MEET THE EXPERT SESSION

PROF ANDREW HILTON

HOW I APPROACH A

HAEMODYNAMICALLY UNSTABLE PATIENT

HISTORY

• 65/Female

• No known medical illness

• Referred from private centre for occult sepsis to rule out dengue fever • - given total of 15ml/kg of fluids prior to transfer

• 3 day history of fever, chills and rigors

• Lethargy

• Reside in East Malaysia

EXAMINATION

• Lethargic looking

• Peripheries warm

• Temp 36.8C

• BP 112/54

• HR 93/min

• Spo2 95% on room air

• RR 28-30/min

EXAMINATION

• LUNGS – fine creps over left lower zone

• CVS – dual heart sounds

• Abdomen soft, no hepatomegaly

• CBD – inserted in ED, urine 100ml

INVESTIGATIONS

FBC Plts Hct WBC Ur Cr K Na ALT AST ALP Bilirubin

CRP

KPMC

13 51 40 6.8 12 194 4.2 130 85 92 120 25 80

ED 11 37 35 5.4 11 133 4.1 140 49 58 84 21

Dengue combo test NS1, IgG, IGM at KPMC negative

ABG 5am

pH 7.34

pCO2 41

pO2 22

HCO3 22.3

BE -3.2

Lactate 1.5

WORKING DIAGNOSIS

• 1) Severe dengue fever, in critical phase, with compensated shock. In AKI and mild metabolic acidosis

• 2) Sepsis secondary to community acquired pneumonia

• Started on IV Rocephine

CXR

PROGRESS IN ED

• GCS full

• T 39.8C

• BP 105/50

• HR 120/min

• Given total fluids 1.5L and urine output 300ml

• Becoming more tachypnoeic RR 40/min

• Changed to high flow mask O2

PROGRESS IN ED

• Lungs – bibasal creps until mid zone

• Abdomen – soft

• Lactate 1.82.5

Upon ICU arrival

• GCS E3T 3V5M6, lethargic

• Peripheries warm

• BP 94/55

• HR 151/min

• RR35-40/min

• Spo2 93% on HFM O2

Bedside echo

• LV moderate contractility

• LV small volume

• LV Apex kissing

• IVC collapsible >50%

• Lactate 2.5 4

IMPRESSION

• 1) Septic shock secondary to community acquired pneumonia

• 2) AKI secondary to sepsis

• 3) Thrombocytopenia secondary to sepsis

• 4) Unlikely dengue fever

Management

• Stabilise

• Intubation

• Fluids

• Vasopressors

Bedside ultrasound post intubation

• IVC 2.3cm

• Good contractility

• LV volume good

Progress in ICU – at 4 hours

• Lactate 42.71.6

• Worsening AKI with oliguria

• Metabolic acidosis worsening

• 7.3/126/32/15/8/-9

Progress at 6 hours

• Oliguric

• Noradrenaline 8mcg/min

• Flotrac • CI 2.9 • SVV 13 SVRI 1400

• PF ratio worsening 190

• Lactate static

• IVC collapsible

D2 ICU 23/1

• Desaturated to 80% on PSIMV peep 10

• Total cumulative balance +ve 5L

• CI 1.8

• SVV 13

• SVRI 1300

D2 ICU

• CRP 80267

• PF ratio 76

• Increasing Noradrenaline support 20mcg/min

• HR 150/min AF

• Metabolic acidosis worsening

ABG 5am 7am 9am 11am

pH 7.31 7.3 7.02 7.07

pCO2 30 30 54 56

pO2 75 79 124 221

HCO3 15 14 13 16

BE -9 -10 -17 -14

O2 sats 93 93 95 99

lactate 3.9 5.8 7.7 6

D2 ICU

CXR D2

D2 ICU Management

• Escalate antibiotics covering for meliodosis

• Muscle paralysis in view of severe ARDS

• Start IV Amiodarone infusion

• For CRRT

D2 ICU

ABG 2pm 5pm 10pm 3am 6am

pH 7.07 7.08 7.14 7.19 7.19

pO2 192 181 130 112 98

pCO2 49 45 41 39 41

BE -16 -16 -14 -12 -11

HCO3 14 13 14 15 15

O2 sats 98 98.7 97 96 95.1

Lactate 6.6 7.4 5.5 5 4.1

HAEMODYNAMIC INSTABILITY

• Hypotensive on IV Noradrenaline 20mcg/min and IV Adrenaline 30mcg/min

• Arrhythmias – HR 150- 170/min AF

• What is the best modality to evaluate haemodynamic status?

D3 ICU 2am

• Noted peripheries cold and dusky

• On IV Noradrenaline/Adrenaline/Vasopressin

• INR 3.5

• Plts 15-30k

D3 ICU (24/1)

• Flotrac study SVRI 2331 CI 2.1 SVV 26

• IV Dobutamine started

• Able to wean down to single vasopressor

• Atracurium infusion off

• Lactate improved to 2.4

CXR D3

D4 ICU (25/1)

• Deteriorated again

• Back in AF; HR 140-160/min

• PF ratio worsened to 84

• Worsening metabolic acidosis

• Lactate 2.535.86.7

D4 ICU

• Fast AF

• Bleeding from oral cavity – INR 2.7, platelets 57

• Ongoing CVVHD – nil extraction

• IO balance + 6.5L

• Dusky coloured toes and fingers

• On IV Noradrenaline 6mcg/min

Management

• Transfuse blood and blood products

• IV MgSO4

• Muscle paralysis

• Started on 2nd vasopressor

CXR D4

D5 ICU

• Fresh blood from NG tube about 400ml

• Hypotensive

• WBC 920

• Lactate increased to 6

• Flotrac • CI 1.9 SVV 22 SVRI 1400

• Bedside echo IVC 1.4cm

CXR D5

D6 ICU

• Management:

• Blood transfusion

• Added IV Vancomycin

CXR D6

D7 ICU

• Able to wean down vasopressors

• Lactate 63

• Bedside ultrasound • IVC 2.3

• LV contractility good

• Flotrac

• CI 3.4 SVV 12

• CVVHD started on extraction

CXR D7

Further progress

• ECHO: EF > 55% no RWMA

• RV normal with good systolic function

• TAPSE > 1.6

• CRP 267 (23/1) 56 (26/1) 54 (30/1) 64.8 (2/2)

• Cultures blood, tracheal aspirate: no growth

• IV Meropenem off after 1 week

CT thorax 6/2

• Patchy consolidations and ground glass changes both lung fields with moderate bilateral pleural effusion suggestive of bronchopneumonia

• Irregular hypodense lesion lower pole of spleen suggestive of small splenic abscess

• started on IV Tazosin

Progress

• Tracheostomy D17 ICU

• Gangrene over bilateral fingers and toes – await demarcation

• Another bout of sepsis t/asp Acinetobacter baumanii

Progress

• CPR for 10 mins 7/3 due to hyperkalaemia

• Dialysed post CPR

• 48 hours post CPR GCS full

Progress

• Klebsiella ESBL from blood C&S – IV Meropenem

• AKI – improving; dialysis-free

• Tracheostomy training

Progress

• D88 hospital admission: ICU discharge

• D114 hospital admission: Ward discharge

• Tracheostomy de-cannulated 2 months after hospital discharge

• On monthly orthopaedics follow-up for hand and foot gangrene

• Last seen in orthopaedics clinic 29/8/18