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Prolong PT/PTT Case Report

Prolong PT/PTT Case Report. Ri 鄭千威. Patient Infomation. Name: 謝 XX Gender: female Age: 19 Chart Number: 5075664. Past history. 1.DM(-), HTN (-), Hyperlipidemia (-) 2.Other major systemic disease: gouty arthritis 3.Alcohol consumption: denied 4.Smoking: denied 5.Allergy: denied

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Prolong PT/PTT Case Report

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  1. Prolong PT/PTT Case Report Ri 鄭千威

  2. Patient Infomation • Name:謝XX • Gender: female • Age: 19 • Chart Number: 5075664

  3. Past history • 1.DM(-), HTN (-), Hyperlipidemia (-) • 2.Other major systemic disease: gouty arthritis • 3.Alcohol consumption: denied • 4.Smoking: denied • 5.Allergy: denied • 6.Surgical history: denied • 7.Family hx not contributory

  4. Brief History • Jan – Feb 2006, felt short of breath, weakness while climbing to her classroom on 4th floor • URI symptoms and exertional dyspnea developed in March then went to 耕莘 hospital on April 18. • Cardiac ECHO showed dialated LA and LV with LEVF = 20%, severe MR and moderate TR and PR without vegetation

  5. Hospitalized from July 27 – Aug 5 due to SOB and cough with sputum for 1 wk • Heart ECHO on July 28: pericardial effusion without tamponade sign, LVEF~16%, mod-severe MR, mod TR, PR with pul. HTN, without evidence of IE • Abd ECHO on July 29: All normal except a 2.61 cm left renal cyst • Refer to NTU OPD on Aug 10

  6. NTU OPD on Aug 24: decided for heart transplant • Hospitalized at 耕莘 H. Sep 25 – Sep 30 due to SOB, vomiting • Hospitalized at 耕莘 H. Oct 2 – Oct 5 due to SOB

  7. Oct 5: Request transfer to NTUH ER with development of SOB, vomiting, flapping tremor, chronic renal insufficiency (CRI) with acute exacerbation • Tremor cause unknown may be due to primperan related EPS

  8. PH 7.47 PCO2 36.0 PO2 114.4 HCO3 25.6 WBC 4.92 RBC 2.94 HB 9.2 PLT 206.0 UN 38.5 CRE 1.8 Lab findings at ER (10/05)

  9. Physical finding • Conscious clear until E1VTM4 (10/14) • Conj: anemic (-) Sclera: icteric (-) • Pupils: isocoric (+) Light reflex : R/L ( + / + ) • Throat: injected (-) Gum bleeding (-) • Neck: supple (+) , LAP (-), JVE (-), goiter (-) • Chest: symmetric expansion • BS: clear (+), rales (-), wheezing (-), crackle (-) • Heart: • PMI : at 6 ICS 3 fb, to LMCL • heart sound: regular heart beat • murmur: systolic murmur at mitral area, diastolic murmur over pulmonary valve area • Abdomen: inspection: soft (+), flat (+), • tenderness (-), rebounding tender(-), shifting • dullness (-) , central obesity (-), striae (-) • Liver: impalpable • Spleen :impalpable • Bowel sound : normoactive • Back: CV angle knocking pain (-) • Ext.: non-pitting edema, • tremor of extremities (+), purpura over forearms & cannulation wounds ;(+),Cyanosis of finger tips & toes(+)

  10. Treatment course • Oct 6: Unasyn: new onset fever (38.5) , resp s/s (cough + sputum) • Blood: no pathogen • Sputum: Gram (-) rods1+, Gram (+) cocci in chains3+ WBC 4920 CRP 0.13 U/A: negative findings BNP 3621.47 • Oct 9: cough with occasional blood tinged sputum • Oct 10: BT↑:39℃ Tazocin: nosocomial infection, new fever onset, persistent cough with sputum WBC 7250 CRP 1.46 U/A: negative findings • Blood: no pathogen • Sputum: few Enterobacter cloacae

  11. Oct 11: fever flare up 39.4 ℃, tremor On CVP, O2 mask Hb↓, blood tinged sputum, susp. pulmonary hemorrhage E4V5M6 • Oct 11 (1700): transfer to 3B1 for ionotropic support Dx: CHF NYFc IV, Cardiac ECHO: LVEF=20%, 4 chamber dilatation

  12. Oct 11 (2000): sudden attack of partial seizure with 2nd generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway E2VTM5 • Oct 11 (2100): profound shock after seizure despite full dose ionotropic On ECMO (L’t femoral a & v), on R’t femoral CVP

  13. Immunology Oct 11: Anti-Nuclear Antibody : - C3 Quantitation: within normal limit C4 Quantitation : within normal limit RA Factor : - Anti-ds DNA : - Oct 12 Adenovirus ab: - Coxsackievirus ab B1-B6: - CMV IgM ab: - Anti-CCP: - P-ANCA: - C-ANCA: - Anticardiolipin: - SLE Rheumatoid arthritis SLE Rheumatoid arthritis Wegener's granulomatosis Wegener’s granulomatosis Anti-phospolipid dz Lab findings

  14. Immunology Oct 13 HBsAg: Non reactive Anti-HBs: reactive HBeAg: Non reactive Anti-HBe:Non reactive Anti-HBc: reactive Anti-HCV: Non reactive Anti-HAV: reactive STS: non reactive Anti-HIV: negative Lab findings

  15. Oct 12: CAVH due to anuria, hyperkalemia • Oct 13: IABP, R’t femoral a. • Transfer to 4FI • Dopamine 20 ml/hr taper to 10 before transplant • Levophed 8 ml/hr DC 10/19 • Isuprol 2 ml/hr DC 10/18 • Oct 14: E1VTM4: fever switch to fortum + vancomycin • Blood: no pathogen • Sputum: Enterobacter cloacae3+ • Prophylaxis MRSA infection CRP: 8.18 WBC: 11020 • Oct 16: bronchoscope • diffuse bloddy secretion, pulmonary parechyma hemorrhage is likely • no obvious airway injury • Oct 17: LA drain with artificial ASD: toes and finger tip darken • Anterior tibial a, dosalis pedis a. L +/+ R +/+ • Oct 18: aortic ligation and aortic valve suturing • PGE1 and nitroderm for improving distal circulation • Oct 21: heart transplant

  16. Fortum Vancomycin Tazocin Unasyn

  17. AST ALT

  18. ECMO DIC 10/11 PT 20.3 -> 23.7 PTT 30.3 ->35.7 10/14 PT 45.3 PTT ＞200

  19. Oct 10

  20. Oct 12

  21. Oct 20, after LA drain

  22. Discussion

  23. a protein produced bythe ventricles of the heart test has a negative predictive value of at least 96%, so heart failure can confidently be ruled out for patients in the normal range B-type natriureticpeptide CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 70 • NUMBER 4 APRIL 2003

  24. Dilated cardiomyopathy Def: dilation & impaired contraction of one or both ventricle Def: LVEF ＜40% • Imparied systolic function -> HF common s/s: progressive dyspnea with exertion, impaired exercise capacity, orthopnea, paroxysmal nocturnal dyspnea, peripheral edema

  25. Primary Idiopathic familial Secondary Infective (coxsaki, CMV, HIV, adeno) Metabolic Familial storage disease (glycogen storage dz) Deficiency (e-, nutrient) Connective tissue disorder (SLE, RA) Infiltration & granulomas (maglinancy, amyloidosis) Neuromuscular (Muscular dystrophy) Toxic reaction (alcohol, drugs-doxorubicin, cyclophosphamide) Peripartum heart disease Etiology Harrison's Principles ofInternal Medicine, 15th Edition

  26. Treatment • Most downhill course • Death due to CHF, arrythmia, sudden death • Systemic embolization • Rx for heart failure • Salt restriction • Beta blocker carvedilol 3.125 mg qd -> 20-50 mg q12h • ACEI captpril 6.25 mg po tid • Digitalis 0.5 mg po/iv ->0.25 mg q6h • Diuretics spirolactone 25 mg po qd • Avoid alcohol, NSAID • transplant

  27. Hemoptysis Def: expectoration of blood from the respiratory tract • From sputum blood streak to large amount of pure blood • Dx: respiratory track vs GI source • GI tract -> a dark red appearance and an acidic pH, • Respiratory track-> bright red appearance and alkaline pH

  28. Systemic coagulopathy, anticoagulant, thrombolytic agents Primary vascular source AVM Embolism ↑pul venous pressure (MS) Tracheobronchial source Neoplasm Bronchitis Bronchiectasis Broncholithiasis Airway trauma Froeign body Pulmonary parenchyma source Lung abscess Pneumonia TB Fungus ball Lung contusion Idiopathic pulmonary hemosiderosis Goodpasture syndrome Wegener’s granulomatosis Lupus pneumonitis Etiology Harrison's Principles ofInternal Medicine, 15th Edition

  29. Treatment • blood-streaking of sputum or small amounts of pure blood -> priority -> diagnosis, (gas exhange usually unaffected) • massive hemoptysis • maintaining adequate gas exchange • preventing blood from spilling into unaffected areas of lung, • avoid asphyxiation. • rest and partially suppressing cough may help the bleeding to subside • If too severe may need endotracheal intubation and mechanical ventilation • laser phototherapy, electrocautery, embolotherapy, and surgical resection of the involved area of lung.

  30. C reactive protein • Why high fever, but low CRP? • CRP produced by hepatocytes stored in ER • During acute phase response, CRP catabolic rate independent of plasma level CRP therefore ambient level depend on syn rate

  31. elevated CRP value is not specific for any condition, • a very sensitive index of ongoing inflammation, • In differentiating between bacterial and viral infections -> very high CRP likely to occur in bacterial than viral infection, and a normal CRP is unlikely in bacterial infection.

  32. Infections Hypersensitivity complications of infections Rheumatic feverErythema nodosum leprosum Inflammatory disease Rheumatoid arthritischronic arthritisAS Psoriatic arthritis Systemic vasculitis Allograft rejection Renal tranplantation Malignancy Lymphoma sarcoma Necrosis MI acute pancratitis Trauma Burns fracture CRP elevation

  33. Production • CRP production in hepatocytes stimulated by IL6 • Cytokines network can be stimulated by various stimuli (IL-1, TNF…) to stimulate and provide feedback to acute phase protein response • Liver failure can affect acute phase protein production • Defects in cytokine network also ↓ acute phase protein production Seminar in dialysis: 17(6): 438 Nov, 2004

  34. ECMO • Extra corporeal membrane oxygenator • GOAL: to increase tissue oxygenation • va was used to bypass pulmonary circulation and pump flow determine the systemic flow perfusion due to poor LVEF • vv better: maintain pul blood flow, ↑myocardial oxygenation, keep thrombin or emboli to pul (vs systemic)

  35. ECMO setup Current Opinion in Critical Care 2005, 11:87–93

  36. Indication ECMO • ECMO high-end therapy for respiratory failure • all other treatment options failed to ↑ tissue oxygenation • defined as a PaO2/FiO2 ratio below 50mmHg. Current Opinion in Critical Care 2005, 11:87–93

  37. Contra-indication of ECMO • Prolonged mechanical ventilation (＞5days) • Sepsis • Absolute contra-indication to systemic anticoagulant

  38. Complication of ECMO • Bleeding (surgical & chest tube site)

  39. IABP • Intra-aortic balloon pump • GOAL: provide hemodynamic support to • critically ill patients with cardiac disease. • Improvement depend on: volume of balloon, position in aorta, heart rate, rhythm, compliance of aorta, systemic resistance Am J Cardiol 2006;97: 1391–1398

  40. Indication for IABP • Hemodynamic support during/after cardiac catherization • cardiogenic shock • Weaning from cardiopulmonay bypass • Pre-op support with severe left main cornary arterial stenosis • Adjuct therapy for high risk patients with • Complicated angioplasy • Restenosis

  41. IABP ↑ afterload + suction effect ↑ preload

  42. Contra-indication of IABP • Aortic regurgitation • Aortic dissection/aneurysm • uncontrolled septicemia • bleeding diathesis

  43. Complication of IABP • Bleeding • systemic embolization • limb ischemia • amputation • Infection • Balloon rupture

  44. Coagulopathy Uptodate

  45. Von Willebrands (lack vWD for platelet adhesion) Thrombocytopenia (genetic, bone marrow dz, iron) Vit K deficiency Mass transfusion (blood lack platelet, factor V) Liver disease DIC Antiphosplipid syndrome (ab against cell memb) Hemophilia A: VIII deficiency B: IX deficiency Protein C deficiency Protein S deficiency Antithrombin III deficiency Causes of prolong PT, PTT POMD 7th ed.

  46. Uptodate

  47. Thank you

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