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Death Round

Death Round. MICU Case By Maruf Aberra Jan 23/2007. Identification. Late F..T. Age -14 years Female Addis Ababa Date of admission- 27/04/99 E.c Date of death - 01/05/99 E.c. Referral Paper ( Private Clinic ) 27/04/99. Known Diabetic on Insulin

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Death Round

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  1. Death Round MICU Case By Maruf Aberra Jan 23/2007

  2. Identification • Late F..T. • Age -14 years • Female • Addis Ababa • Date of admission- 27/04/99 E.c • Date of death - 01/05/99 E.c

  3. Referral Paper (Private Clinic)27/04/99 • Known Diabetic on Insulin • Cough productive of on and off blood mixed sputum • Fast & deep breathing • Failure to communicate. • BP =unrecordable Pulse=Feeble, fast T=35 • Decreased air entry & crept over the left lung • RBS 260 mg/dl • DX= DKA, Pneumonia R/O PTB • MGT= (N/S +R/L) 2500ml, Ampicillin 500mgIV

  4. History at presentation Vomiting and diarrhea / 04 days Change in mentation/08 hours • Known type-1 DM for five years, at the time taking Humulin N 10+10 /day • Since 4-days prior had reported to have watery diarrhea and Vomiting of ingested matter associated with abdominal cramp. Followed by change in mention for 8 hours before presentation. • Preceding polyuria and polydypsia. • No fever • No cough/ chest pain • No nuchal pain/rigidity

  5. Examination • Vital signs BP= unrecordable 100/60 mmHg after 3 bags of fluid PR= 114/m RR=32 deep and labored T= 36 • Pink conjunctiva, no icturus • Dry mucosa • No sLAP • Fine crackles on bilateral lower lungs • No murmur or gallop

  6. Examination contd… • Full abdomen, moves with respiration No organomegally, No shifting dullness or fluid thrill • Urinary catheter in place draining clear urine • Skin turgor goes back slowly • No edema • No active skin lesions • Non communicating with GCS=11/15 No cranial nerve or motor deficit appreciated Funduscopy= Clear disc margins, No Background changes Meningeal irritation signs- negative

  7. Investigations27/04/99 • CBC WBC 26,400 N= 74% L=19.3% Hgb 11.6g/dl HCT 34.30% Plt 138,000 • BF NEG • RBS 254 • U/A Ketone 4+ Sugar 2+ WBC 1—2/ HpF RBC 8—12/HpF ALB Trace

  8. Diagnosis & Mgt. • Asst=DKA Type 1 DM R/O Sepsis of GI onset Management (27/04/99 5:30 PM) • DKA Mgt Fluid - N/S 2000cc over 3 hours then 1000cc 8 hourly Insulin- Bolus & Infusion KCL • Ceftriaxone 1gm BID

  9. MICU mgt and course • 28/04/99 8:30AM On Insulin Infusion 10 units/Hour , took ~80 units Fluid 3 litres given , KCL given Urine output =3200ml/12 hrs Ketone= +3 RBS= 201 • Agonizing pain ? Abdominal • BP 60/40 mmHG PR-88 RR - 28 T <35 C Spo2=88% with room air • Chest- bilateral basal crackles • ABD=Tenderness on right lower quadrant • Restless

  10. Course & mgt contd… • Impression= Acute abdomen, Sepsis • Plan workups CXR, plain ABD X-RAY OFT, Lipase Dopamine 5 mic /min Hydrocortisone 100mg QID Surgical consultation

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

  12. MGT & course contd… • Surgical Resident Note(28/04/99) ABD= moves with respiration, soft , Active bowel sounds PR= formed normal colored stool on examining finger, No mass • IMP= severe pneumonia + DKA Doesn’t seem to have acute abdomen

  13. Mgt & course contd… 28/04/99 11:00 AM • Restless pointing to her abdomen and shouting • BP= 90/60 mm Hg PR=114 T= 37.4 spo2=90% • ABD- Not distended Diffuse abdominal tenderness, more over the epigastria area No sign of fluid collection, Normoactive bowel sounds • CNS -Disoriented, GCS 13/15 ASS’t -Severe CAP with sepsis Acute abdomen R/O Acute pancreatitis Analgesics Given LP done Opening pressure….normal Appearance ……… Crystal clear WBC……….5 cells

  14. Mgt. & course contd… 29/04/99, 9:00 AM • Grunting, in pain, not communicating well • B/P=100/60 mmHg • Tachypnoeic RR=40/min • Bilateral lower lung BBS and decreased air entry • Soft abdomen with differential tenderness in the RLQ, normoactive bowel sounds • Non communicating, a bit obeys commands to some extent • Ketones= negative • RBS= 264 mg/dl

  15. Mgt & course contd… • Ass’t - Multi focal pneumonia + R/O Acute abdomen • Plan - Re Consultation (surgical/ Gyn) Rx= Cloxacillin Cimetidine

  16. Mgt & course Contd… GYN- resident Noted(29/04/99) • RLQ tenderness, No guarding or rebound tenderness • PR=No adnexial mass , free cul de sac • R/o appendicitis Suggested- Consult surgical side, can plan joint operation if they plan exploration SURGICAL-resident note • ABD- Flat moves with respiration No area of tenderness Active bowel sounds • NO sign of acute abdomen

  17. ABDOMINAL + PELVIC ULTRASOUND (30-04-99) • Liver =11.0 CM, Blunt edge, mildly heterogeneous, no focal lesions PV and CBD have normal caliber, GB free • Spleen= 9 CMs, normal echo pattern • Kidneys= Normal • Minimal free fluid collection within the pelvis • Pancreas, par aortic and RLQ= difficult to comment because of increased bowel gas.

  18. Mgt & Course contd… 30/04/99 (4th day admission) • BP-100/55 mmHg PR-140/m RR-52 T-35.8 SPo2-80% • Distended abdomen Hypoactive bowel sounds • GCS=6/15 • UOP=200 ml/8 hr Ass’t - Deteriorating ACTION • Antibiotics revised Vancomycin + Ceftazidime + Gentamycin • Sliding Scale • Hydrocortisone • Cimetidine

  19. Course at 4th day MICU 30/04/99 4:45 PM • Mechanical ventilation Started 01/05/99 • MV IppV mode • B/P 85/50 mmHg- Dopamine initiated • UOP < 50ml/16 hours. Gentamycin held • Flaccid extremities • Bilateral dilated fixed pupils • Brain stem reflexes- intact initially • 02/05/99 9:15AM Died

  20. Discussion • Diagnosis DKA SEPTIC SHOCK Focus GI Chest • Presentation DKA can mimic acute abdomen • Management Antibiotic Corticosteroid Blood Glucose level SURGICAL INTERVENTION ?

  21. Discussion… Mgt of septic shock • ANTIMICROBIAL AGENTS Pending culture results Empirical Rx Maximal dose and IV • Delayed, inadequate, or inappropriate antimicrobial therapy is associated with poor outcome. • In Patients with septic shock the time to initiation of appropriate antimicrobial therapy was the strongest predictor of mortality. • Severely ill patients presenting with sepsis of unclear etiology should be treated with intravenous vancomycin (adjusted for renal function) until the possibility of MRSA sepsis has been excluded.

  22. Discussion… Mgt of septic shock • Acceptable regimens • Combining vancomycin with: Cephalosporin, 3rd or 4th generation Or Beta-lactam/ beta- lactamase inhibitor Or Carbapenem • Alternatively, if Pseudomonas is a possible pathogen Combine vancomycin with Antipseudomonal cephalosporin Or Antipseudomonal carbapenem Or Antipseudomonal beta-lactam/beta-lactamase inhibitor Or Fluoroquinolone with good anti-pseudomonas activity Or Aminoglycoside Or Monobactam

  23. Discussion… Mgt of septic shock • CORTICOSTEROIDS many septic patients have a relative adrenal insufficiency may benefit from low dose corticosteroids • REMOVAL OF THE SOURCE OF INFECTION • HEMODYNAMIC, RESPIRATORY, AND METABOLIC SUPPORT blood glucose should be aggressively controlled with an insulin infusion aiming for a blood level of 80 to 110 mg/dL.

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