ICU Case Presentation: Hypotension and Pyrexia

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ICU Case PresentationHypotension and Pyrexia

• Bradley J. Phillips, MD
• Burn-Trauma-ICU
• Adults Pediatrics

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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 ??

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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

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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
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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

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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 ??

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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

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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

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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

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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

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Pancreatitis Case 1

• Lines changed and cultures obtained
• CXR revealed ARDS
• Cultures
• sputum leukocytes, no bacteria
• urine no bacteria
• blood - E coli
• ?? plan

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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??

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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

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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

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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

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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

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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

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Pancreatitis

• 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

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Pancreatitis

• Signs/Symptoms
• Epigastric pain
• N/V
• Anorexia
• Ileus
• Sepsis
• Jaundice
• Cullens sign
• Grey Turners sign

• Tests
• ABG
• CBC/Plts/PT/PTT
• Lytes/BUN/Cr
• Ca/Mg/Phos
• LFTs, Triglycerides
• Amylase (S60-90,Sp 70)
• Lipase (S/Sp 90-99)
• CXR/AXR
• U/S
• CT

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Pancreatitis

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

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Pancreatitis - Current Issues

• Antibiotic coverage
• Role of fine needle aspiration
• Role of octreotide
• Predictive criteria of mortality

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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

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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

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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
• consensus improved survival with infected
  pancreatic necrosis

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Pancreatitis - Role of Octreotide

• SQ vs IV dosing
• SQ dose 100-200ug tid
• Trials
• Numerous both retro and prospective
• No benefit

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Pancreatitis - Predictive Mortality

• Ranson criteria
• Risk Factors
• APACHE II score gt 8
• Organ failure ( higher in infected necrosis)
• Substantial necrosis ( gt 30)

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