ICU Case Presentation

Maria Margarita A. MejiaCCU Internal Medicine Rotation The Medical CityDecember 1, 20101ICU Case Presentation1Identifying Data2CFG, 58 y/o Filipino femaleRoman CatholicFrom PasigInformants: Patient and sister (good reliability)2Chief Complaint3Abdominal pain3History of Present Illness4Experienced epigastric pain (6/10) after eating breakfastPain was described as crushing and intermittent lasting for 30 minutes, with radiation to the backNo associated fever, nausea, vomiting, and changes in bowel movementMorning PTA4History of Present Illness5Epigastric pain (6/10) persistedWith associated chills and undocumented feverPersistence of symptoms prompted consult at TMC-ER and subsequent admissionAfternoon PTA5Other HistoryPertinent ROSPast Medical History6No weight gain or weight loss, easy fatigability(+) generalized weaknessNo headache, seizures, blurring of vision, ear problemsNo dyspnea, cough, coldsNo Palpitations, chest painNo nausea, vomitingNo dysuria, frequency(+) Hypertension 20 years2005 open cholecystectomy with biliary stent insertion2007 biliary stent replacementAllergic to erythromycin rashes6Other HistoryFamily HistoryPersonal-Social History7HypertensionAsthmaDivorcedSmokerOccasional alcohol beverage drinkerUsual diet: prefers meat and fatty food, soda7Physical Exam8Anthropometrics: Height=152 cm, weight=68 kg, BMI=29.4 (overweight)Vitals: BP: 150/70 (at the ER), 125/65 (ICU); T: 39.5oC (at ER), 36.4oC (ICU), RR 21, HR 88General: conscious, coherent, alertHEENT: Icteric sclerae, pink palpebral conjunctiva, neck veins non-distended, no cervicolymphadenopathiesChest: Symmetric chest expansion, no retractions , clear breath sounds8Physical ExamAbdomen: Protuberant, 5 bowel sounds per minute (normoactive), tympanitic, no masses palpated, epigastric and right upper quadrant tenderness (at the ER)Extremities: Full and equal pulses, jaundiced, good skin turgorDigital rectal exam: not done9Salient Features58 year old, femaleAbdominal pain (epigastric, RUQ areas)Accompanied by chills and feverPast medical history of cholecystectomy with biliary stent insertion and replacement (2005 and 2007)

Acute onsetHypertensive, smokerOverweight (BMI=29.4)At the ER: febrile and hypertensiveIcteric sclerae and jaundicedEpigastric and RUQ tenderness10Problem ListCNS Off midazolam; GCS 15CVS off levophed (11/30); noted atrial fibrillation (11/30); ECG (12/1): left atrial enlargement, leftward deviationRespiratory weaningGI NGT (supportan-1200kcal/day); jaundicedGU Creatinine=1.68 GFR of 38.4 (CKD Stage 3)Hematology anemia (Hb=108; Hct=0.32)Infectious on ampicillin and ceftriaxone day 1AssessmentSeptic shock secondary to ascending cholangitis s/p ERCPAKI vs. CKDCASE DISCUSSION1313Shocked!!!Shock clinical syndrome of the following:HypotensionAcidemiaTissue hypoperfusion impaired vital organ functionSeptic Shock characterized by the following:VasodilationLow central filling pressures, decreased intravascular volume, reduced peripheral vascular resistanceLeaky capillaries transudation of intravascular fluid14Ascending CholangitisInfection of the biliary tractCommon causes:Choledocholithiasis*Manipulations / interventions done on the biliary tract*Stents*Hepatobiliary malignancies

15Ascending CholangitisPotential for mortality and morbidity (13-88%)Asian (pyogenic) cholangitis common in Southeast AsiaAffects males and females equally; 50-60 y/o

16Differential Diagnosis17Cholecystitis and biliary colicDiverticular diseaseHepatitisMesenteric ischemiaPancreatitisCirrhosisLiver failureLiver abscessAcute appendicitisPerforated peptic ulcerPyelonephritis17HepatitisSalient Features+/-Pancreatitis58 year old, female+Mortality: < 5 y/o and >50 y/oAbdominal pain and tenderness (epigastric, RUQ areas) radiating to the back+Epigastric or RUQ pain with radiation to back Accompanied by chills and fever+Accompanied by feverAcute onset+Acute onsetIcteric sclerae and jaundiced+Jaundice18PancreatitisSalient Features+/-Pancreatitis58 year old, female+African- American; 35-64 y/oAbdominal pain and tenderness (epigastric, RUQ areas) radiating to the back+Epigastric or RUQ pain with radiation to back Accompanied by chills and fever+Accompanied by feverHistory of cholecystectomy with biliary stent insertion and replacement (2005 and 2007)-History of recent surgery or invasive procedureAcute onset+Acute onsetIcteric sclerae and jaundiced+Mild jaundice1920Diagnostic Plan (1 of 2)Laboratory TestRationaleCBC with differential countBaseline values; determine presence of infection, anemia, etc.Electrolyte panel with renal functionAssess metabolic state and kidney functionLiver function testDetermine possible liver pathology (e.g. hepatitis)Prothrombin time/activated partial thromboplastin timeCoagulopathies (e.g. DIC, cirrhosis)LipaseUsually elevated in pancreatitis2021Diagnostic Plan (2 of 2)Laboratory TestRationaleUrinalysisBaseline values; determine presence of infection, glucose, protein, etc.Culture and sensitivity for blood, bile, stentDetermine foci of infection and resistance profilesChest x-rayBaseline studyUltrasoundVisualization of the biliary tree21Principles of ManagementSeptic ShockAscending Cholangitis22Close monitoring (vital signs, I/O)Hemodynamic support with IV fluids and vasopressorsIdentify underlying cause for sepsisABC assessmentIV Fluid resuscitation with crystalloids (e.g. plain NSS)Parenteral antibioticsBiliary decompression (severe cases)Extracorporeal shockwave lithotripsy (ESWL) for choleliths22

Source: http://emedicine.medscape.com/article/774245-mediaLooking Ahead Ascending CholangitisPrognosisComplicationsDepends on the following:Early recognition and treatment of cholangitisResponse to therapyUnderlying medical conditions of the patientMortality rate: 5-10%, (higher in patients who require emergency decompression or surgery)Good response to antibiotics = good prognosis

Liver failure, hepatic abscess, microabscessAcute renal failureBacteremia, sepsis (gram-negative)

Looking Ahead Septic ShockPrognosisComplicationsDepends on the following:Severity of illnessCo-morbiditiesAgeResponse to antibiotics

Acute respiratory distress syndrome (ARDS)Renal dysfunctionDisseminated intravascular coagulation (DIC)Mesenteric ischemiaMyocardial ischemia and dysfunction

Other Aspects of the CasePsycho-socio-economic ImpactPrevention and Public HealthP100,000 per day with ICU admissions current expense for the patient is around P400,000 On patients personal accountLifestyle and health-seeking behavior changes (e.g. low-fat diet, quit smoking, stent-removal)Patient educationMaria Margarita A. MejiaCCU Internal Medicine Rotation The Medical CityDecember 1, 201027ICU Case Presentation27