Death Round MICU Case By Maruf Aberra Jan 23/2007

Identification Late F..T. Late F..T. Age -14 years Age -14 years Female Female Addis Ababa Addis Ababa Date of admission- 27/04/99 E.c Date of admission- 27/04/99 E.c Date of death - 01/05/99 E.c Date of death - 01/05/99 E.c

Referral Paper ( Private Clinic ) 27/04/99 Known Diabetic on Insulin Known Diabetic on Insulin Cough productive of on and off blood mixed sputum Cough productive of on and off blood mixed sputum Fast & deep breathing Fast & deep breathing Failure to communicate. Failure to communicate. BP =unrecordable Pulse=Feeble, fast T=35 BP =unrecordable Pulse=Feeble, fast T=35 Decreased air entry & crept over the left lung Decreased air entry & crept over the left lung RBS 260 mg/dl RBS 260 mg/dl DX= DKA, Pneumonia R/O PTB DX= DKA, Pneumonia R/O PTB MGT= (N/S +R/L) 2500ml, Ampicillin 500mgIV MGT= (N/S +R/L) 2500ml, Ampicillin 500mgIV

History at presentation Vomiting and diarrhea / 04 days Change in mentation/08 hours Known type-1 DM for five years, at the time taking Humulin N /day Known type-1 DM for five years, at the time taking Humulin N /day Since 4-days prior had reported to have watery diarrhea and Vomiting of ingested matter associated with abdominal cramp. Followed by change in mention for 8 hours before presentation. Since 4-days prior had reported to have watery diarrhea and Vomiting of ingested matter associated with abdominal cramp. Followed by change in mention for 8 hours before presentation. Preceding polyuria and polydypsia. Preceding polyuria and polydypsia. No fever No fever No cough/ chest pain No cough/ chest pain No nuchal pain/rigidity No nuchal pain/rigidity

Examination Vital signs Vital signs BP= unrecordable BP= unrecordable 100/60 mmHg after 3 bags of fluid 100/60 mmHg after 3 bags of fluid PR= 114/m RR=32 deep and labored PR= 114/m RR=32 deep and labored T= 36 T= 36 Pink conjunctiva, no icturus Pink conjunctiva, no icturus Dry mucosa Dry mucosa No sLAP No sLAP Fine crackles on bilateral lower lungs Fine crackles on bilateral lower lungs No murmur or gallop No murmur or gallop

Examination contd… Full abdomen, moves with respiration Full abdomen, moves with respiration No organomegally, No shifting dullness or fluid thrill No organomegally, No shifting dullness or fluid thrill Urinary catheter in place draining clear urine Urinary catheter in place draining clear urine Skin turgor goes back slowly Skin turgor goes back slowly No edema No edema No active skin lesions No active skin lesions Non communicating with GCS=11/15 Non communicating with GCS=11/15 No cranial nerve or motor deficit appreciated No cranial nerve or motor deficit appreciated Funduscopy= Clear disc margins, No Background changes Funduscopy= Clear disc margins, No Background changes Meningeal irritation signs- negative Meningeal irritation signs- negative

Investigations 27/04/99 CBC WBC 26,400 N= 74% L=19.3% CBC WBC 26,400 N= 74% L=19.3% Hgb 11.6g/dl Hgb 11.6g/dl HCT 34.30% HCT 34.30% Plt 138,000 Plt 138,000 BF NEG BF NEG RBS 254 RBS 254 U/A Ketone 4+ U/A Ketone 4+ Sugar 2+ Sugar 2+ WBC 1—2/ HpF WBC 1—2/ HpF RBC 8—12/HpF RBC 8—12/HpF ALB Trace ALB Trace

Diagnosis & Mgt. Asst=DKA Asst=DKA Type 1 DM Type 1 DM R/O Sepsis of GI onset R/O Sepsis of GI onset Management (27/04/99 5:30 PM) DKA Mgt DKA Mgt Fluid - N/S 2000cc over 3 hours then 1000cc 8 hourly Fluid - N/S 2000cc over 3 hours then 1000cc 8 hourly Insulin- Bolus & Infusion Insulin- Bolus & Infusion KCL KCL Ceftriaxone 1gm BID Ceftriaxone 1gm BID

MICU mgt and course 28/04/99 8:30AM 28/04/99 8:30AM On Insulin Infusion 10 units/Hour, took ~80 units On Insulin Infusion 10 units/Hour, took ~80 units Fluid 3 litres given, KCL given Fluid 3 litres given, KCL given Urine output =3200ml/12 hrs Urine output =3200ml/12 hrs Ketone= +3 Ketone= +3 RBS= 201 RBS= 201 Agonizing pain ? Abdominal Agonizing pain ? Abdominal BP 60/40 mmHG BP 60/40 mmHG PR-88 RR - 28 T <35 C Spo2=88% with room air PR-88 RR - 28 T <35 C Spo2=88% with room air Chest- bilateral basal crackles Chest- bilateral basal crackles ABD=Tenderness on right lower quadrant ABD=Tenderness on right lower quadrant Restless Restless

Course & mgt contd… Impression= Acute abdomen, Sepsis Impression= Acute abdomen, Sepsis Plan workups CXR, plain ABD X-RAY Plan workups CXR, plain ABD X-RAY OFT, Lipase OFT, Lipase Dopamine 5 mic /min Dopamine 5 mic /min Hydrocortisone 100mg QID Hydrocortisone 100mg QID Surgical consultation Surgical consultation

Investigations LAB 27/04/99 28/04/99 LAB 27/04/99 28/04/99 BUN ………….48 BUN ………….48 Creatinine……..0.9 Creatinine……..0.9 AST……………77 AST……………77 ALT…………...52 ALT…………...52 ALP………… ALP………… Bilirubin……….0.8 Bilirubin……….0.8 Total protein… Total protein… HBsAg……… NEG HBsAg……… NEG HEP C Ab…………………NEG HEP C Ab…………………NEG PT…………….. …………….15 PT…………….. …………….15 PTT………………………….30.8 PTT………………………….30.8 INR………………………….1.24 INR………………………….1.24 Amylase……….. ………… Amylase……….. ………… K+………………………… K+………………………… Na+………… Na+………… Cl-………………………… Cl-…………………………

MGT & course contd… Surgical Resident Note(28/04/99) Surgical Resident Note(28/04/99) ABD= moves with respiration, soft, Active ABD= moves with respiration, soft, Active bowel sounds bowel sounds PR= formed normal colored stool on examining finger, No mass PR= formed normal colored stool on examining finger, No mass IMP= severe pneumonia + DKA IMP= severe pneumonia + DKA Doesn’t seem to have acute abdomen Doesn’t seem to have acute abdomen

Mgt & course contd… 28/04/99 11:00 AM Restless pointing to her abdomen and shouting Restless pointing to her abdomen and shouting BP= 90/60 mm Hg PR=114 T= 37.4 spo2=90% BP= 90/60 mm Hg PR=114 T= 37.4 spo2=90% ABD- Not distended ABD- Not distended Diffuse abdominal tenderness, more over the epigastria area Diffuse abdominal tenderness, more over the epigastria area No sign of fluid collection, Normoactive bowel sounds No sign of fluid collection, Normoactive bowel sounds CNS -Disoriented, GCS 13/15 CNS -Disoriented, GCS 13/15 ASS’t -Severe CAP with sepsis Acute abdomen R/O Acute pancreatitis Acute abdomen R/O Acute pancreatitis Analgesics Given LP done Opening pressure….normal Appearance ……… Crystal clear WBC……….5 cells WBC……….5 cells

Mgt. & course contd… 29/04/99, 9:00 AM Grunting, in pain, not communicating well Grunting, in pain, not communicating well B/P=100/60 mmHg B/P=100/60 mmHg Tachypnoeic RR=40/min Tachypnoeic RR=40/min Bilateral lower lung BBS and decreased air entry Bilateral lower lung BBS and decreased air entry Soft abdomen with differential tenderness in the RLQ, normoactive bowel sounds Soft abdomen with differential tenderness in the RLQ, normoactive bowel sounds Non communicating, a bit obeys commands to some extent Non communicating, a bit obeys commands to some extent Ketones= negative Ketones= negative RBS= 264 mg/dl RBS= 264 mg/dl

Mgt & course contd… Ass’t - Multi focal pneumonia + R/O Acute abdomen Ass’t - Multi focal pneumonia + R/O Acute abdomen Plan - Re Consultation (surgical/ Gyn) Plan - Re Consultation (surgical/ Gyn) Rx= Cloxacillin Rx= Cloxacillin Cimetidine Cimetidine

Mgt & course Contd… GYN- resident Noted(29/04/99) RLQ tenderness, No guarding or rebound tenderness RLQ tenderness, No guarding or rebound tenderness PR=No adnexial mass, free cul de sac PR=No adnexial mass, free cul de sac R/o appendicitis R/o appendicitis Suggested- Consult surgical side, can plan joint operation if they plan exploration Suggested- Consult surgical side, can plan joint operation if they plan exploration SURGICAL-resident note ABD- Flat moves with respiration ABD- Flat moves with respiration No area of tenderness No area of tenderness Active bowel sounds Active bowel sounds NO sign of acute abdomen NO sign of acute abdomen

ABDOMINAL + PELVIC ULTRASOUND ( ) Liver =11.0 CM, Blunt edge, mildly heterogeneous, no focal lesions Liver =11.0 CM, Blunt edge, mildly heterogeneous, no focal lesions PV and CBD have normal caliber, GB free PV and CBD have normal caliber, GB free Spleen= 9 CMs, normal echo pattern Spleen= 9 CMs, normal echo pattern Kidneys= Normal Kidneys= Normal Minimal free fluid collection within the pelvis Minimal free fluid collection within the pelvis Pancreas, par aortic and RLQ= difficult to comment because of increased bowel gas. Pancreas, par aortic and RLQ= difficult to comment because of increased bowel gas.

Mgt & Course contd… 30/04/99 (4 th day admission) BP-100/55 mmHg PR-140/m RR-52 T-35.8 SPo2-80% BP-100/55 mmHg PR-140/m RR-52 T-35.8 SPo2-80% Distended abdomen Distended abdomen Hypoactive bowel sounds Hypoactive bowel sounds GCS=6/15 GCS=6/15 UOP=200 ml/8 hr UOP=200 ml/8 hr Ass’t - Deteriorating Ass’t - Deteriorating ACTION ACTION Antibiotics revised Antibiotics revised Vancomycin + Ceftazidime + Gentamycin Vancomycin + Ceftazidime + Gentamycin Sliding Scale Sliding Scale Hydrocortisone Hydrocortisone Cimetidine Cimetidine

Course at 4 th day MICU 30/04/99 4:45 PM Mechanical ventilation Started Mechanical ventilation Started01/05/99 MV IppV mode MV IppV mode B/P 85/50 mmHg- Dopamine initiated B/P 85/50 mmHg- Dopamine initiated UOP < 50ml/16 hours. Gentamycin held UOP < 50ml/16 hours. Gentamycin held Flaccid extremities Flaccid extremities Bilateral dilated fixed pupils Bilateral dilated fixed pupils Brain stem reflexes- intact initially Brain stem reflexes- intact initially 02/05/99 9:15AM Died 02/05/99 9:15AM Died

Discussion Diagnosis DiagnosisDKA SEPTIC SHOCK Focus GI Chest Chest Presentation Presentation DKA can mimic acute abdomen DKA can mimic acute abdomen Management Management Antibiotic Antibiotic Corticosteroid Corticosteroid Blood Glucose level Blood Glucose level SURGICAL INTERVENTION ? SURGICAL INTERVENTION ?

Discussion… Mgt of septic shock ANTIMICROBIAL AGENTS ANTIMICROBIAL AGENTS Pending culture results Empirical Rx Pending culture results Empirical Rx Maximal dose and IV Maximal dose and IV Delayed, inadequate, or inappropriate antimicrobial therapy is associated with poor outcome. Delayed, inadequate, or inappropriate antimicrobial therapy is associated with poor outcome. In Patients with septic shock the time to initiation of appropriate antimicrobial therapy was the strongest predictor of mortality. In Patients with septic shock the time to initiation of appropriate antimicrobial therapy was the strongest predictor of mortality. Severely ill patients presenting with sepsis of unclear etiology should be treated with intravenous vancomycin (adjusted for renal function) until the possibility of MRSA sepsis has been excluded. Severely ill patients presenting with sepsis of unclear etiology should be treated with intravenous vancomycin (adjusted for renal function) until the possibility of MRSA sepsis has been excluded.

Discussion… Mgt of septic shock Acceptable regimens Acceptable regimens Combining vancomycin with: Combining vancomycin with: Cephalosporin, 3rd or 4th generation Cephalosporin, 3rd or 4th generation Or Beta-lactam/ beta- lactamase inhibitor Or Beta-lactam/ beta- lactamase inhibitor Or Carbapenem Or Carbapenem Alternatively, if Pseudomonas is a possible pathogen Alternatively, if Pseudomonas is a possible pathogen Combine vancomycin with Combine vancomycin with Antipseudomonal cephalosporin Antipseudomonal cephalosporin Or Antipseudomonal carbapenem Or Antipseudomonal carbapenem Or Antipseudomonal beta-lactam/beta- lactamase inhibitor Or Antipseudomonal beta-lactam/beta- lactamase inhibitor Or Fluoroquinolone with good anti- pseudomonas activity Or Fluoroquinolone with good anti- pseudomonas activity Or Aminoglycoside Or Aminoglycoside Or Monobactam Or Monobactam

Discussion… Mgt of septic shock CORTICOSTEROIDS CORTICOSTEROIDS many septic patients have a relative adrenal insufficiency many septic patients have a relative adrenal insufficiency may benefit from low dose corticosteroids may benefit from low dose corticosteroids REMOVAL OF THE SOURCE OF INFECTION REMOVAL OF THE SOURCE OF INFECTION HEMODYNAMIC, RESPIRATORY, AND METABOLIC SUPPORT HEMODYNAMIC, RESPIRATORY, AND METABOLIC SUPPORT blood glucose should be aggressively controlled with an insulin infusion aiming for a blood level of 80 to 110 mg/dL. blood glucose should be aggressively controlled with an insulin infusion aiming for a blood level of 80 to 110 mg/dL.