Acute Medical Cases

1. Acute Medical Cases Dr Jack Bond Clinical Teaching Fellow Nov 2011

2. Aims To introduce you to the presentation and initial management of: Obstructive airways disease Acute kidney injury GI bleed

3. Group work Divide into groups of 4-6 Each group given a case Spend 10 minutes working through the case Select a member of your group to present the case and management back to the whole group

4. COPD - Objectives Be able to diagnose COPD Describe the initial management of COPD exacerbation List the indications/contraindications for NIV Understand set up and monitoring of NIV List complications associated with NIV

5. Case 1 A 75 year old man attends his GP with breathlessness over the last 6 months. He has been coughing up phlegm most days for the last few months, but worse over the last few days. He has smoked 20 cigarettes a day for the past 30 years. On examination, sats are 93% on air, RR 24, temp 38.3, BP 124/75, HR 85. The chest shows widespread wheeze throughout.

6. Case 1 1. List your differential diagnosis 2. what diagnostic tests would confirm a diagnosis of chronic obstructive pulmonary disease? 3. How would you assess severity of COPD? 4. in A+E, what would be your initial management of this patient?

7. COPD - Background • COPD is predominantly caused by smoking and is characterised by airflow obstruction that: • - is not fully reversible • - does not change markedly over several months • - is usually progressive in the long term 11/21/2011

8. Diagnose COPD • over 35, and • smokers or ex-smokers, and • have any of these symptoms: • - exertional breathlessness • - chronic cough • - regular sputum production, • frequent winter ‘bronchitis’ • Wheeze • And no clinical features of asthma [2004]

9. Differentiating COPD from asthma Clinical features COPD Asthma Smoker or ex-smoker Nearly all Possibly Symptoms under age 35 Rare Often Chronic productive cough Common Uncommon Breathlessness Persistent and progressive Variable Night time waking with breathlessness and or wheeze Uncommon Common Significant diurnal or day to day variability of symptoms uncommon Common 11/21/2011 [2004]

10. Differentiating COPD from asthma: 2 • If diagnostic uncertainty remains:- • - FEV1 and FEV1/FVC ratio return to normal with drug therapy • - a very large (>400ml) FEV1 response to bronchodilators or to 30mg prednisolone daily for 2 weeks • - serial peak flow measuremenst showing significant (20% or greater) diurnal or day-to-day variability • [2004]

11. Diagnose COPD: assessment of severity • Assess severity of airflow obstruction using reduction in FEV1 NICE clinical guideline 12 (2004) ATS/ERS 2004 GOLD 2008 NICE clinical guideline 101 (2010) Post-bronchodilator FEV1/FVC FEV1 % predicted Post-bronchodilator Post-bronchodilator Post-bronchodilator < 0.7 80% Mild Stage 1 (mild) Stage 1 (mild)* < 0.7 50–79% Mild Moderate Stage 2 (moderate) Stage 2 (moderate) < 0.7 30–49% Moderate Severe Stage 3 (severe) Stage 3 (severe) < 0.7 < 30% Severe Very severe Stage 4 (very severe)** Stage 4 (very severe)** * Symptoms should be present to diagnose COPD in people with mild airflow obstruction ** Or FEV1 < 50% with respiratory failure 11/21/2011 [new 2010]

12. 4 year survival • 0-2 Points: 80% • 3-4 Points: 67% • 5-6 Points: 57% • 7-10 Points: 18% 11/21/2011

13. COPD: acute exacerbations Increasing dyspnoea Increasing sputum volume Increasing sputum purulence (change in character) → treat as infective exacerbation

14. Initial management A-E - Sepsis! Oxygen – high flow initally, consider controlled to aim sats 88-92% when stable Nebulised bronchodilators Steroids Antibiotics (sepsis six pathway)

15. If not responding Recheck A-E – your patient is probably septic and you haven't noticed ABG CXR Consider NIV Consider aminophylline

16. Case 2 An 76 year old man attends A+E with breathlessness. He has known COPD, with an FEV1/FVC 0.3, predicted FEV1 35% a few months ago. He uses oxygen at home, 2L for 16 hours a day. Over the last week he has had a productive cough with phlegm and fever. His obs are RR 16, sats 85% on 2L oxygen, HR 110, BP 134/68, temp 33.5. The examination shows crackles in his right lung base, but widespread wheeze throughout both lung fields. The paramedics have given him a few salbutamol nebs and some IV hydrocortisone in the ambulance an hour ago but he is not improving as yet. What's your initial management plan?

17. Case 2 continued The nurse calls you as he has become drowsy. You take an ABG which shows pH 7.23, pO2 8.3kPa, pCO2 8.4kPa, HCO3- 24 mmol/l. His obs are repeated and show RR 12, sats 90% on 4L oxygen, HR 115, BP 115/68. What is your management plan? How would you start someone on NIV? How would you monitor their progress on the ward? What are the indications for NIV? What are the contraindications? List complications of NIV

18. NIV – non-invasive ventilation Ventilation (V) = Tidal volume x Resp rate Increase V, increase CO2 clearance

19. NIV – BiPAP diagram

20. NIV – indications in COPD Respiratory acidosis (pH <7.35, PaCO2 >6kPa) – Hypercapnic respiratory failure Persistent despite maximal medical therapy for no more than one hour

21. Other indications for NIV Might be considered in:- controversial Hypercapnic resp failure due to other causes Cardiogenic pulmonary oedema Weaning from tracheal intubation

22. NIV contraindications - respiratory arrest - uncooperative patients – confused - unable to protect airway - reduced conscious - facial, oesophageal, gastric surgery - face trauma

23. Starting NIV Dedicated area that allows high dependency nursing HDU/ITU Respiratory ward A+E resus Medical admissions Not usually on a general ward – the nursing staff will not know how to deal with it

24. Starting NIV Physio or nursing help Select settings for IPAP, EPAP and resp rate IPAP start at 10cm H20 EPAP start at 5 cm H20 Backup rate of 8 breaths per minute Most patients tolerate these settings, but may vary, especially those on long term NIV

25. NIV Management IPAP increased by 2-5 cm H20 every 10 mins until either therapeutic response or IPAP of 20 cm H20 reached Oxygen through circuit, aim sats 88-92% Bronchodilators can continually be given though it affects the pressures

26. Monitoring NIV Baseline ABG, RR, HR Repeat ABG after one hour of starting After every setting change, repeat ABG at 1 hour Otherwise, every 4 hours, or if not well Aim minimum 6 hours treatment Most people better by 24 hours on NIV Weaning thereafter

27. Complications of NIV Increased IPAP – pneumothorax Decreased pre-load – may drop BP Increased risk of aspiration Face mask discomfort Anxiety + confusion

28. Escalation of care Plan for the failure of NIV Are they appropriate for invasive ventilation and why? Factors limiting survival Pre-morbid state Severity of physiological disturbance Reversibility of acute illness Relative contraindications Patients wishes Long term oxygen therapy

29. Decision making Consultant led, but involves MDT input You as the FY1 can influence this Nursing staff have valuable input Involve the patient where possible Family involvement is best practice However we are not asking them to make a decision Decisions are the responsibility of doctors

30. Palliation Symptoms of breathlessness are distressing NIV can be continued if it provides symptom relief, but would normally be withdrawn Opiates and benzodiazepines for breathless are optimal therapy Palliative care team involvement Liverpool care pathways

31. COPD Key Messages Hypercapnic respiratory failure is indication for non-invasive ventilation in COPD Call for early support (within 1 hour) of maximum medical therapy Limits of care should be clearly planned when starting NIV

32. AKI Questions “Everything you wanted to know about kidneys but were afraid to ask” Write down your question Pass it forward Answers later

33. Acute Kidney Injury - Objectives To recognise AKI To differentiate between pre-renal, renal and post renal causes of AKI To recognise and manage hypovolemia To manage hyperkalemia and pulmonary odema To know indications for emergency dialysis How to call a nephrologist without getting shouted at

34. 11/21/2011 June 2009

35. Definition of AKI Rise in serum creatinine >50% from baseline Or Urine output <0.5ml/kg/hr for 6 hours

36. SIMPLIFIED RIFLE OR AKIN DEFINITIONUsually based on Creatinine rise Loss and End stage components of RIFLE now dropped Urine output criteria Creatinine criteria High sensitivity Urine output <0.5 ml/kg/hrfor 6 hours (=240 ml at 80 kg) ≥ 50-100% rise in Cr Risk or AKIN 1 101-200% rise in Cr Urine output <0.5 ml/kg/hrfor 12 hours (= 480 ml at 80 kg) Injury or AKIN 2 Urine output <0.3 ml/kg/hr for 24 hours or anuria 12 hours >200% rise in Cr High specificity Failure or AKIN 3 Oliguria 11/21/2011

37. Which scenario is AKI? T/F/Can't tell? 85 male, D+V, creat 120, usually 80 2. 82 female, D+V, Urea 15.2, Creat 150 3. 60 male, diabetic, creat 250, usual 200 4. 74 male, legionella pneumonia, Na 118, Creat 130, usual creat 70 5. 63 female, diabetic, myocardial infarct, eGFR 25, usual eGFR 35 11/21/2011

38. Suspect AKI in a sick patient with a modest rise in their creatinine Large acute drop in GFR with oligoanuria GFR falls rapidly to near zero - only shown by oliguria Slow rise in Cr until eventually a new steady state is reached Only a small early rise in Cr: not easy to recognise as AKI 11/21/2011

39. Effect of AKI on odds of deathChertow GM et al J Am Soc Nephrol 2005 11/21/2011

40. Rise in serum creat > 50% baseline baseline creatinine of 80 mmol/L Rises to 120 mmol/L Significant kidney injury This is the moment to act – it is too late when the creatinine reaches 400 Mehta et al. Critical Care 2007 11:R31

41. Case 3 66 year old man is admitted to A+E with breathlessness. He has been unwell for a week, coughing up phlegm and having fevers. His past medical history includes diabetes and hypertension. His medication is metformin, aspirin, ramipril, atenolol and simvastatin. On examination he is unwell. His obs are BP 85/50, HR 115, Sats 92% on air, RR 25, Temp 38.3. You hear coarse crackles on the right side of his chest. A CXR confirms pneumonia. His blood results come back which show Na 130, K 4.5, Urea 14.3, Creat 189. The nurse asks you to assess him as he hasn't passed urine since admisssion.

42. Case 3 Outline the management you would undertake in A+E. What is the likely cause for his renal failure? Is this acute or chronic renal failure? How severe is his renal failure? What investigations would you order and why? What risk factors are evident in this man's case that make him more likely to have renal failure? What information can be gained from a urine dipstick?

43. AKI risk factors Most people have > 1 risk factor Age Drugs (ACEi, diuretics, NSAIDS) Chronic kidney disease Hypovolemia/Sepsis Diabetes

44. AKI: causes PRE-RENAL RENAL Important to attempt to categorise broadly into one of 3 groups sepsis/hypovolemia 70% drug related, acute GN 20% obstruction 10% POST-RENAL

45. Cause of AKI – 3 tests 3 assessments result in a 45% 36 months survival, compared with 15% for 0 assessments Fluid/volume assessment PRE Urinalysis RENAL Ultrasound POST

46. Question • Which of these is the most useful indicator of hypovolaemia?: • capillary refill time > 5 seconds • jugular venous pulse not visible at 30º • postural pulse rise > 30 bpm • systolic blood pressure < 95 mm Hg • systolic BP rise with 250 ml saline bolus > 20 mm 11/21/2011

47. Volume assessment - key MEWS score Cap refill BP, HR, Postural BP JVP Auscultate lungs Peripheral odema Urine output

48. Volume assessment You are the FY1 covering orthopedics. You have been asked to see 74 female post #NOF as she has low urine output PMH - diabetes, hypertension Creat 150, baseline 100, urine output 20mls in last hour CRT 2 secs, BP 110/50, HR 98, JVP ??, chest couple of creps, no edema Is patient fluid depleted, euvolemic or overloaded? How much fluid would you prescribe?

49. Volume management Most patients are hypovolemic (70%) If not grossly overloaded – fluid challenge - 500ml + recheck “Normal” BP for 75 year old – 150/70 - a post op BP of 110 is relatively hypotensive

50. Volume assessment Most patients are likely 2-3 liters or more fluid deficient Sepsis – doubly important