7. Case 1 v7_I1 TLL DSS

8/2/2019 7. Case 1 v7_I1 TLL DSS

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Case Study I1 SJ Author: TLL

Kementerian Kesihatan Malaysia

Pusat Perubatan Universiti Malaya

2006

8/2/2019 7. Case 1 v7_I1 TLL DSS


KKM PPUM 2006

Known hypertensive X 10 years

Atenolol 50mg OD

Nifedipine 10mg BD

Female 52y Malay, BWt 90 kg13 April

8/2/2019 7. Case 1 v7_I1 TLL DSS


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.

8/2/2019 7. Case 1 v7_I1 TLL DSS


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

8/2/2019 7. Case 1 v7_I1 TLL DSS


KKM PPUM 2006

Female 52y Malay, BWt 90 kg (4)Past medical history Open cholecystectomy 5 y previously

1 previous admission for uncontrolledhypertension.

8/2/2019 7. Case 1 v7_I1 TLL DSS


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

8/2/2019 7. Case 1 v7_I1 TLL DSS


KKM PPUM 2006

Uncontrolled hypertension

Upper respiratory tract infection


Diagnosis

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KKM PPUM 2006

1. 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 80to 104/min.

In addition to URTI symptoms, patient also hasGIT symptoms and her haemodynamic status

can not be explained solely by the diagnosis of URTI.


Discussion

8/2/2019 7. Case 1 v7_I1 TLL DSS


KKM PPUM 2006

Reviewed by Medical MO

c/o epigastric pain

Noted patient in shock

Cold and clammy peripheries


Radial pulse barely palpable

Tachypnoeic, RR not recorded Abdominal distension, epigastric tenderness,

ascites


13 April, 19:35

8/2/2019 7. Case 1 v7_I1 TLL DSS


KKM PPUM 2006

Intra-abdominal sepsis (to rule out perforatedgastric ulcer).

Investigations:

Blood C&S

ABG

Chest (erect) and abdominal X-Ray

ECG


Diagnosis

8/2/2019 7. Case 1 v7_I1 TLL DSS


KKM PPUM 2006

Female 52y Malay, BWt 90 kg (10) Discussion2. What is the physiologic status?

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

3. Analyse the diagnosis of perforated gastric ulcer

with intrabdominal sepsis in relation to the clinicalprogress. The haemodynamic instability preceded the onset of

abdominal pain. Fever preceded the onset of abdominal pain.

At the time of haemodynamic instability, the patient isactually afebrile.

8/2/2019 7. Case 1 v7_I1 TLL DSS


KKM PPUM 2006

Female 52y Malay, BWt 90 kg (11) Treatment

IVI Gelofusine 500mL rapid bolus

IV NS 500mL rapid bolus then 500mL/1 hfollowed by

IV NS 7 pints/24 h

IV Ceftriaxone 2g stat then 1g q 24 h

IV Metronidazole 500mg stat then q 8 h

8/2/2019 7. Case 1 v7_I1 TLL DSS


KKM PPUM 2006

Female 52y Malay, BWt 90 kg (12) BP, HR, RR monitoring by nurse

13/4 Time BP HR RR IVI given

18:30 117/95 104 25 Maintenance 2.5 L/day

19:30 90/70 100 20 Maintenance 2.5 L/day

Gelafundin 500 mL fast+ NS 500 mL fast+ NS 500 mL / 1 h

20:40 133/96 93 20 Maintenance 3.5L/day

22:30

108/90 109 24 Maintenance 3.5L/day23:40 129/99 108 24 Total fluids so far =

Colloids 500mL +

Crystalloids 1,500mL

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KKM PPUM 2006


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 ½ hourly Insert central venous catheter

Trace investigations

8/2/2019 7. Case 1 v7_I1 TLL DSS


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%

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KKM PPUM 2006

Female 52y Malay, BWt 90 kg (15) Discussion4. What is the diagnosis?

DSS – decompensated

Hct of 55%, thrombocytopenia, relative

leucopenia are in keeping with DHF withsignificant plasma leakage that has led to DSS.

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KKM PPUM 2006

Female 52y Malay, BWt 90 kg (16)Investigations

@16:30

Urea 15.7 mmol/L

Na 130 mmol/L

K 4.7 mmol/L

Cl 98 mmol/L

Creat 188 mol/L

ABG:

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%

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KKM PPUM 2006

Female 52y Malay, BWt 90 kg (17)Other investigations

Total Protein 63 g/L

Albumin 35 g/L

Total bilirubin 54 mol/L ALP 213 U/L

ALT 1,707 U/L

AST (not sent)

Serum amylase 206 U/L

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KKM PPUM 2006

Female 52y Malay, BWt 90 kg (18)Discussion5. 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

8/2/2019 7. Case 1 v7_I1 TLL DSS


KKM PPUM 2006

Female 52y Malay, BWt 90 kg (19)Diagnosis

Dengue shock syndrome

Referred for intensive care management

8/2/2019 7. Case 1 v7_I1 TLL DSS


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 accessorymuscles,

Speaking in short sentences,

Lethargic, sweating, cold and clammyperipheries,

BP 80/60mmHg, PR 140/min

On IVI dopamine 20g/kg/min.

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KKM PPUM 2006


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

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KKM PPUM 2006


14 April 00:40 Discussion6. 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 whilegetting blood for transfusion.

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KKM PPUM 2006


14 April 00:40 Discussion8. 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)

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KKM PPUM 2006

Impression : Dengue Shock Syndrome withbilateral pleural effusion, ascites, hepatitisand renal impairment

Patient admitted to ICU

Patient accompanied to ICU with Venturi mask O2 40%

IVI Dopamine 20g/kg/min


8/2/2019 7. Case 1 v7_I1 TLL DSS


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, bothsides unsuccessful

IVI Gelofusine 500ml stat

Started IVI noradrenaline 5 g/min

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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 ofresuscitation.

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

8/2/2019 7. Case 1 v7_I1 TLL DSS


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

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KKM PPUM 2006


11. Comment on the choice of induction agents

Fentanyl is preferred in adults if available as it ismore 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.

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KKM PPUM 2006


Further fluid resuscitation 1.5L Gelofusine

Dopamine 20 cg/kg/min and noradrenaline20g/min.


Urinary catheterisation 600ml urine

No urine from admission to ward.

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KKM PPUM 2006


Attended by ICU specialist on call.

Central venous catheterisation via leftexternal jugular vein.

Inotropes infused via CVL.

CVP not documented.

Urine output 20ml/hr.

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KKM PPUM 2006


12. Why is the patient’s haemodynamic stillunstable?

Inadequate fluid resuscitation

High possibility of bleeding13. What should be done? Look for sites of bleeding especially the femoral

puncture site

Transfuse blood ASAP

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KKM PPUM 2006


Noted massive haematoma both groins

Ordered blood products : platelets, freshfrozen plasma, cryoprecipitate.

Skin mottled.

Another 250mL IV Gelofusine given.

Started IV dobutamine 5 g/kg/min.


8/2/2019 7. Case 1 v7_I1 TLL DSS


KKM PPUM 2006

Female 52y Malay, BWt 90 kg (33)Central venous blood gas

Time 02:45 03:30 pH 7.044 7.064

pCO2 mmHg 34.4 23.4

pO2 mmHg 34.7 37.6

BE mmol/L 19.5 -21.9HCO3 mmol/L 8.9 7.5

SaO2 % 43.1 49.8

Na mmol/L 133 137

Cl mmol/L 114 115K mmol/L 5.4 5.1

Hb g/dL 10.9 5

Lactate mmol/L 16 18

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KKM PPUM 2006


14. Comment on the serial central venous bloodgas, 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 byfemoral punctures.

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KKM PPUM 2006



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

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KKM PPUM 2006


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.

8/2/2019 7. Case 1 v7_I1 TLL DSS


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 apatient with HPT may indicate shock).

Prolonged shock will lead to significantbleeding.

8/2/2019 7. Case 1 v7_I1 TLL DSS


KKM PPUM 2006

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

Fluid resuscitation should be initiated withany available peripheral vascular access

Central venous access should be reserved forthose without peripheral access

Inotropes should not be the priority measurein restoring the haemodynamic status in DSSbefore adequate fluid resuscitation has beenattempted

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7. Case 1 v7_I1 TLL DSS