Download 2010-11-15 Elevated Temperature

Synthesis & Integration
Unknown Case
Infection & Immunity
Elevated Temperature
November 15th, 2010
Amanda Kocoloski, OMS IV
Patient Profile
 Orvill R. Baker is a 58-year-old
white male who exhibits a sudden
elevation of body temperature
during surgery
2
Subjective
 CC/HxCC: Mr. Baker was undergoing radical
prostatectomy under general anesthesia for
prostate cancer. He suddenly began to spike a
fever, and developed muscle rigidity on the OR
table just after initial abdominal incision was
made. A sterile dressing was applied to his
incision and he was brought to the recovery
room. Chart review discloses that his prostate
cancer was diagnosed by his primary care
physician who noted a firm irregular nodule on
his prostate during a routine physical exam.
When biopsy confirmed the diagnosis, he was
scheduled for surgery.
3
Definitions
 Fever
 Regulated rise to a new “set point” of body
temperature
 Hyperthermia
 Body metabolic heat production or
environmental heat load exceeds normal heat
loss capacity or when there is impaired heat
loss
 Why do we differentiate?
 Hyperthermia can be rapidly fatal and characteristically
does not respond to antipyretics
Temperature Regulation
PO/AH
5
Differentials?








Severe infection
Thermoregulatory dysfunction
Malignant hyperthermia
Neuroleptic malignant syndrome
Serotonin syndrome
Thyrotoxicosis
Prolonged seizures
Illegal drugs
 Amphetamines, cocaine, PCP, LSD
6
Subjective
 Past Medical History: Prostate hypertrophy and
doubling of PSA in one year to 8.0.
 Injuries: Denies any past injuries.
 Immunizations: No immunizations beyond
childhood.
 Medications: Presently takes no medication on a
regular basis, including no OTC drugs.
 Allergies: Denies any significant drug or
environmental allergies.
 Surgical History: Has had no prior surgery.
 Hospitalizations: Never been hospitalized.
7
Health Influencing Behaviors
 Diet: The patient eats a “balanced diet”
but follows no special dietary restrictions.
 Exercise: Follows no particular exercise
plan.
 Sleep patterns: Sleeps approximately six
hours nightly.
 Caffeine use: Denies.
 Alcohol use: Denies.
 Nicotine use: Denies.
 Other substances: Denies.
8
Subjective
 Family Medical History: 3 siblings and
2 sons, all alive and well. Mother died
unexpectedly during routine
hysterectomy 30 years ago. Father
living, age 82, with metastatic cancer
of prostate.
 Sexual History:No sexual activity for
past 5 years due to erectile dysfunction.
9
Social History
 Family: Very supportive 58 year-old
spouse whose only medical problem is
DM Type II; 2 grown sons, healthy
and living away from home.
 Faith or spiritual beliefs: Attends a
community church regularly.
 Hobbies: Likes to travel and work
around the house.
 Occupation: Took early retirement
from high school teaching last year.
10
Review of Systems
System(s)
Findings
HEENT
No headaches, blurry vision, difficulty swallowing
Face
Symmetrical, no unusual facies
CV
No chest pain or palpitations
Lungs
No shortness of breath or cough
GI
No diarrhea, constipation or abdominal pain
GU
Complains of hesitancy, frequency, and difficulty
starting stream
MSK
No joint or muscle pain
Neuro
No difficulties with movement, numbness or
paresthesias
Endo
No easy bruising, heat or cold intolerance
11
Objective
 Vital Signs:
 T: 40.5 ˚C (105˚F)
 P: 150 bpm
 R: 14 resp/min (mechanical ventilation)
 BP:100/60 mmHg
 General Appearance: Unconscious under
general halothane anesthesia and succinylcholine
muscle relaxation; mechanical ventilation via
volume-cycled ventilator
12
Where Was the Temperature
Taken?
Modified from Iaizzo PA, Kehler CH, Zink RS, et al: Thermal response in
acute porcine malignant hyperthermia. Anesth Analg 82:803-809, 1996.)
13
Objective: Physical Exam
 Head, Eyes, Ears, Nose: Normocephalic; PERRL;
EACs patent, TMs clear; nasal mucosa pink.
 Throat: Mucosa dry; no pharyngeal inflammation or
exudates. Remainder of exam hindered by presence
of orotracheal tube.
 Face: Symmetrical; no maxillary or frontal sinus
tenderness.
 Neck: Rigid and spastic; no palpable masses; no
lymphadenopathy; thyroid is not palpable; trachea is
midline and movable; no JVD; no carotid bruits.
 Heart: Rapid, bounding rhythm; apical impulse
palpated in left intercostal spaces four and five,
lateral to midclavicular line; + S1 and S2; no S3 or
S4; no murmurs, gallops or rubs.
14
Objective: Physical Exam
 Lungs: (The patient is intubated and being
ventilated with a volume-cycled
respirator) clear to auscultation and
percussion; full breath sounds bilaterally.
 Breast: No masses, discharge or
tenderness noted.
 Abdomen: Slightly distended, firm; no
masses or organomegaly; no fluid wave;
no hepatojugular reflux; no inguinal
lymphadenopathy; bowel sounds present
in four quadrants; no bruits auscultated.
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Objective: Physical Exam
 Rectal: Deferred
 Structural: Deferred
 Extremities: Generalized muscular rigidity
and spasm; no cyanosis or clubbing; no
edema or varicosities.
 Skin: Hot, dry.
 Genital: Circumcised male; no scrotal
masses or penile discharge.
 Neurological: Generalized muscular
rigidity and spasm; unresponsive to any
stimuli (patient under general anesthesia);
mechanical ventilation.
16
Diagnostic Studies?
17
Diagnostics- Urinalysis
Results
Normal
color
brown
amber-yellow
myoglobin
positive
negative
18
Diagnostics- Electrolytes
Result
Normal
Sodium
140 mEq/L
135-147 mEq/L
Potassium
5.8 mEq/L
3.5-5.0 mEq/L
Chloride
100 mEq/L
95-105 mEq/L
Bicarbonate
18 mEq/L
24-40 mEq/L
BUN
26 mg/dL
8-25 mg/dL
Creatine kinase
(CK, CPK)
5400 IU/mL
0-160 IU/mL
Creatinine
2.4 mg/dL
0.6-1.2 mg/dL
Phosphate
6.0 mg/dL
2.5-5 mg/dL
Uric Acid
8 mg/dL
2-7 mg/dL
Diagnostics- Electrolytes
Result
Normal
Sodium
140 mEq/L
135-147 mEq/L
Potassium
5.8 mEq/L
3.5-5.0 mEq/L
Chloride
100 mEq/L
95-105 mEq/L
Bicarbonate
18 mEq/L
24-40 mEq/L
BUN
26 mg/dL
8-25 mg/dL
Creatine kinase
(CK, CPK)
5400 IU/mL
0-160 IU/mL
Creatinine
2.4 mg/dL
0.6-1.2 mg/dL
Phosphate
6.0 mg/dL
2.5-5 mg/dL
Uric Acid
8 mg/dL
2-7 mg/dL
Diagnostics- Arterial
Blood Gases (ABGs)
Results
Normal
PaO2
86 mmHg
(80-100mmHg)
PaCO2
40 mmHg
(35-45mmHg)
pH
7.22
(7.38-7.44)
HCO3
16
(21-30 mEq/L)
21
Diagnostics- Arterial
Blood Gases (ABGs)
Results
Normal
PaO2
86 mmHg
(80-100mmHg)
PaCO2
40 mmHg
(35-45mmHg)
pH
7.22
(7.38-7.44)
HCO3
16
(21-30 mEq/L)
Rhabdomyolysis
 Muscle necrosis results in systemic
manifestations
 Related to muscle injury or excessive muscle
contraction
 A syndrome of multiple etiologies
 Features include:




Myoglobinuria
Renal insufficiency
Markedly elevated creatine kinase (CK) levels
Frequently, multiorgan failure as a consequence
of other complications of the trauma
 Hyperkalemia in 10-40% of cases, due to release
of K+ from injured skeletal muscle
23
Cause of Elevated
Temperature?
24
Assessment
 Primary Diagnosis: Malignant hyperthermia
 Secondary Diagnoses:
 Rhabdomyolysis
 Myoglobinuria
 Hyperkalemia
 Tachycardia
 Possible acute renal failure
 Modifiable Risk Factors (MRF): None
 Non- Modifiable Risk Factors (NMRF): None
25
Malignant hyperthermia
 Genetic mutation of
ryanodine receptor type
1; autosomal
 Disorder causes
increased intracellular
calcium; prevents Ca2+
reuptake after
contraction and
prevents relaxation
 Usually asymptomatic
until anesthesia
26
Signs and Symptoms
 Rigidity after
induction of
anesthesia
 Sinus tachycardia or
arrhythmias
 Decrease in 02
saturation
 Increase in PCO2
with ventilation
 Increase in
temperature above
38.8 ˚C (101.8 ˚F)
 Elevated temperature
can be a late finding
 Extreme acidosis
 Damage of skeletal
muscle
 Rhabdomyolysis
 Myoglobinuria
 Hyperkalemia
 Acute renal
failure
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CLINICAL FEATURES
NEUROLEPTIC
MALIGNANT SYNDROME
SEROTONIN
SYNDROME
MALIGNANT
HYPERTHERMIA
Triggering agent
Neuroleptic
Proserotonergic agent
Succinylcholine or inhaled
anesthetic
Onset
Slow (hours to days)
Fast (minutes to hours)
Very fast to fast (minutes to hours)
Duration
Long (days to weeks)
Short (1–2 days)
Short (1–3 days)
Agitation
Sometimes
Yes
No
Confusion
Yes
Sometimes
Unusual
Hyperactivity
No
Yes
No
Bradykinesia/stupor
Yes
No
Unusual
Myoclonus
No
Yes
No
Shivering
No
Yes/sometimes
No
Tremor
Sometimes
Yes
No
Pupils
Mid-sized
Large
Not specific
Rigidity
Severe
Sometimes
Severe
Rigidity type
Extrapyramidal (leadpipe)
Pyramidal (clasp-knife)
Generalized
Hyperpyrexia
Yes
Yes
Severe
Tachypnea
Yes
Yes
Yes
Tachycardia
Yes
Yes
Yes (severe)
Leukocytosis
Yes
Uncommon
Not typical
Elevated creatine
phosphokinase
Severe
Mild
Severe
28
Plan
 Treatment:
 Stop surgery and anesthesia ASAP
 Dantrolene
 Inhibits the release of calcium from the
sarcoplasmic reticulum, reducing actin-myosin
contractile activity
 Manage metabolic acidosis
 Initiate core and surface cooling
Avoid all future anesthesia using
halothane and muscle relaxants
29
Plan
 Diagnostic follow-up:
Monitor for myoglobinuria
Monitor for renal failure (kidney
function studies)
Monitor for cardiac dysrhythmias
 Patient Education:
 Avoid all future anesthesia using
halothane and muscle relaxants
Cooling Measures




Alcohol sponges
Cold sponges
Ice bags
Ice-water enemas
(burr)
 Ice baths
http://emedicine.medscape.com/article/149546treatment
31
Quiz!
32
The elevated temperature in this
patient is most likely caused by
25%
25%
25%
25%
1. increased hypothalamic
set point
2. endogenous pyrogens
3. excessive heat
production
4. fever
1
2
3
4
What is the likely cause of the abnormal
urinalysis and serum potassium in this
patient?
25%
1
25%
25%
2
3
25%
4
1. Acidosis
2. Excessive muscle
contraction and loss
of sarcolemma
integrity
3. Acute renal failure
4. Severely elevated
temperature
The muscle rigidity in this patient
is caused by
25%
1
25%
25%
2
3
25%
4
1. excessive motor unit
activation
2. excessive release of
calcium from the
sarcoplasmic reticulum
3. halothane induction of
calcium influx into
muscle cells
4. hyperkalemia
25%
What is the most likely reason why homeostatic
mechanisms were unable to defend the thermal
challenge presented in the malignant hyperthermia
case?
25%
25%
25%
1.
2.
3.
4.
1
2
3
4
Body heat storage occurred too
rapidly
General anesthetics impaired the
normal shivering response
General anesthetics impaired
normal behavioral
thermoregulatory responses
Surgery-induced dehydration
changed the gain in the feedback
control system
The elevated temperature in this patient can
be effectively controlled by
25%
1
25%
25%
2
3
25%
4
1. dantrolene sodium
(inhibits Ca2+ release)
2. high-dose aspirin
(inhibits PGE synthesis)
3. normalizing serum
potassium
4. succinylcholine
(neuromuscular blocking
agent)