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ICU Case Presentation: Hypotension and Pyrexia

ICU Case Presentation: Hypotension and Pyrexia. Bradley J. Phillips, MD Burn-Trauma-ICU Adults & Pediatrics. Case #1. 52 yof school teacher POD 5 Lap Chole for recurrent RUQ with U/S + gallstones Uncomplicated OR except transient SBP 70 during insufflation corrected with 1 L bolus IVF

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ICU Case Presentation: Hypotension and Pyrexia

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  1. ICU Case Presentation:Hypotension and Pyrexia Bradley J. Phillips, MD Burn-Trauma-ICU Adults & Pediatrics

  2. Case #1 • 52 yof school teacher POD 5 Lap Chole for recurrent RUQ with U/S + gallstones • Uncomplicated OR except transient SBP 70 during insufflation corrected with 1 L bolus IVF • D/C POD1 • Returned POD3 with abdominal pain, nausea, fever (38.7C) • Diff dx ??

  3. Case #1 • Presumptive dx: Cholangitis • IVF, NPO, ABX (Ceph 3, Flagyl) • Over 24 hrs developed oliguria unresponsive to fluid challenges ( total 5 L positive balance) • Progressive tachypnea (RR 40) and SBP 85-90 • Abdominal pain more widespread with focus RUQ and fever increased 40.4C • ?? More information

  4. Case #1 • PMH: HTN, ankle swelling, NIDDM • PSH: appy, hysterectomy, tonsillectomy • Meds: captopril, lasix 40mg qd • Labs: • Abdominal U/S - limited from bowel gas, no calculi in CBD although dilated upper limit of normal 6.5 9.6 133 120 15.2 127 184 5.2 13 4.0 0.5 ABG 7.28 / 28 / 54 / 12 INR 1.4 PTT 44 Tbil 2.6 AST 98 Alk Phos 428 Amylase 2416 Albumin 3.0

  5. Case #1 • DX - Pancreatitis • Transferred to ICU • CVL inserted - CVP 2 cm H20 • Dopamine qtt started 10 ug/kg/min for SBP 100 • Very distressed, tachypneic and confused • NGT inserted with 1.5 L light brown fluid • RR decreased to 34/min on FiO2 50% • ?? Management

  6. Case #1 Pancreatitis • IVF bolus 1.5 L colloid increased CVP 14 cmH20 • Remained tachypneic, UOP 8 ml/hr • Dopamine qtt at 16 ug/kg/min • Repeat labs: ABG pH 7.07 / 45 / 61 / 8 Na 130, K 6.4, Glu 331 • ?? Issues and management ??

  7. Case #1 Pancreatitis • Respiratory distress - Intubation • Hyperkalemia • Amp of D50 • Insulin 10 units • Amp of calcium chloride • Continuous venovenous hemofiltration • TPN • Further hypotension requiring norepinephrine qtt

  8. Pancreatitis Case #1 • Insertion of PA catheter • Wedge 12 mmHg, CI 5.7 L/min/m2 • Next 3 days continued hemofiltration, norepi qtt decreased, CI high (4.9) • Hyperglycemia remained a problem despite insulin in TPN ( 750 cc 10% AA, 750 cc D50) • Increased jaundice with Tbil 9.8 mg/dl • ?? Diff dx and management

  9. Pancreatitis Case #1 • Repeat U/S unsatisfactory • CT Abd - moderate bilateral pleural effusions, marked dilation of CBD, dilated loops of bowel, extensive pancreatic edema and phelgmon with question 10% necrosis of pancreatic head • ?? plan

  10. Pancreatitis Case #1 • ERCP - obst. calculus removed and sphincterotomy performed • Next 48 hrs, bilirubin decreased to 4.8 • Continued vasopressors, ventilation, hemofiltration, and TPN • New onset of fever, 39.7 C accompanied by increased inotropic drugs to maintain MAP • CVP 8, wedge 14, CI 5.2 • ?? Diff dx and plan

  11. Pancreatitis Case #1 • Lines changed and cultures obtained • CXR revealed ARDS • Cultures • sputum leukocytes, no bacteria • urine no bacteria • blood - E coli • ?? plan

  12. Pancreatitis Case #1 • Imipemem q 6hrs started • Repeat CT scan - peripancreatic fat necrosis, extensive edema, and fluid in paracolic gutters, definitive 15-20% pancreatic head necrosis • Plan??

  13. Pancreatitis Case #1 • Taken to OR for debridement ( EBL 500 cc) • ICU return very unstable with fever 40.2, increased amount of norepi qtt and now epi qtt added • Wedge 12 despite 4L blood and colloid (Hgb 12.4) • Worsening O2 requiring FiO2 100%, PEEP 10 • ABG 7.18 / 48 / 63/ 14 lactate 6.2 • CXR 0 extensive bilateral pulmonary infiltrates with interstitial edema • ?? management

  14. Pancreatitis Case #1 • Hemofiltration restarted with negative balance of 100 ml/hr • Next 12 hrs, gradual decrease of FiO2 to 0.6 • Decreased inotropic qtt • Repeat laparotomy x2 with debridement • Temperature 37-3C and pressors weaned off

  15. Pancreatitis Case #1 • Traps • Insertion of NGT • rarely needed in mild/mod pancreatitis • acute pancreatitis causes acute dilatation • obstruction from pancreatic head swelling • diabetic autonomic neuropathy • Jaundice etiology • swelling of the head of the pancreas • reabsorption of hematoma • sepsis • biliary obstruction from gallstone

  16. Pancreatitis Case #1 • Traps • ARDS • pulmonary edema worsens oxygenation • monitor intravascular volume closely • may require PA catheter • may require dialysis if renal failure ensues • Fevers • common sources of infection common in ICU • rule out infected pancreas if necrotizing pancreatitis

  17. Pancreatitis Case #1 • Tricks • Diagnosis of biliary obstruction • U/S commonly unsatisfactory in early pancreatitis and limited by bowel gas (ileus common) • ERCP indications • suspicion of gallstone induced pancreatitis, not improving by 24 hrs • traumatic pancreatitis if CT scan nondiagnostic

  18. Etiology (common) EtOH Gallstone Bilary sludge Hyperlipidemia Hypercalcemia Anatomic tumor divisium stricture Etiology (uncommon) Trauma ERCP Infection (viral) Drugs ( thaizides, lasix, steroids, estrogens, valproic acid, clonidine, tetracyclins, sulfonamides) Toxins ( scorpion, methanol, insecticides Hereditary Pancreatitis

  19. Signs/Symptoms Epigastric pain N/V Anorexia Ileus Sepsis Jaundice Cullen’s sign Grey Turner’s sign Tests ABG CBC/Plts/PT/PTT Lytes/BUN/Cr Ca/Mg/Phos LFT’s, Triglycerides Amylase (S60-90,Sp 70) Lipase (S/Sp 90-99) CXR/AXR U/S CT Pancreatitis

  20. Pancreatitis • Complications • Death • Renal failure • Sepsis • ARDS • Infected pancreas (early as 1st week) • Hemorrhage • Pancreatic abscess (late) • Pseudocyst (late) • Diabetes

  21. Pancreatitis - Current Issues • Antibiotic coverage • Role of fine needle aspiration • Role of octreotide • Predictive criteria of mortality

  22. Pancreatitis - Antibiotic Coverage • Common isolates • E coli (26%), Pseudomonas (16%), anaerobic (16%), S. aureus (15%), Klebsiella (10%), Proteus (10%) • Need broad coverage if indicated • Indications? • Prophylatic use in necrotizing pancreatitis • Early studies no benefit (use ampicillin) • Imipenem drug of choice • Clinical trials show benefit by decreased frequency in infection • Imipenem and quinolones highest in pancreatic tissue with aminoglycosides lowest, PCN intermediate

  23. Pancreatitis - Antibiotics • Gut decontamination • experimental studies show bacterial translocation and hematogenous seeding • clinical trial with oral norfloxacin, colistin, and ampho B shows significant reduction in GNR pancreatic infection • adjusted for illness severity, improved outcome • not achieved widespread acceptance • Anti-fungal

  24. Pancreatitis -Role of FNA • Pancreatic necrosis - r/o infected necrosis • Options • observation and antibiotics for selected organisms • percutaneous drainage? • debridement • percutaneous/endoscopic - reported cases/trials • operative • controversial ( must weigh hemodynamics/MSOF) • worse in EtOH pancreatitis secondary to nutritional status • consensusimproved survival with infected pancreatic necrosis

  25. Pancreatitis - Role of Octreotide • SQ vs IV dosing • SQ dose 100-200ug tid • Trials • Numerous both retro and prospective • No benefit

  26. Pancreatitis - Predictive Mortality • Ranson criteria • Risk Factors • APACHE II score > 8 • Organ failure ( higher in infected necrosis) • Substantial necrosis ( > 30%)

  27. Pancreatitis Management Severity Mod/Severe (SICU) Mild/Mod (Floor) Routine Management Necrosis? No NPO, IVF +/- NGT H2 Blockers ?TPN vs Jejunal ?etiology Yes No antibiotics Antibiotics Observation noninfected FNA Unstable infected Operation

  28. Pancreatitis Case #1 • Follow up • Slow improvement in respiratory function • 12 days after last laparotomy, UOP returned • Extubated 24 hours later • Discharged to floor 2 weeks after last operation with enteral feeding established • Still required SQ insulin for BS control

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