ICU Case Presentation:Hypotension and Pyrexia

Bradley J. Phillips, MDBurn-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

D/C POD1 Returned POD3 with abdominal pain, nausea,

fever (38.7C) Diff dx ??

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

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

9.615.2 127

133

5.2 13

120

4.0184

0.5

6.5

ABG 7.28 / 28 / 54 / 12 INR 1.4 PTT 44

Tbil 2.6 AST 98 Alk Phos 428 Amylase 2416 Albumin 3.0

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

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 ??

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

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

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

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

Pancreatitis Case #1

Lines changed and cultures obtained CXR revealed ARDS Cultures

• sputum leukocytes, no bacteria• urine no bacteria• blood - E coli

?? plan

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??

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

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

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

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

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

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

Pancreatitis

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

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

Pancreatitis - Current Issues

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

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

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

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

Pancreatitis - Role of Octreotide

SQ vs IV dosing• SQ dose 100-200ug tid

Trials• Numerous both retro and prospective• No benefit

Pancreatitis - Predictive Mortality

Ranson criteria Risk Factors

• APACHE II score > 8• Organ failure ( higher in infected necrosis)

• Substantial necrosis ( > 30%)

Pancreatitis Management

Mild/Mod (Floor) Mod/Severe (SICU)

Severity

Observation

No antibiotics Antibiotics

Necrosis?YesNo

Routine Management

NPO, IVF +/- NGT H2 Blockers ?TPN vs Jejunal ?etiology

FNA

Operation

infectedUnstable

noninfected

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