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Case Study I1 SJ Author: TLL
Kementerian Kesihatan Malaysia
Pusat Perubatan Universiti Malaya
2006
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KKM PPUM 2006
Known hypertensive X 10 years
Atenolol 50mg OD
Nifedipine 10mg BD
Female 52y Malay, BWt 90 kg13 April
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KKM PPUM 2006
Female 52y Malay, BWt 90 kg (2)13 April
Went to OPD for feeling unwell.
BP 220/180 mmHg, PR 80/min
Sent to A&E for high BP.16:55, in A&E
BP 130/61 mmHg, PR 111/min.
No available info whether anti-HPT was given in OPD Remainder of clinical examination unremarkable.
Diagnosis: Poorly controlled hypertension.
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KKM PPUM 2006
Female 52y Malay, BWt 90 kg (3)
13 April, 18:10, Day 3 Admitted to medical ward, clerked by HO
Fever
Headache Abdominal pain
Myalgia 3 days
Arthralgia Sorethroat
Nausea and loss of appetite
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KKM PPUM 2006
Female 52y Malay, BWt 90 kg (4)Past medical history Open cholecystectomy 5 y previously
1 previous admission for uncontrolledhypertension.
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KKM PPUM 2006
Female 52y Malay, BWt 90 kg (5)Clinical examination on admission
Alert, conscious
Mildly dehydrated
BP 117/95 mmHg PR 104/min
T 37oC
Lungs clear Abdomen soft
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KKM PPUM 2006
Uncontrolled hypertension
Upper respiratory tract infection
Female 52y Malay, BWt 90 kg (6)
Diagnosis
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KKM PPUM 2006
1. Comment on the diagnosis
BP no longer high.
In fact, SBP has dropped from 220 to 117 mmHg
and at the same time HR has increased from 80to 104/min.
In addition to URTI symptoms, patient also hasGIT symptoms and her haemodynamic status
can not be explained solely by the diagnosis of URTI.
Female 52y Malay, BWt 90 kg (7)
Discussion
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KKM PPUM 2006
Reviewed by Medical MO
c/o epigastric pain
Noted patient in shock
Cold and clammy peripheries
BP 90/70 mmHg, PR 100/min
Radial pulse barely palpable
Tachypnoeic, RR not recorded Abdominal distension, epigastric tenderness,
ascites
Female 52y Malay, BWt 90 kg (8)
13 April, 19:35
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KKM PPUM 2006
Intra-abdominal sepsis (to rule out perforatedgastric ulcer).
Investigations:
Blood C&S
ABG
Chest (erect) and abdominal X-Ray
ECG
Female 52y Malay, BWt 90 kg (9)
Diagnosis
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KKM PPUM 2006
Female 52y Malay, BWt 90 kg (10) Discussion2. What is the physiologic status?
Patient is in decompensated shock Her SBP has dropped from 220 to 90 mmHg!
3. Analyse the diagnosis of perforated gastric ulcer
with intrabdominal sepsis in relation to the clinicalprogress. The haemodynamic instability preceded the onset of
abdominal pain. Fever preceded the onset of abdominal pain.
At the time of haemodynamic instability, the patient isactually afebrile.
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KKM PPUM 2006
Female 52y Malay, BWt 90 kg (11) Treatment
IVI Gelofusine 500mL rapid bolus
IV NS 500mL rapid bolus then 500mL/1 hfollowed by
IV NS 7 pints/24 h
IV Ceftriaxone 2g stat then 1g q 24 h
IV Metronidazole 500mg stat then q 8 h
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KKM PPUM 2006
Female 52y Malay, BWt 90 kg (12) BP, HR, RR monitoring by nurse
13/4 Time BP HR RR IVI given
18:30 117/95 104 25 Maintenance 2.5 L/day
19:30 90/70 100 20 Maintenance 2.5 L/day
Gelafundin 500 mL fast+ NS 500 mL fast+ NS 500 mL / 1 h
20:40 133/96 93 20 Maintenance 3.5L/day
22:30
108/90 109 24 Maintenance 3.5L/day23:40 129/99 108 24 Total fluids so far =
Colloids 500mL +
Crystalloids 1,500mL
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KKM PPUM 2006
Female 52y Malay, BWt 90 kg (13)
13 April, 22
:45
, 3h post-resuscitation
Reviewed by HO and informed to MO
BP 108/90 (auto) mmHg, 104/94 (manual)
HR 104/min SpO2 97%
Management
BP, PR ½ hourly Insert central venous catheter
Trace investigations
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KKM PPUM 2006
Female 52y Malay, BWt 90 kg (14) 14 April, 00:15
Review of investigations sent @16:30
Hb 17.9
Hct 55 Plt 20,000
WBC 5,200
Neutrophil 74% Lymphocytes 22%
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KKM PPUM 2006
Female 52y Malay, BWt 90 kg (15) Discussion4. What is the diagnosis?
DSS – decompensated
Hct of 55%, thrombocytopenia, relative
leucopenia are in keeping with DHF withsignificant plasma leakage that has led to DSS.
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KKM PPUM 2006
Female 52y Malay, BWt 90 kg (16)Investigations
@16:30
Urea 15.7 mmol/L
Na 130 mmol/L
K 4.7 mmol/L
Cl 98 mmol/L
Creat 188 mol/L
ABG:
ABG @19:30
(on nasal prongs O2 3L/min)
pH 7.209
pCO2 2.54kPa pO2 21.25kPa
HCO3 7.4 mmol/L
BE –18mmol/L
SaO2 98.7%
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KKM PPUM 2006
Female 52y Malay, BWt 90 kg (17)Other investigations
Total Protein 63 g/L
Albumin 35 g/L
Total bilirubin 54 mol/L ALP 213 U/L
ALT 1,707 U/L
AST (not sent)
Serum amylase 206 U/L
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KKM PPUM 2006
Female 52y Malay, BWt 90 kg (18)Discussion5. Comment on the lab results.
Patient has developed multi-organ impairment
Renal impairment (caution: can not exclude pre-existing
renal impairment secondary to HPT) Liver dysfunction
Metabolic acidosis
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KKM PPUM 2006
Female 52y Malay, BWt 90 kg (19)Diagnosis
Dengue shock syndrome
Referred for intensive care management
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KKM PPUM 2006
Female 52y Malay, BWt 90 kg (20)14 April 00:40
Seen by intensive care MO in general ward RR
Respiratory rate >30/min with use of accessorymuscles,
Speaking in short sentences,
Lethargic, sweating, cold and clammyperipheries,
BP 80/60mmHg, PR 140/min
On IVI dopamine 20g/kg/min.
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KKM PPUM 2006
Female 52y Malay, BWt 90 kg (21)
14 April 00:40
Seen by Intensive Care medical officer
Lungs – reduced air entry bibasally
Abdomen distended but soft Epigastric tenderness
PV bleed but not excessive
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KKM PPUM 2006
Female 52y Malay, BWt 90 kg (22)
14 April 00:40 Discussion6. Comment on the physiologic state
Patient is still in shock.
7. Comment on the use of inotropic support. Fluid resuscitation is still not adequate, only ~20ml/kg has
been given (based on estimated ideal BW of 70 kg) so far, More fluid should be given instead of inotropes at this
juncture, If after 60 ml/kg of fluid resuscitation and patient remains
hypotensive, inotropic support can be considered whilegetting blood for transfusion.
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KKM PPUM 2006
Female 52y Malay, BWt 90 kg (23)
14 April 00:40 Discussion8. What parameters should be looked at to
assess the adequacy of fluid resuscitation
BP, PR, Pulse pressure/volume
Urine output, urine SG
HCT
ABG (particularly the lactate & base excess)
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KKM PPUM 2006
Impression : Dengue Shock Syndrome withbilateral pleural effusion, ascites, hepatitisand renal impairment
Patient admitted to ICU
Patient accompanied to ICU with Venturi mask O2 40%
IVI Dopamine 20g/kg/min
Female 52y Malay, BWt 90 kg (24)
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KKM PPUM 2006
Female 52y Malay, BWt 90 kg (25)14 April, 01:13, Admission to ICU
GCS 15/15
BP 80/46 mmHg, HR 151/min
RR 32/min, SpO2 100% 2 peripheral venous access
Attempted to insert femoral CVL x3, bothsides unsuccessful
IVI Gelofusine 500ml stat
Started IVI noradrenaline 5 g/min
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KKM PPUM 2006
Female 52y Malay, BWt 90 kg (26)Discussion
9. Comment on femoral CVL cannulation There are 2 venous access available, can be use for fluid
resuscitation,
CVL insertion is not indicated at this juncture, Repeated attempts of CVL cannulation increase risks of
infection and bleeding.
10. Comment on the sequence of steps ofresuscitation.
Fluid resuscitation should be the priority rather than tryingto get femoral CVL access.
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KKM PPUM 2006
Female 52y Malay, BWt 90 kg (27)14 April, 01:40
Intubated for impending respiratory arrest
IV fentanyl 50 g
IV midazolam 2mg
Ventilator settings :FiO21.0,
SIMV + PS
RR 20/min, PEEP 10 cm H2O,IP 15 cm H2O, PS 14 cm H2O
Achieved TV 450-560ml.s
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KKM PPUM 2006
Female 52y Malay, BWt 90 kg (28)Discussion
11. Comment on the choice of induction agents
Fentanyl is preferred in adults if available as it ismore cardiostable; if fentanyl is not available
morphine, carefully titrated, is acceptable. Ketamine is preferred in children with
hypotension, it can be used for adults as well.
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KKM PPUM 2006
Female 52y Malay, BWt 90 kg (29)14 April, 02:00
Further fluid resuscitation 1.5L Gelofusine
Dopamine 20 cg/kg/min and noradrenaline20g/min.
BP 83/44 mmHg, PR 144/min.
Urinary catheterisation 600ml urine
No urine from admission to ward.
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KKM PPUM 2006
Female 52y Malay, BWt 90 kg (30)14 April, 02:35
Attended by ICU specialist on call.
Central venous catheterisation via leftexternal jugular vein.
Inotropes infused via CVL.
CVP not documented.
Urine output 20ml/hr.
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KKM PPUM 2006
Female 52y Malay, BWt 90 kg (31)Discussion
12. Why is the patient’s haemodynamic stillunstable?
Inadequate fluid resuscitation
High possibility of bleeding13. What should be done? Look for sites of bleeding especially the femoral
puncture site
Transfuse blood ASAP
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KKM PPUM 2006
Female 52y Malay, BWt 90 kg (32)14 April, 03:00
Noted massive haematoma both groins
Ordered blood products : platelets, freshfrozen plasma, cryoprecipitate.
Skin mottled.
Another 250mL IV Gelofusine given.
Started IV dobutamine 5 g/kg/min.
BP 97/91 mmHg, PR 141/min.
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KKM PPUM 2006
Female 52y Malay, BWt 90 kg (33)Central venous blood gas
Time 02:45 03:30 pH 7.044 7.064
pCO2 mmHg 34.4 23.4
pO2 mmHg 34.7 37.6
BE mmol/L 19.5 -21.9HCO3 mmol/L 8.9 7.5
SaO2 % 43.1 49.8
Na mmol/L 133 137
Cl mmol/L 114 115K mmol/L 5.4 5.1
Hb g/dL 10.9 5
Lactate mmol/L 16 18
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KKM PPUM 2006
Female 52y Malay, BWt 90 kg (34)Discussion
14. Comment on the serial central venous bloodgas, Hb and lactate.
Worsening metabolic acidosis due to prolonged
shock. Rapid drop in Hb indicating massive bleeding as
a result of prolonged shock and contributed byfemoral punctures.
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KKM PPUM 2006
Female 52y Malay, BWt 90 kg (35)14 April, 04:00
BP 43/26 mmHg, PR 141/min
IV Gelofusine another 250 ml
Started IVI adrenaline 10g/min
Transfused FFP 2 units,
Cryoprecipitate 6 units,
Platelets 4 units
Pupils 8mm sluggish bilaterally
Transfused packed cells
Urine output 20ml/hr
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KKM PPUM 2006
Female 52y Malay, BWt 90 kg (36)14 April, 05:00
Persistent hypotension on
IVI dopamine 20 g/kg/min
IVI noradrenaline 20 g/min
IVI adrenaline 10 g/min
IVI dobutamine 5 g/kg/min
Started IVI NaHCO3 20ml/hr
Patient died at 07:00
. Cause of death : Dengue Shock Syndrome.
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KKM PPUM 2006
Female 52y Malay, BWt 90 kg (37)Learning Points
DSS can present with acute abdomen.
BP should be interpreted carefully in patients
with pre-existing HPT (“normal” BP for apatient with HPT may indicate shock).
Prolonged shock will lead to significantbleeding.
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KKM PPUM 2006
Female 52y Malay, BWt 90 kg (38)Learning Points
Fluid resuscitation should be initiated withany available peripheral vascular access
Central venous access should be reserved forthose without peripheral access
Inotropes should not be the priority measurein restoring the haemodynamic status in DSSbefore adequate fluid resuscitation has beenattempted