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ICU Case Presentation: Hypotension and Pyrexia. Bradley J. Phillips, MD Burn-Trauma-ICU Adults & Pediatrics. Case #1. 52 yof school teacher POD 5 Lap Chole for recurrent RUQ with U/S + gallstones Uncomplicated OR except transient SBP 70 during insufflation corrected with 1 L bolus IVF

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icu case presentation hypotension and pyrexia

ICU Case Presentation:Hypotension and Pyrexia

Bradley J. Phillips, MD

Burn-Trauma-ICU

Adults & Pediatrics

case 1
Case #1
  • 52 yof school teacher POD 5 Lap Chole for recurrent RUQ with U/S + gallstones
  • Uncomplicated OR except transient SBP 70 during insufflation corrected with 1 L bolus IVF
  • D/C POD1
  • Returned POD3 with abdominal pain, nausea, fever (38.7C)
  • Diff dx ??
case 11
Case #1
  • Presumptive dx: Cholangitis
  • IVF, NPO, ABX (Ceph 3, Flagyl)
  • Over 24 hrs developed oliguria unresponsive to fluid challenges ( total 5 L positive balance)
  • Progressive tachypnea (RR 40) and SBP 85-90
  • Abdominal pain more widespread with focus RUQ and fever increased 40.4C
  • ?? More information
case 12
Case #1
  • PMH: HTN, ankle swelling, NIDDM
  • PSH: appy, hysterectomy, tonsillectomy
  • Meds: captopril, lasix 40mg qd
  • Labs:
  • Abdominal U/S - limited from bowel gas, no calculi in CBD although dilated upper limit of normal

6.5

9.6

133

120

15.2

127

184

5.2

13

4.0

0.5

ABG 7.28 / 28 / 54 / 12 INR 1.4 PTT 44

Tbil 2.6 AST 98 Alk Phos 428 Amylase 2416 Albumin 3.0

case 13
Case #1
  • DX - Pancreatitis
  • Transferred to ICU
  • CVL inserted - CVP 2 cm H20
  • Dopamine qtt started 10 ug/kg/min for SBP 100
  • Very distressed, tachypneic and confused
  • NGT inserted with 1.5 L light brown fluid
  • RR decreased to 34/min on FiO2 50%
  • ?? Management
case 1 pancreatitis
Case #1 Pancreatitis
  • IVF bolus 1.5 L colloid increased CVP 14 cmH20
  • Remained tachypneic, UOP 8 ml/hr
  • Dopamine qtt at 16 ug/kg/min
  • Repeat labs: ABG pH 7.07 / 45 / 61 / 8 Na 130, K 6.4, Glu 331
  • ?? Issues and management ??
case 1 pancreatitis1
Case #1 Pancreatitis
  • Respiratory distress - Intubation
  • Hyperkalemia
    • Amp of D50
    • Insulin 10 units
    • Amp of calcium chloride
  • Continuous venovenous hemofiltration
  • TPN
  • Further hypotension requiring norepinephrine qtt
pancreatitis case 1
Pancreatitis Case #1
  • Insertion of PA catheter
    • Wedge 12 mmHg, CI 5.7 L/min/m2
  • Next 3 days continued hemofiltration, norepi qtt decreased, CI high (4.9)
  • Hyperglycemia remained a problem despite insulin in TPN ( 750 cc 10% AA, 750 cc D50)
  • Increased jaundice with Tbil 9.8 mg/dl
  • ?? Diff dx and management
pancreatitis case 11
Pancreatitis Case #1
  • Repeat U/S unsatisfactory
  • CT Abd - moderate bilateral pleural effusions, marked dilation of CBD, dilated loops of bowel, extensive pancreatic edema and phelgmon with question 10% necrosis of pancreatic head
  • ?? plan
pancreatitis case 12
Pancreatitis Case #1
  • ERCP - obst. calculus removed and sphincterotomy performed
  • Next 48 hrs, bilirubin decreased to 4.8
  • Continued vasopressors, ventilation, hemofiltration, and TPN
  • New onset of fever, 39.7 C accompanied by increased inotropic drugs to maintain MAP
  • CVP 8, wedge 14, CI 5.2
  • ?? Diff dx and plan
pancreatitis case 13
Pancreatitis Case #1
  • Lines changed and cultures obtained
  • CXR revealed ARDS
  • Cultures
    • sputum leukocytes, no bacteria
    • urine no bacteria
    • blood - E coli
  • ?? plan
pancreatitis case 14
Pancreatitis Case #1
  • Imipemem q 6hrs started
  • Repeat CT scan - peripancreatic fat necrosis, extensive edema, and fluid in paracolic gutters, definitive 15-20% pancreatic head necrosis
  • Plan??
pancreatitis case 15
Pancreatitis Case #1
  • Taken to OR for debridement ( EBL 500 cc)
  • ICU return very unstable with fever 40.2, increased amount of norepi qtt and now epi qtt added
  • Wedge 12 despite 4L blood and colloid (Hgb 12.4)
  • Worsening O2 requiring FiO2 100%, PEEP 10
  • ABG 7.18 / 48 / 63/ 14 lactate 6.2
  • CXR 0 extensive bilateral pulmonary infiltrates with interstitial edema
  • ?? management
pancreatitis case 16
Pancreatitis Case #1
  • Hemofiltration restarted with negative balance of 100 ml/hr
  • Next 12 hrs, gradual decrease of FiO2 to 0.6
  • Decreased inotropic qtt
  • Repeat laparotomy x2 with debridement
  • Temperature 37-3C and pressors weaned off
pancreatitis case 17
Pancreatitis Case #1
  • Traps
    • Insertion of NGT
      • rarely needed in mild/mod pancreatitis
      • acute pancreatitis causes acute dilatation
        • obstruction from pancreatic head swelling
        • diabetic autonomic neuropathy
    • Jaundice etiology
      • swelling of the head of the pancreas
      • reabsorption of hematoma
      • sepsis
      • biliary obstruction from gallstone
pancreatitis case 18
Pancreatitis Case #1
  • Traps
    • ARDS
      • pulmonary edema worsens oxygenation
      • monitor intravascular volume closely
        • may require PA catheter
        • may require dialysis if renal failure ensues
    • Fevers
      • common sources of infection common in ICU
      • rule out infected pancreas if necrotizing pancreatitis
pancreatitis case 19
Pancreatitis Case #1
  • Tricks
    • Diagnosis of biliary obstruction
      • U/S commonly unsatisfactory in early pancreatitis and limited by bowel gas (ileus common)
      • ERCP indications
        • suspicion of gallstone induced pancreatitis, not improving by 24 hrs
        • traumatic pancreatitis if CT scan nondiagnostic
pancreatitis
Etiology (common)

EtOH

Gallstone

Bilary sludge

Hyperlipidemia

Hypercalcemia

Anatomic

tumor

divisium

stricture

Etiology (uncommon)

Trauma

ERCP

Infection (viral)

Drugs ( thaizides, lasix, steroids, estrogens, valproic acid, clonidine, tetracyclins, sulfonamides)

Toxins ( scorpion, methanol, insecticides

Hereditary

Pancreatitis
pancreatitis1
Signs/Symptoms

Epigastric pain

N/V

Anorexia

Ileus

Sepsis

Jaundice

Cullen’s sign

Grey Turner’s sign

Tests

ABG

CBC/Plts/PT/PTT

Lytes/BUN/Cr

Ca/Mg/Phos

LFT’s, Triglycerides

Amylase (S60-90,Sp 70)

Lipase (S/Sp 90-99)

CXR/AXR

U/S

CT

Pancreatitis
pancreatitis2
Pancreatitis
  • Complications
    • Death
    • Renal failure
    • Sepsis
    • ARDS
    • Infected pancreas (early as 1st week)
    • Hemorrhage
    • Pancreatic abscess (late)
    • Pseudocyst (late)
    • Diabetes
pancreatitis current issues
Pancreatitis - Current Issues
  • Antibiotic coverage
  • Role of fine needle aspiration
  • Role of octreotide
  • Predictive criteria of mortality
pancreatitis antibiotic coverage
Pancreatitis - Antibiotic Coverage
  • Common isolates
    • E coli (26%), Pseudomonas (16%), anaerobic (16%), S. aureus (15%), Klebsiella (10%), Proteus (10%)
  • Need broad coverage if indicated
  • Indications?
    • Prophylatic use in necrotizing pancreatitis
    • Early studies no benefit (use ampicillin)
    • Imipenem drug of choice
      • Clinical trials show benefit by decreased frequency in infection
      • Imipenem and quinolones highest in pancreatic tissue with aminoglycosides lowest, PCN intermediate
pancreatitis antibiotics
Pancreatitis - Antibiotics
  • Gut decontamination
    • experimental studies show bacterial translocation and hematogenous seeding
    • clinical trial with oral norfloxacin, colistin, and ampho B shows significant reduction in GNR pancreatic infection
    • adjusted for illness severity, improved outcome
    • not achieved widespread acceptance
  • Anti-fungal
pancreatitis role of fna
Pancreatitis -Role of FNA
  • Pancreatic necrosis - r/o infected necrosis
  • Options
    • observation and antibiotics for selected organisms
    • percutaneous drainage?
    • debridement
      • percutaneous/endoscopic - reported cases/trials
      • operative
        • controversial ( must weigh hemodynamics/MSOF)
        • worse in EtOH pancreatitis secondary to nutritional status
        • consensusimproved survival with infected pancreatic necrosis
pancreatitis role of octreotide
Pancreatitis - Role of Octreotide
  • SQ vs IV dosing
    • SQ dose 100-200ug tid
  • Trials
    • Numerous both retro and prospective
    • No benefit
pancreatitis predictive mortality
Pancreatitis - Predictive Mortality
  • Ranson criteria
  • Risk Factors
    • APACHE II score > 8
    • Organ failure ( higher in infected necrosis)
    • Substantial necrosis ( > 30%)
pancreatitis management
Pancreatitis Management

Severity

Mod/Severe (SICU)

Mild/Mod (Floor)

Routine Management

Necrosis?

No

NPO, IVF +/- NGT H2 Blockers ?TPN vs Jejunal ?etiology

Yes

No antibiotics

Antibiotics

Observation

noninfected

FNA

Unstable

infected

Operation

pancreatitis case 110
Pancreatitis Case #1
  • Follow up
    • Slow improvement in respiratory function
    • 12 days after last laparotomy, UOP returned
    • Extubated 24 hours later
    • Discharged to floor 2 weeks after last operation with enteral feeding established
    • Still required SQ insulin for BS control