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Prolong PT/PTT Case Report. Ri 鄭千威. Patient Infomation. Name: 謝 XX Gender: female Age: 19 Chart Number: 5075664. Past history. 1.DM(-), HTN (-), Hyperlipidemia (-) 2.Other major systemic disease: gouty arthritis 3.Alcohol consumption: denied 4.Smoking: denied 5.Allergy: denied

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patient infomation
Patient Infomation
  • Name:謝XX
  • Gender: female
  • Age: 19
  • Chart Number: 5075664
past history
Past history
  • 1.DM(-), HTN (-), Hyperlipidemia (-)
  • 2.Other major systemic disease: gouty arthritis
  • 3.Alcohol consumption: denied
  • 4.Smoking: denied
  • 5.Allergy: denied
  • 6.Surgical history: denied
  • 7.Family hx not contributory
brief history
Brief History
  • Jan – Feb 2006, felt short of breath, weakness while climbing to her classroom on 4th floor
  • URI symptoms and exertional dyspnea developed in March then went to 耕莘 hospital on April 18.
  • Cardiac ECHO showed dialated LA and LV with LEVF = 20%, severe MR and moderate TR and PR without vegetation
slide5
Hospitalized from July 27 – Aug 5 due to SOB and cough with sputum for 1 wk
  • Heart ECHO on July 28:

pericardial effusion without tamponade sign, LVEF~16%, mod-severe MR, mod TR, PR with pul. HTN, without evidence of IE

  • Abd ECHO on July 29:

All normal except a 2.61 cm left renal cyst

  • Refer to NTU OPD on Aug 10
slide6
NTU OPD on Aug 24: decided for heart transplant
  • Hospitalized at 耕莘 H. Sep 25 – Sep 30 due to SOB, vomiting
  • Hospitalized at 耕莘 H. Oct 2 – Oct 5

due to SOB

slide7
Oct 5: Request transfer to NTUH ER with development of SOB, vomiting, flapping tremor, chronic renal insufficiency (CRI) with acute exacerbation
  • Tremor cause unknown may be due to primperan related EPS
lab findings at er 10 05
PH 7.47

PCO2 36.0

PO2 114.4

HCO3 25.6

WBC 4.92

RBC 2.94

HB 9.2

PLT 206.0

UN 38.5

CRE 1.8

Lab findings at ER (10/05)
physical finding
Physical finding
  • Conscious clear until E1VTM4 (10/14)
  • Conj: anemic (-) Sclera: icteric (-)
  • Pupils: isocoric (+) Light reflex : R/L ( + / + )
  • Throat: injected (-) Gum bleeding (-)
  • Neck: supple (+) , LAP (-), JVE (-), goiter (-)
  • Chest: symmetric expansion
  • BS: clear (+), rales (-), wheezing (-), crackle (-)
  • Heart:
  • PMI : at 6 ICS 3 fb, to LMCL
  • heart sound: regular heart beat
  • murmur: systolic murmur at mitral area, diastolic murmur over pulmonary valve area
  • Abdomen: inspection: soft (+), flat (+),
  • tenderness (-), rebounding tender(-), shifting
  • dullness (-) , central obesity (-), striae (-)
  • Liver: impalpable
  • Spleen :impalpable
  • Bowel sound : normoactive
  • Back: CV angle knocking pain (-)
  • Ext.: non-pitting edema,
  • tremor of extremities (+), purpura over forearms & cannulation wounds ;(+),Cyanosis of finger tips & toes(+)
treatment course
Treatment course
  • Oct 6: Unasyn: new onset fever (38.5) , resp s/s (cough + sputum)
    • Blood: no pathogen
    • Sputum: Gram (-) rods1+, Gram (+) cocci in chains3+

WBC 4920

CRP 0.13

U/A: negative findings

BNP 3621.47

  • Oct 9: cough with occasional blood tinged sputum
  • Oct 10: BT↑:39℃ Tazocin: nosocomial infection, new fever onset, persistent cough with sputum

WBC 7250

CRP 1.46

U/A: negative findings

    • Blood: no pathogen
    • Sputum: few Enterobacter cloacae
slide11
Oct 11: fever flare up 39.4 ℃, tremor

On CVP, O2 mask

Hb↓, blood tinged sputum, susp. pulmonary hemorrhage

E4V5M6

  • Oct 11 (1700): transfer to 3B1 for ionotropic support

Dx: CHF NYFc IV, Cardiac ECHO: LVEF=20%, 4 chamber dilatation

slide12
Oct 11 (2000): sudden attack of partial seizure with 2nd generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway

E2VTM5

  • Oct 11 (2100): profound shock after seizure despite full dose ionotropic

On ECMO (L’t femoral a & v), on R’t femoral CVP

lab findings
Immunology

Oct 11:

Anti-Nuclear Antibody : -

C3 Quantitation: within normal limit

C4 Quantitation : within normal limit

RA Factor : -

Anti-ds DNA : -

Oct 12

Adenovirus ab: -

Coxsackievirus ab B1-B6: -

CMV IgM ab: -

Anti-CCP: -

P-ANCA: -

C-ANCA: -

Anticardiolipin: -

SLE

Rheumatoid arthritis

SLE

Rheumatoid arthritis

Wegener's granulomatosis

Wegener’s granulomatosis

Anti-phospolipid dz

Lab findings
lab findings1
Immunology

Oct 13

HBsAg: Non reactive

Anti-HBs: reactive

HBeAg: Non reactive

Anti-HBe:Non reactive

Anti-HBc: reactive

Anti-HCV: Non reactive

Anti-HAV: reactive

STS: non reactive

Anti-HIV: negative

Lab findings
slide15
Oct 12: CAVH due to anuria, hyperkalemia
  • Oct 13: IABP, R’t femoral a.
      • Transfer to 4FI
        • Dopamine 20 ml/hr taper to 10 before transplant
        • Levophed 8 ml/hr DC 10/19
        • Isuprol 2 ml/hr DC 10/18
  • Oct 14: E1VTM4: fever switch to fortum + vancomycin
    • Blood: no pathogen
    • Sputum: Enterobacter cloacae3+
    • Prophylaxis MRSA infection

CRP: 8.18

WBC: 11020

  • Oct 16: bronchoscope
    • diffuse bloddy secretion, pulmonary parechyma hemorrhage is likely
    • no obvious airway injury
  • Oct 17: LA drain with artificial ASD: toes and finger tip darken
    • Anterior tibial a, dosalis pedis a. L +/+ R +/+
  • Oct 18: aortic ligation and aortic valve suturing
    • PGE1 and nitroderm for improving distal circulation
  • Oct 21: heart transplant
slide16

Fortum

Vancomycin

Tazocin

Unasyn

slide17

AST

ALT

slide18

ECMO

DIC

10/11 PT 20.3 -> 23.7

PTT 30.3 ->35.7

10/14 PT 45.3

PTT >200

b type natriuretic peptide
a protein produced bythe ventricles of the heart

test has a negative predictive value of at least 96%, so heart failure can confidently be ruled out for patients in the normal range

B-type natriureticpeptide

CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 70 • NUMBER 4 APRIL 2003

dilated cardiomyopathy
Dilated cardiomyopathy

Def: dilation & impaired contraction of one or both ventricle

Def: LVEF <40%

  • Imparied systolic function -> HF

common s/s: progressive dyspnea with exertion, impaired exercise capacity, orthopnea, paroxysmal nocturnal dyspnea, peripheral edema

etiology
Primary

Idiopathic

familial

Secondary

Infective (coxsaki, CMV, HIV, adeno)

Metabolic

Familial storage disease (glycogen storage dz)

Deficiency (e-, nutrient)

Connective tissue disorder (SLE, RA)

Infiltration & granulomas (maglinancy, amyloidosis)

Neuromuscular (Muscular dystrophy)

Toxic reaction (alcohol, drugs-doxorubicin, cyclophosphamide)

Peripartum heart disease

Etiology

Harrison's Principles ofInternal Medicine, 15th Edition

treatment
Treatment
  • Most downhill course
  • Death due to CHF, arrythmia, sudden death
  • Systemic embolization
  • Rx for heart failure
    • Salt restriction
    • Beta blocker carvedilol 3.125 mg qd -> 20-50 mg q12h
    • ACEI captpril 6.25 mg po tid
    • Digitalis 0.5 mg po/iv ->0.25 mg q6h
    • Diuretics spirolactone 25 mg po qd
    • Avoid alcohol, NSAID
    • transplant
hemoptysis
Hemoptysis

Def: expectoration of blood from the respiratory tract

  • From sputum blood streak to large amount of pure blood
  • Dx: respiratory track vs GI source
  • GI tract -> a dark red appearance and an acidic pH,
  • Respiratory track-> bright red appearance and alkaline pH
etiology1
Systemic coagulopathy, anticoagulant, thrombolytic agents

Primary vascular source

AVM

Embolism

↑pul venous pressure (MS)

Tracheobronchial source

Neoplasm

Bronchitis

Bronchiectasis

Broncholithiasis

Airway trauma

Froeign body

Pulmonary parenchyma source

Lung abscess

Pneumonia

TB

Fungus ball

Lung contusion

Idiopathic pulmonary hemosiderosis

Goodpasture syndrome

Wegener’s granulomatosis

Lupus pneumonitis

Etiology

Harrison's Principles ofInternal Medicine, 15th Edition

treatment1
Treatment
  • blood-streaking of sputum or small amounts of pure blood -> priority -> diagnosis, (gas exhange usually unaffected)
  • massive hemoptysis
    • maintaining adequate gas exchange
    • preventing blood from spilling into unaffected areas of lung,
    • avoid asphyxiation.
  • rest and partially suppressing cough may help the bleeding to subside
  • If too severe may need endotracheal intubation and mechanical ventilation
  • laser phototherapy, electrocautery, embolotherapy, and surgical resection of the involved area of lung.
c reactive protein
C reactive protein
  • Why high fever, but low CRP?
  • CRP produced by hepatocytes stored in ER
  • During acute phase response, CRP catabolic rate independent of plasma level CRP therefore ambient level depend on syn rate
slide33
elevated CRP value is not specific for any condition,
  • a very sensitive index of ongoing inflammation,
  • In differentiating between bacterial and viral infections -> very high CRP likely to occur in bacterial than viral infection, and a normal CRP is unlikely in bacterial infection.
crp elevation
Infections

Hypersensitivity complications of infections

Rheumatic feverErythema nodosum leprosum

Inflammatory disease

Rheumatoid arthritischronic arthritisAS

Psoriatic arthritis Systemic vasculitis

Allograft rejection

Renal tranplantation

Malignancy

Lymphoma

sarcoma

Necrosis

MI

acute pancratitis

Trauma

Burns

fracture

CRP elevation
production
Production
  • CRP production in hepatocytes stimulated by IL6
  • Cytokines network can be stimulated by various stimuli (IL-1, TNF…) to stimulate and provide feedback to acute phase protein response
  • Liver failure can affect acute phase protein production
  • Defects in cytokine network also ↓ acute phase protein production

Seminar in dialysis: 17(6): 438 Nov, 2004

slide36
ECMO
  • Extra corporeal membrane oxygenator
  • GOAL: to increase tissue oxygenation
  • va was used to bypass pulmonary circulation and pump flow determine the systemic flow perfusion due to poor LVEF
  • vv better: maintain pul blood flow, ↑myocardial oxygenation, keep thrombin or emboli to pul (vs systemic)
ecmo setup
ECMO setup

Current Opinion in Critical Care 2005, 11:87–93

indication ecmo
Indication ECMO
  • ECMO high-end therapy for respiratory

failure

  • all other treatment options failed to ↑

tissue oxygenation

  • defined as a PaO2/FiO2 ratio below 50mmHg.

Current Opinion in Critical Care 2005, 11:87–93

contra indication of ecmo
Contra-indication of ECMO
  • Prolonged mechanical ventilation (>5days)
  • Sepsis
  • Absolute contra-indication to systemic anticoagulant
complication of ecmo
Complication of ECMO
  • Bleeding (surgical & chest tube site)
slide41
IABP
  • Intra-aortic balloon pump
  • GOAL: provide hemodynamic support to
  • critically ill patients with cardiac disease.
  • Improvement depend on: volume of balloon, position in aorta, heart rate, rhythm, compliance of aorta, systemic resistance

Am J Cardiol 2006;97:

1391–1398

indication for iabp
Indication for IABP
  • Hemodynamic support during/after cardiac catherization
  • cardiogenic shock
  • Weaning from cardiopulmonay bypass
  • Pre-op support with severe left main cornary arterial stenosis
  • Adjuct therapy for high risk patients with
    • Complicated angioplasy
    • Restenosis
slide43
IABP

↑ afterload + suction effect

↑ preload

contra indication of iabp
Contra-indication of IABP
  • Aortic regurgitation
  • Aortic dissection/aneurysm
  • uncontrolled septicemia
  • bleeding diathesis
complication of iabp
Complication of IABP
  • Bleeding
  • systemic embolization
  • limb ischemia
  • amputation
  • Infection
  • Balloon rupture
coagulopathy
Coagulopathy

Uptodate

causes of prolong pt ptt
Von Willebrands (lack vWD for platelet adhesion)

Thrombocytopenia (genetic, bone marrow dz, iron)

Vit K deficiency

Mass transfusion (blood lack platelet, factor V)

Liver disease

DIC

Antiphosplipid syndrome (ab against cell memb)

Hemophilia

A: VIII deficiency

B: IX deficiency

Protein C deficiency

Protein S deficiency

Antithrombin III deficiency

Causes of prolong PT, PTT

POMD 7th ed.