BY BRIANA VITTORINI PRECEPTOR: KRISTEN ABATECOLA Critical Care Case Study Mister J.V. On Admission History & Physical Patient is a 33 year old man who was brought to the ER after he was found unresponsive. He had a cough, fever and vomiting for 1 week PTA. Temperature in the ER was 104 degrees Fahrenheit. Past Medical History: Unremarkable Social History: He works construction. He does not smoke and only drinks on holidays minimally. Medications at home: None Family History: His mother had diabetes On Admission History & Physical Physical Examination He is intubated and sedated, temperature of 106 F, BP 90/45 receiving 100% O2, PEEP of 5 Abdomen soft- no edema Chest X-ray was clear with a right jugular central line and ET tube in good position Urinalysis showed no ketones A1C- 16.2 On Admission Impression: Respiratory failure on mechanical ventilation secondary to change in mental status, most probably secondary to severe dehydration and hyperosmolar state Hyperglycemia Metabolic acidosis Sepsis with fever Hypertension secondary to his volume status, most probably caused by acute tubular necrosis (ATN) and sepsis Renal Failure On Admission Initial Plan of Care: Decrease O2 and keep Sat at ~95% Resuscitated with IVF- started on levo Continue Vancomycin, Levaquin, and Zosyn Renal Consult ordered Replete potassium This patient is a FULL CODE Metabolic Acidosis A brief Overview Metabolic acidosis is a clinical disturbance characterized by an increase in plasma acidity. It should be considered a sign of an underlying disease process and identification of this underlying condition is essential to initiate appropriate therapy. It occurs when the body produces too much acid, or when the kidneys are not removing enough acid from the body. Acute Tubular Necrosis (ATN) Acute tubular necrosis (ATN) is usually caused by a lack of oxygen to the kidney tissues (ischemia of the kidneys). It may also occur if the kidney cells are damaged by a poison or harmful substance. The internal structures of the kidney, particularly the tissues of the kidney tubule, become damaged or destroyed. ATN is one of the most common structural changes that can lead to acute renal failure and is one of the most common causes of kidney failure in hospitalized patients. Labs on Admission 1/14/131/15/131/16/131/17/13 Sodium Potassium Chloride (H)128 (H) Bicarbonate Glucose BUN Creatine Phosphorus Magnesium Amylase283 Lipase Triglycerides665373 Nutrition Consult 1/15/13 Clinical Note: Recent Weight Changes? No Height: 55 Weight:185# BMI:30.7 Estimated Nutritional Needs: based on ABW of 67Kg a) Kcals (22-25 Kcals/Kg) b) Protein (in grams) ( g/Kg) c) Fluid (in ml) 2300 (35 ml/Kg) This is a HIGH risk patient T+3 Nutrition Consult 1/15/13 continued ICU pt vented- sedated with versed, 10MCG Severe hyperglycemia (adm glucose 1650) receiving NS with 20K at 250ml/hr. Insulin drip- 0.2U/1ml at 20ml/hr. Acute renal insufficiency BUN-66 Cr-4.6 Phos- 0.5 Nutritional Intervention: If glucose improves within the next hours, recommend Glucerna 55cc/hr. This will provide 1584Kcals, 78g of protein and 1047cc fluid. Nutritional Monitoring/Evaluation: 1. Monitor glucose level, potassium, renal labs, and electrolytes. 2. Initiate TF within hours if glucose improves. Renal Consultation 1/15/13 Renal Consultation Impression: Acute kidney injury- the patient has acute kidney injury secondary to prerenal azotemia secondary to hyperosmolar non-ketotic coma associated with diabetes and sepsis. He may also have now acute tubular necrosis, as his creatinine is rising, though he is nonoliguric Small amount of protein in the urine, but not in the nephrotic range and most likely time will tell if this will clear or not Hypokalemia. This is rather critical. It is now finally normalizing Renal Consultation 1/15/13 Renal Consultation Impression: Hyperosmolar coma- Dr. Yacoub to check phosphorus level Severe hypophosphatemia- In this setting can cause rhabdomyolysis Diabetes Renal Consultation GI Consultation 1/17/13 GI Consult: Reason- ?pancreatitis ?etiology Of note labs: Amylase- 283 Lipase- 133 Triglycerides are normal- 373 (down from 655) Impression: Judging by his labs he has pancreatitis, but no signs of cause or confirmation by CT scan. ?binge drinking (pancreas divisum is NOT a consideration at this time) Abdominal ultra sound showed no gallstones, kidneys show atrophia Abdominal/Pelvic CT shows grossly normal pancreas without evidence of peripancreatic inflammation changes or fluid collection *Consider feeding early to prevent refeeding (he does not appear to have an ileus) Neurology Consultation 1/19/13 Neurology Consult Impression: Nonlocalizing neurologic exam attributable to ongoing, but correcting metabolic derangements Check EEG to evaluate for possible underlying intermittent seizure disorder Check Thiamine, B12, and folate Nutrition Note 1/17/13 Clinical Note: Nutritional Assessment of needs remains the same ICU pt vented- sedated with NPO day #3. Severe hyperglycemia (adm glucose 1650) receiving D5 NS with 20K at 100ml/hr. Insulin drip d/cd per MD order. Acute renal insufficiency BUN-43 Cr-4.9. Acute pancreatitis noted- amylase 283 Lipase 133. Urine output ~ Nutrition Consult 1/17/13 continued Nutritional Intervention: If patient remains NPO X5 days, recommend Promote with X24 hours. This will provide 1560Kcals, 94g protein, and 1246cc fluid (if not on D5 fluids) Nutritional Monitoring/Evaluation: 1. Monitor initiation of TF, tolerance, and pertinent labs. Nutrition Note 1/19/13 Clinical Note: Estimated Nutritional Needs Pt remains vented with versed sedation. NPO day #5. Per Dr. Nass- he is okay with starting tube feedings via OGT. Will start Glucerna for a day and then increase per protocol to a goal of 55cc. Nutritional Intervention: Will start Glucerna 1.2 trickle. Increase per toleration to goal of 55cc/hr per protocol Nutritional Monitoring/Evaluation: Pt will tolerate trickle and increase to goal. JV IS EXTUBATED!! Infectious Disease Consultation 1/21/13 Infectious Disease Consult Reason: Persistent fevers Impression: Persistent low-grade fevers Pancytopenia Pancreatitis Acute episode of hyperglycemia and diabetes Renal insufficiency Neurology Follow up 1/21/13 Neurology Follow Up Note: Patient is presently extubated and awake. Spanish- speaking but even with the Spanish-speaking translator the patient foes not follow commands and he is unable to communicate. Impression: The pts working diagnosis is metabolic encephalopathy; however, the pt is awake and alert. He does not have lethargy or hypersomnia. Overall, his clinical presentation is somewhat suggestive of brain stem dysfunction. He is unable to communicate or more but his extraocular movements and C- nerve examination seems to be intact. January Lab Values 1/22/131/24/131/25/13 Sodium Potassium Chloride Bicarbonate Glucose BUN Creatine Phosphorus Magnesium1.9 Amylase Lipase Triglycerides Nutritional Note 1/22/13 Clinical Note: ICU pt extubated 1/20/13- on D5W with Cr still slightly elevated- pt does not follow commands, does not respond to painful stimuli- failed swallow eval. Start TF per MD- NG tube placed. Nutritional Intervention: Will start Glucerna 30cc/hr with goal of 55cc/hr. This will provide 1584Kcals, and 79g of protein. Nutritional Monitoring/Evaluation: Pt will tolerate TF at goal with minimal residuals. GI Consultation 1/24/13 GI consult: Reason- PEG placement Impression: Unable to eat Suspected anoxic brain injury Diabetes mellitus I had a long discussion with the patients listed contact person, his sister-in-law, MV. She has discussed the treatment goals with the family, and they have all decided that they wish to have the PEG placement. JV GETS A PEG! Nutrition Note 1/25/13 Clinical Note Nutritional Needs Assessment remains the same ICU pt- tolerating TF at 55cc/hr (goal) with minimal residuals- failed second swallow eval- due to neurological prognosis- speech rec PEG placement. Urine output ~ L/day. IVF d/cd Nutrition Note 1/25/13 continued Nutritional Intervention: Continue Glucerna 1.2 at goal rate of 55cc/hr providing 1584Kcals, and 79g of protein. Nutritional Monitoring/Evaluation: Pt will tolerate TF at goal with minimal residuals. F/U with MD order for PEG placement. January 25, 2013 LOS: Day #11 JV gets transferred to regular floor! Nutritional Needs Reassessed a. Kcals (25-30Kcal/Kg) b. Protein (in grams) (1-1.2g/Kg) c. Fluid 2010 ml per pulmonology February 5, 2013 JV pulls out PEG tube, RN unable to place NG LOS: Day #21 Highlights of February Nutritional Highlights: 1:1 for safety Weight is down from 185# on admission to 164# New ABW used is 65Kg Tolerating Glucerna at goal with minimal residuals with 300cc fluid flushes 5x/day per MD order JV pulls out PEG, and passes swallow evaluation. Started on Dysphagia diet regular/thin liquids with poor PO intake; NG tube d/cd. Glucerna Shake was added TID Diet advanced to Diabetic 1800Kcal regular solids and thin liquids with good PO intake. Endocrine- consult only February Lab Values 2/4/132/11/132/22/132/27/13 Sodium Potassium Chloride Bicarbonate Glucose BUN Creatine Phosphorus (2/26) Magnesium (2/26) March 25, 2013 JV gets transferred to Southeast Rehab LOS: Day # 69. Highlights of March Nutritional Highlights JV continues on a Diabetic 1800Kcal, regular solids, thin liquid diet with good PO intake at most meals. Per SLP, pt is only to be fed when he is alert and oriented to decrease the potential risk of aspiration Patient was transferred to Southeast Rehab A calorie count was ordered from 3/20/13-3/21/13 and good PO was documented for these days Diabetes- now well controlled Levemir Tradjenta Ac/hs correctional scale March Lab Values 3/4/133/12/133/22/133/30/13 Sodium Potassium Chloride Bicarbonate Glucose BUN Creatine Phosphorus Magnesium1.8 Highlights of April Nutritional Highlights JV continues with good PO intake, however his PO intake can be variable at times The last clinical note was done on 4/14/13 Medically stable, however JV continues with a 1:1 for safety LOS: Day #89 April Lab Values 4/4/134/10/134/19/13 Sodium Potassium Chloride Bicarbonate2623 Glucose BUN Creatine Phosphorus4.8 (4/12) Magnesium2.2 (4/12) April 21 st 2013 JV is finally discharged from Charlton Memorial Hospital via a Medflight Helicopter to Mexico. LOS: Day # 95 Discharge Summary Discharge Diagnosis 1. Metabolic Encephalopathy 2. Diabetes mellitus 3. S/P acute renal failure 4. S/P pancreatitis (resolved) 5. Hypertension (controlled) 6. Hx of iron deficiency anemia (on iron) 7. Hx of esophagitis noted on EGD on Jan. 25 th (on Protonix) Pertinent Discharge Medications Coreg Heparin Iron Sulfate Humalog insulin sliding scale #1 and Humalog 75/25 twelve units subcutaneous with breakfast and 10 units with supper. Protonix Miralax Colace Summary of Interdisciplinary Consults Ordered Critical Care Endocrinology Nephrology GI Neurology Infectious Disease Psychology Podiatry Dietitian Physical Therapy Occupational Therapy Speech Pathology Discharge Summary Gracias! Questions? Preguntas? Comments? Comentrios?