Case Studies in Critical Care: Evidence-Based Diagnosis and Treatment

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Case Studies in Critical Care Evidence-Based
Diagnosis and Treatment

• Linda DeStefano, MSN, NP, CCNS, CCRN, FCCM
• Saddleback Memorial Medical Center, Laguna Hills,
  CA
• Assistant Clinical Professor
• UCLA CNS/NP Program

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Severe Acute Pancreatitis Evidence-Based
Diagnosis and Treatment

• Clostridium difficile Colitis An
  Emerging Disaster!

3
Severe Acute Pancreatitis Evidence-Based
Diagnosis and Treatment
4
Severe Acute Pancreatitis
SAP A Sticky Situation
5

• Faculty Disclosures

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Barney, Inc.
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Case Study
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Case Study

• Mr. H
• 62 year old male
• Admitted 11-2-08
• Dx N/V, abdominal pain, malaise

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History

• NIDDM
• Obesity
• ETOH use (moderate)
• HTN
• Appy
• Hypercholesterolemia
• Smoker in remote past
• Allergic PCN

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Home Meds

• HCTZ
• Amaryl
• Glucophage
• Zocor
• Quinapril
• Atenolol
• Avandiamet
• MVI, fish oil

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Physical Exam

• Alert, oriented
• Weak
• Vital Signs
• Temp 99.5 (100.4 ER)
• B/P 98/53, HR 75
• RR 20, SpO2 94 room air
• Abdomen soft, tender
• Lungs clear
• Other systems not remarkable

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Differential Diagnosis

• Pancreatitis
• Acute cholecystitis
• Common bile duct obstruction
• Perforated duodenal ulcer (acute
  abdomen)
• Acute intestinal obstruction

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Differential Diagnosis

• Leaking AAA
• Renal colic
• Acute mesenteric vascular insufficiency or
  thrombus
• Gastroenteritis
• Inferior wall myocardial infarction

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Not an Exact Science!
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Lab Results
Test Result Day 1 Day 2 Day 3
WBC 18.1 22.8 24.5
HGB BUN/ Cr 10.4 45/2.2 9.3 92/4.9 9.1 95/5.1
K 4.0 4.7 4.9
Blood glucose 491 186 236
Calcium 7.6 7.9 7.4
Amylase 63 57
Lipase 397 476 871
AST 235
ALT 123
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Other Diagnostic Findings

• CXR mild cardiomegaly
• Abdominal CT diffuse pancreatits and biliary
  stones

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SAP Etiology
Drugs
Pregnancy
Obstructive
Vascular
Infectious
Toxic
Metabolic
Hereditary
Traumatic
Image adapted from http//telmeds.org/Capsulamedi
ca/images
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SAP Etiology
Drugs
Pregnancy
Obstructive
Vascular
Infectious
Toxic
Metabolic
Hereditary
Traumatic
Image adapted from http//telmeds.org/Capsulamedi
ca/images
19
SAP Etiology
Drugs
Pregnancy
Obstructive
Vascular
Infectious
Toxic
Metabolic
Hereditary
Traumatic
Image adapted from http//telmeds.org/Capsulamedi
ca/images
20
SAP Etiology
Drugs
Pregnancy
Obstructive
Vascular
Infectious
Toxic
Metabolic
Hereditary
Traumatic
Image adapted from http//telmeds.org/Capsulamedi
ca/images
21
SAP Etiology
Drugs
Pregnancy
Obstructive
Vascular
Infectious
Toxic
Metabolic
Hereditary
Traumatic
Image adapted from http//telmeds.org/Capsulamedi
ca/images
22
SAP Etiology
Drugs
Pregnancy
Obstructive
Vascular
Infectious
Toxic
Metabolic
Hereditary
Traumatic
Image adapted from http//telmeds.org/Capsulamedi
ca/images
23
SAP Etiology
Drugs
Pregnancy
Obstructive
Vascular
Infectious
Toxic
Metabolic
Hereditary
Traumatic
Image adapted from http//telmeds.org/Capsulamedi
ca/images
24
SAP Etiology
Drugs
Pregnancy
Obstructive
Vascular
Infectious
Toxic
Metabolic
Hereditary
Traumatic
Image adapted from http//telmeds.org/Capsulamedi
ca/images
25
SAP Etiology
Drugs
Pregnancy
Obstructive
Vascular
Infectious
Toxic
Metabolic
Hereditary
Traumatic
Image adapted from http//telmeds.org/Capsulamedi
ca/images
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Etiology ObstructiveCholelithiasis /
Choledocholithiasis
2.
3.
1.
B
A
Gall stones vary from pure cholesterol (white),
through mixed, to bile salt that are
predominantly (black)
A. Cholelithiasis B. Choledocholithiasis
Excised gallbladder full of stones
Images from

1. http//www.emedicine.com/med/images/1226gs1.
jpg 2. http//www.studentbmj.com/issue
s/01/03/education/56.php 3.
http//www.aiclancaster.com
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Etiology Alcohol
Images from http//www.hopkins-gi.org/images/shar
ed/disease/database/shared_850_AP-08.jpg
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Classification

• Edematous
• Biliary or Gallstone
• Inflammatory
• Necrotic
• Infectious
• Hemorrhagic

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SAP Hemorrhagic Signs

• Cullens Grey
  Turners
• (Periumbilical)
  (Flank)

2
1
Images from

1.
http//bms.brown.edu/pedisurg/images/ImageBank/Tra
uma/Cullen.jpg 2. http//www.edu.rcsed
.ac.uk/photoalbum/ph95.htm
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SAP Prognostication/Severity Assessment Tools

• Ransons criteria
• APACHE II score
  (Acute Physiology and
  Chronic Health Evaluation)
• Imrie score (Glasgow criteria)
• Balthazar score (CT severity index)
• SAPS (Simplified Acute Physiology Score)

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Ransons Criteria
Tool from the medical algorithms project
http//www.medal.org
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Gallstone Pancreatitis

• Ranson score on admission 3
• Age gt 55
• WBC gt 16,000/ul
• BSgt 200mg/dl
• Ranson score at 48º was 6
• Hct fall gt 10
• BUN increase gt 5mg/dl
• Serum Calcium lt 8mg/dl
• Ranson score gt5 is associated with 40 mortality
  and significant systemic complications

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Problem List / Plan

• Dx pancreatitis with stones
• GI consult for possible ERCP
• Severe leukocytosis and bandemia
• Possible cholangitis (start abx)
• ARF likely pre-renal (start IVF)
• DM OOC (control BS)
• Anemia (secondary to renal?) (obtain iron
  studies)

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Problem List / Plan

• Admit to medical-surgical unit

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SAP Patient Placement
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What is the Evidence for Management?

• 2004 International Consensus Conference
  definition of severe acute pancreatitis
  associated with organ dysfunction with management
  direction

Washington, DC
Nathens, A.B. et al. 2004. Management of the
critically ill patient with severe acute
pancreatitis. Critical Care Medicine,
32(12)2524-2536.
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The Story Continues...

• Dialysis catheter inserted 11-3
• Anuric???
• Renal ultrasound negative
• Dialysis performed 11-4
• ERCP ordered 11-7
• Unable, could not lie flat
• Too weak to get OOB

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Other Events..

• R/O clostridum difficile???
• Temp dialysis cath removed, cx tip
• Consent for permanent cath (hemosplit)
• 11-8 PICC line inserted
• 11-8 UGI deep gastric ulcers
• 11-9 CXR R/O pneumothorax

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Visit by CNS

• Pt still on Med/Surg unit 11-10
• Asked by dietitian to evaluate for NJT placement
  (TPN ordered)
• Pt being placed on NIPPV, RR 30, labored
  breathing
• Transferred to ICU 11-10-08...

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ICU Day 2

• HIDA scan- negative for obstruction
• Doppler R groin r/o pseudoaneurysm negative
• CXR- left pleural effusion
• No DVT prophylaxis
• Lying in bed for almost a week
• 11-11-08

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SAP Systemic ComplicationsPancreatitis-associate
d Acute Lung Injury
Acute lung injury (ALI) PaO2/FIO2 ratio lt
300 Acute respiratory distress syndrome
(ARDS) PaO2/FIO2 ratio lt 200
mild left pleural effusion day 2
Cooper, et al., (1999). Critical Care Med
27(12) Angus, et al. (2001). Am J Respir Crit
Care Med 163(6) Neff, et al. (2003). Chest
123(3) Images from Pastor, C. M. et al. (2003).
Chest1242341-235
bilateral pulmonary infiltrates day 5
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ICU Day 3

• Still SOB
• Orthopneic
• On NIPPV at night
• Not doing well
• NJT placed
• 11-12-08

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Nutritional Support in Severe Acute Pancreatitis
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Severe Acute Pancreatitis

• Should I feed the patient with SAP?
• A) NPO
• B) TPN/PPN
• C) Enteral via NGT
• D) Enteral via NJT
• E) Any of the above?

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Sometimes you just have to hang it and see what
happens!
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Severe Acute Pancreatitis

• Should I feed the patient with SAP?
• A) NPO
• B) TPN/PPN
• C) Enteral via NGT
• D) Enteral via NJT
• E) Any of the above?

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Enteral vs Parenteral Nutrition

• Recommendation
• According to 1 level 1 and 12 level 2 studies,
  when considering nutrition support for critically
  ill patients, we strongly recommend the use of EN
  over PN.

EN is the Winner!
TPN
www.criticalcarenutrition.com
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Best PracticesManagement and Safety Issues
Related to Enteral Feeding
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Safety
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Tube Malposition Insertion

• Pleural
• Radiograph at 30-40 cm
• Final radiograph confirmation
• Air bolus not reliable
• AACN practice alert 2005
• Intracranial
• Metheny et al (2002) Am J Nursing, 102(8) 25-27

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Complications of Placement

• Intracranial case reports
• Genu- Paloma et al J-Oral-Maxillofac-Surg 2004
  621435
• Metheny Am J Nursing, 2002 102 25-7
• Castiglione et al Am J forensic med path 1998
  19 329-334

• Associated with
• head facial trauma
• transsphenoidal surgery

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NJ Tube Placement
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Pylorus
Duodenal-jejunal flexure (ligament of Treitz)
Image adapted from http//en.wikipedia.org/wiki/S
mall_intestine
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Blind Direct Placement

• Weighted small bore with stylet
• Entriflex (Kendall Inc.) and others
• Non-weighted small bore with stylet
• Corflo (Viasys Medsystems) and others
• Several techniques
• insert into stomach
• bend stylet 3cm from end
• corkscrew technique
• insufflate stomach with 300-500ml air

Zaloga Chest 1991 Salasadis, CritCareMed
1998 Powers, Crit Care Nurse 2003
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Past Ligament of Treitz
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ICU Day 4

• SOB still not resolved
• On NIPPV at night
• LE doppler r/o DVT ordered positive
• IVC filter placed
• CT A/P ordered probable distal obstructing
  stone, increased pancreatic enlargement
• 11-13-08

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CAT Scan
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Reading CT scans
1. Portal vein 2. Colon 3. Stomach 4.
Pancreas 5. Splenic vein 6. Spleen 7. Left
Adrenal Gland 8. Left Kidney 9. Aorta 10.
Inferior Vena Cava 11. Right Kidney 12. Right
Adrenal Gland 13. Liver
Image from http//anatomy.med.umich.edu/radiology
/abdomen/splenic_vein.html
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Reading CT scans
Right kidney
Left kidney
Left kidney
Images adapted from http//www.pankreaszentrum.de
/en/akute.html
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Reading CT scans
Zone of necrosis
Left kidney
Images adapted from http//www.pankreaszentrum.de
/en/akute.html
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Gallstone Pancreatitis
Pleural effusions Peripancreatic
fluid Abdominal ascites
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CBD Stone, 5.7mm
c
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Major Duodenal Papilla
Image from http//www.scmh.org.tw/images/pic10.jp
g
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ICU Day 5

• CT abd/pelvis with contrast
• Heme consult
• Anemia with thrombocytosis
• Platelet count 750K, remained ?until Nov 11
• Nov 11 525k
• Nov 12 184k
• Nov 13 43k
• Nov 14 21k1 unit SD plt
• HIT??? Alteplase to dialysis ports
• 11-14-08

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ICU Day 6

• MRCP ordered but still not able to be performed
  (orthopnea)
• Echo
• LVH, right heart dilated
• EF 55
• Chest pain
• Cardiac workup negative
• Transfused with platelets
• 11-15-08

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ICU Day 7

• CT abdomen and pelvis ordered
• CNS requested chest be included r/o PE
• CTA positive for PE extensive L side thrombus
• Argatroban infusion ordered
• 11-16-08

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c
? Emboli
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ICU Day 10

• Patient stable in ICU
• Transferred to Telemetry
• Several attempts to have MRCP but unable due to
  various circumstances
• To rehab for 6 weeks
• Home for holidays
• 11-19-08 to 12-23-08

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Questions?
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• Clostridium difficile Colitis An
  Emerging Disaster!

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Introduction

• First isolated in 1935 neonates
• Gram rod
• Spore-forming
• bacillus difficilis named due to difficulty!
• Iatrogenic and/or nosocomial
• 1.1 billion US healthcare costs USA (2002)

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Bacteria slides
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Incidence

• Statistics On the rise!
• 1990s 30-40 cases /100,000 population
• 2001 50 cases /100,000
• 2005 84 cases /100,000
• 15-20 abx-related diarrhea
• 3 million cases annually

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Mortality

• Mortality rate 1-2.5 (2005)
• In England
• 1999 primary cause death 499 pts
• 2005 primary cause death 1998 pts
• 2006 primary cause death 3393 pts

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Clinical Presentation

• N/V/D (bloody?)
• Hypotension
• Dehydration
• Fever
• Leukocytosis
• Acute renal failure
• Colitis

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Diagnosis

• C-diff assay
• 2-4 hours to result
• Sensitivity 63-99
• Specificity 93-100
• Positive assay without sx should NOT prompt
  treatment
• Cultures

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Diagnosis

• Flex sigmoidoscopy immediate diagnosis

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Treatment

• Discontinue culprit antibiotics
• Metronidazole vs vancomycin
• Similar outcomes with mild infection
• Vanco first line for severe infection
• Less treatment failure
• Faster resolution of symptoms
• Metronidazole has benefits
• Lower cost
• Less risk resistance/VRE
• Enteral regimens may not be absorbed with
  associated toxic megacolon or ileus

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Case Study
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An Unusual Case.

• 49 year old female
• s/p uncomplicated TAH 2 days ago
• To ER with N/V/D, rule out sepsis
• Temp 101.1 (F)
• B/P 92/48
• WBC 22,500 / bands 18
• Abdominal distension
• 2 liters normal saline administered

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Admitted to Telemetry

• B/P dropping 3 hours later
• Increasing abdominal pain
• Fever persists
• Lactate checked 6.4
• More FLUIDS!
• Transferred to ICU

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ICU Day 1

• GI consult ordered
• C-diff assay ordered
• Renal function worsening
• IV and PO metronidazole ordered
• Norepinephrine started for B/P

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ICU Day 5

• Fevers persist
• Foul, watery diarrhea
• Hgb 7.9, dropping transfused
• INR 1.7 2 units FFP
• ID consult
• IV and rectal vanco (enema) ordered

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ICU Day 8

• Fevers persist
• Foul, watery diarrhea persists
• Vasopressors restarted
• KUB shows dilated bowel
• Sigmiodoscopy ordered

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ICU Day 9

• Second vasopressor added after norepi up to 12
  mcg/min max dose
• Sigmiodoscopy shows extensive pseudomembranes in
  colon

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ICU Day 9

• GI ordered donor stool enemas BID

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ICU Day 9

• What???????

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Horrified.
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Literature Review
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Successful Treatment of Fulminant Clostridium
difficile Infecton with Fecal Bacteriotherapy

• You, D. Franzos, A. (2008). Successful treatment
  of fulminant clostridium colitis with fecal
  bacteriotherapy. Annals of Internal Medicine 148
  (8) 632-633

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Details

• Stool transplant
• Described in various case series/reports
• For fulminant, life threatening infection
• Refractory to other medical therapy
• Surgical interventions risky

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Methods?
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Step 1

• Son donates stool
• Diluted 300ml NS

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Step 2
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Step 3

• Transport

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Step 4

• Administration/transplantation
• -Retention enema
• -NG tube option

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How Could This Work?
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Prevention

• Decrease use of antobiotics
• Decontamination
• Handwashing
• Barrier precautions
• PPIs can contribute

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• TeamworkRequired!

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The END!
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Questions?
nurselindaicu_at_msn.com ldestefano_at_menorialcare.org
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Laguna Beach, California
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Thank You!
nurselindaicu_at_msn.com ldestefano_at_menorialcare.org