 20ml/hr
KKM PPUM 2006

Female 52y Malay, BWt 90 kg (36) 14 April, 05:00

Persistent hypotension on IVI dopamine 20 g/kg/min IVI noradrenaline 20 g/min IVI adrenaline 10 g/min IVI dobutamine 5 g/kg/min Started IVI NaHCO3 20ml/hr Patient died at 07:00. Cause of death : Dengue Shock Syndrome.

KKM PPUM 2006

Female 52y Malay, BWt 90 kg (37) Learning Points

DSS can present with acute abdomen. BP should be interpreted carefully in patients with pre-existing HPT (normal BP for a patient with HPT may indicate shock). Prolonged shock will lead to significant bleeding.

KKM PPUM 2006

Female 52y Malay, BWt 90 kg (38) Learning Points

Fluid resuscitation should be initiated with any available peripheral vascular access Central venous access should be reserved for those without peripheral access Inotropes should not be the priority measure in restoring the haemodynamic status in DSS before adequate fluid resuscitation has been attempted
KKM PPUM 2006