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Shockingly Painful A Case Presentation Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong December 22, 2010 Medicine Clerkship Rotation The Medical City General Data CFG 58 years old Female Filipino Roman Catholic From Pasig City Informants: Patient and sister (good reliability) Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Chief Complaint: Abdominal pain Morning PTA Persistent Abdominal pain Post-prandial Epigastric 30 minute duration Crampy, 6/10 pain scale No relief with Itopride (Ganaton) No aggravating factors Radiates to the back Intermittent No associated: Fever, Nausea, Vomiting, Bowel movement changes Afternoon PTA Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Chief Complaint: Abdominal pain Morning PTA Abdominal pain Persistent Afternoon PTA Abdominal pain Increased intensity Epigastric 30 minute duration Crampy, 6/10 pain scale No relief with Itopride (Ganaton) No aggravating factors Radiates to the back Intermittent Associated chills and undocumented fever Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Chief Complaint: Abdominal pain ER Consult Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Pertinent Review of Systems • (+) Generalized weakness No weight gain or weight loss. Easy fatiguability • •No headache, seizures, blurring of vision, ear problems •No dyspnea, cough, colds •No palpitations, chest pain •No nausea, vomiting •No dysuria, frequency Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Past Medical History Hypertension Stage II 20 years On Losartan + Hydrochlorothiazide Asthma No recent consults Unrecalled last exacerbation No maintenance medications Erythromycin allergy (rashes) Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Past Medical History s/p Laparoscopic cholecystectomy with subsequent development of stricture, s/p biliary stent placement (2005) s/p Biliary stent replacement (2007) Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Family History • • Hypertension Asthma Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Personal-Social History • Divorced • Smoker (20 pack years) • Occasional alcoholic drinks • Usual diet: meat, fatty food, soda • Occupation: Businesswoman/student Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Physical Examination Vital Signs General HEENT Chest Abdominal Extremities Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Physical Examination Ht: 152 cm, Weight 68 kg, BMI: 29.4 (overweight) BP: 150 / 70 Temp: 39.5oC Vital Signs General HEENT Chest HR: 88 RR: 21 Abdominal Extremities Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Physical Examination Conscious Coherent Vital Signs General HEENT Alert Not in respiratory distress Chest Abdominal Extremities Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Physical Examination Icteric sclerae Pink palpebral conjunctiva Vital Signs General HEENT Neck veins not distended No CLAD Chest Abdominal Extremities Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Physical Examination Symmetric chest expansion No retractions Vital Signs General HEENT Clear breath sounds Adynamic precordium Chest Abdominal Extremities Normal S1 and S2 Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Physical Examination Protuberant 5 bowel sounds per minute (normoactive) Tympanitic No masses Epigastric and right upper quadrant tenderness Vital Signs General HEENT Chest Abdominal Extremities Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Physical Examination Full and equal pulses Vital Signs General Normal skin color Good skin turgor HEENT Chest Abdominal Extremities Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Salient Features 58 year old female Acute abdominal pain (epigastric) Accompanied by chills and fever History of cholecystectomy with biliary stent placement and replacement (2005 and 2007) Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Admitting Impression Acid Peptic Disease r/o failed biliary stent r/o viral hepatitis r/o beginning pancreatitis Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Differential Diagnoses Cholecystitis and biliary Liver abscess colic Acute appendicitis Diverticular disease ✓ Perforated peptic ulcer ✓ Hepatitis ✓Ascending cholangitis ✓ Pancreatitis Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong ✓ Hepatitis Salient Features +/- Hepatitis + Mortality: < 5 y/o and > 50 y/o Abdominal pain and tenderness (epigastric) radiating to the back + Epigastric or RUQ pain with radiation to back Accompanied by chills and fever + Accompanied by fever Acute onset + Acute onset Icetric sclerae and not jaundiced - Jaundice 58 year old, female Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong ✓ Pancreatitis Salient Features +/- Pancreatitis + African-American; 35-64 y/o Abdominal pain and tenderness (epigastric) radiating to the back + Epigastric or RUQ pain with radiation to back Accompanied by chills and fever + Accompanied by fever History of cholecystectomy with biliary stent insertion and replacement (2005 and 2007) - History of recent surgery or invasive procedure Acute onset + Acute onset Icetric sclerae and not jaundiced - Jaundice 58 year old, female Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong ✓ Peptic Ulcer Disease Salient Features +/- Peptic Ulcer Disease 58 year old, female + Tends to occur later in life Abdominal pain and tenderness (epigastric) radiating to the back + Epigastric pain Accompanied by chills and fever +/- Not usually associated with chills and fever History of cholecystectomy with biliary stent insertion and replacement (2005 and 2007) - Not significant +/- Recurrent unless perforation occus Acute onset Icetric sclerae and not jaundiced Usually normal PE findings Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong ✓ Ascending cholangitis Salient Features +/- Ascending cholangitis 58 year old, female + No age or sex prediliction Abdominal pain and tenderness (epigastric) radiating to the back + Presents as abdominal pain Accompanied by chills and fever + Patient was febrile + Associated with biliary tract manipulation + +/- Acute onset History of cholecystectomy with biliary stent insertion and replacement (2005 and 2007) Acute onset Icetric sclerae and not jaundiced Presents with jaunice Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Diagnostic Plan Laboratory test Rationale Baseline values; determine presence of CBC with differential count infection , anemia, etc. Electrolyte panel with renal Assess metabolic state and kidney function function Liver function test Determine possible liver pathology (e.g. hepatitis) Prothrombin time/ activated Coagulapthies (e.g. DIC, cirrhosis) partial thromboplastin time Lipase Usually elevated in pancreatitis Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Diagnostic Plan Laboratory test Rationale Urinalysis Baseline values; determine presence of infection , glucose, protein, etc. Culture and sensitivity for blood, bile, stent Determine foci of infection and resistance profiles Chest x-ray Baseline study Ultrasound Visualization of the biliary tree Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Objective Subjective Hospital Day 1: Floors to ICU AM: Stable at the floors Decreased responsiveness Restlessness Febrile BP: 160/90→90/60 HR: 100s RR: 40s O2 saturation: 97%→88% + Alar flaring, + Ronchi and rales Occasional wheezing Distended abdomen; soft, non-tender Normal rate, regular rhythm Distinct S1 No edema Full and equal pulses Flushed skin Signs of jaundice Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Definition of terms Septicemia • Presence of microbes or their toxins in blood Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Definition of terms SIRS • Systemic Inflammatory Response Syndrome •2 or more of the following: >38oC < 36oC > 24 breaths /min > 90 beats /min > 12000/L < 4000/L WBC Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Definition of terms Sepsis • 2 or more of SIRS components with a proven or suspected microbial etiology >38oC > 90 beats /min < 36oC > 12000/L < 4000/L WBC > 24 breaths /min Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Definition of terms Septic shock • SIRS + hypotension >38oC BP: < 90 systolic < 40 mmHg less than > 90 beats /min < 36oC > 24 breaths /min patient’s normal > 12000/L < 4000/L WBC Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Definition of terms Ascending Colangitis • Charcot’s Triad: • Right upper quadrant pain, Fever, Jaundice >38oC Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Acute Cholangitis Biliary obstruction Host antibacterial defenses bacteria bacteria Immune dysfunction bacteria bacteria bacteria bacteria bacteria bacteria bacteria bacteria bacteria bacteria bacteria bacteria bacteria bacteria Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, 33 Ong Acute Cholangitis Hepatic Ducts Biliary Tree bacteria Duodenum Portal venous bacteria blood Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, 34 Ong Septic Shock Monocytes Peptidoglycan LPS Bacteria Host binding protein fimbriae DNA CD 14 Lipoteichoic acid macrophages Neutrophils Cytokines leukotriens TLR chemokines prostanoids Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, 35 Ong Septic Shock Inc. Blood flow IL-6 Enhance vessel permeability Recruit neutrophils monocytes Endothelial cells Elicit pain Coagulation! Cytokines leukotriens chemokines prostanoids Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, 36 Ong Septic Shock • Control Mechanisms •Prevent inflammation within organs distant from infection site Work of anti-inflammatory molecules • Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Septic Shock • Organ dysfunction and shock • Prevalence of anti-inflammatory • • molecules Blood leukocytes often HYPOresponsive to agonists such as LPS - Increases risk of mortality Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Septic Shock • Vascular injury Leukokcyte-derived mediators Vascular injury Platelet-leukocytefibrin thrombi • Endothelial injury TNFa Vascular endothelial cells Procoagulant Nitric oxide PAF cytokines molecules SHOCK!!! Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, 39 Ong Objective Subjective Hospital Day 1: Floors to ICU AM: Stable at the floors Decreased responsiveness Restlessness Febrile BP: 160/90→90/60 HR: 100s RR: 40s O2 saturation: 97%→88% + Alar flaring, + Ronchi, rales Occasional wheezing Distended abdomen; soft, non-tender Normal rate, regular rhythm Distinct S1 No edema Full and equal pulses Flushed skin Signs of jaundice Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Assessment • Severe septic shock secondary to ascending cholangitis • secondary to biliary duct stricture s/p stent replacement (2007) Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Plan • Intubation • Transfer to ICU • Stat ERCP • Antibiotics (Pip-Tazo) → Linezolid and imipinem Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong ERCP • Endoscopic Retrograde Cholangiopancreatography • Diagnosis and treatment of benign malignant pancreaticobiliary diseases Indications Benefits • • • • Gallstones trapped in main bile duct • Diagnostic and therapeutic Blockage of bile duct technique (e.g. gallstones, Jaundice blockage) Undiagnosed persistent, recurrent upper • Shorter hospital stay abdominal pain • Unexplained loss of appetite and weight loss • Cancer of the bile ducts or pancreas • Pancreatitis Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong ERCP • Duodenoscope • Fiber-optic duodenoscope • Videoscope “ERCP”. Jackson Siegelbaum. Gastroenterology. (http://gicare.com/Endoscopy-Center/ERCP.aspx) Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Antibiotics Linezolid and Imipenem Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Diagnostics CBC Urinalysis ABG Liver Function Tests Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Diagnostics CBC Hemoglobin = 132 g/dl Hematocrit = 0.37 Platelets = 224 WBC = 14.5 Neutrophils = 0.93 Lymphocyte - 0.06 Monocyte = 0.01 ABG pH = 7.352 pCO2 = 26.4 pO2 = 63.1 HCO3 = 15.7 BE = -7.1 O2 sat. = 91.73 Urinalysis Color: Dark Yellow Sp. gravity: 1.015 + Erythrocytes, urobilinogen, bilirubin Liver Function Tests Hepatitis tests: non-reactive SGOT: 542.7 U/L ↑ SGPT: 636.8 U/L ↑ Alk. Phos: 137.1 U/L ↑ Total Bilirubin: 6.17 mg/dL ↑ Direct Bilirubin: 4.02 mg/dL ↑ Indirect Bilirubin: 2.15 mg/dL ↑ Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong ABG Interpretation ABG pH = 7.352 pCO2 = 26.4 pO2 = 63.1 HCO3 = 15.7 BE = -7.1 O2 sat. = 91.73 Acceptable ranges: pH: 7.35-7.45 pCO2: 35-45 HCO3: 22-26 BE: +2 to -2 • pH: Acidotic • HCO : below normal, metabolic 3 acidosis • pCO : below normal, respiratory 2 alkalosis Metabolic acidosis with concomitant respiratory alkalosis Oxygenation: adequate Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Diagnostics CBC Hemoglobin = 132 g/dl Hematocrit = 0.37 Platelets = 224 WBC = 14.5 Neutrophils = 0.93 Lymphocyte - 0.06 Monocyte = 0.01 ABG pH = 7.352 pCO2 = 26.4 pO2 = 63.1 HCO3 = 15.7 BE = -7.1 O2 sat. = 91.73 Urinalysis Color: Dark Yellow Sp. gravity: 1.015 + Erythrocytes, urobilinogen, bilirubin Liver Function Tests Hepatitis tests: non-reactive SGOT: 542.7 U/L ↑ SGPT: 636.8 U/L ↑ Alk. Phos: 137.1 U/L ↑ Total Bilirubin: 6.17 mg/dL ↑ Direct Bilirubin: 4.02 mg/dL ↑ Indirect Bilirubin: 2.15 mg/dL ↑ Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Liver Function Interpretation Liver Function Tests Hepatitis tests: non-reactive SGOT: 542.7 U/L ↑ SGPT: 636.8 U/L ↑ Alk. Phos: 137.1 U/L ↑ Total Bilirubin: 6.17 mg/dL ↑ Direct Bilirubin: 4.02 mg/dL ↑ Indirect Bilirubin: 2.15 mg/dL ↑ • Inflammation or damage to hepatocytes • Usually due to biliary obstruction in the occurrence of abdominal pain • Elevated alkaline phosphatase cholestasis Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Diagnostics ECG Chest X-ray Cardiac Enzymes Cultures Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Diagnostics ECG Normal sinus rhythm Leftward axis Left atrial enlargement Non-specific ST-T wave changes No significant changes from 11/27/2010 Chest X-ray Subsegmental atelectasis, right Cardiomegaly Atheromatous aorta Thoracic spondylosis and dextroscoliosis Cardiac Enzymes Troponin T = 0.57 ng/ml CK Total = 306.3 U/L ↑ CK MB = 23.44 U/L CK MM = 282.9 U/L ↑ Cultures Stent and blood Bile Stent Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Diagnostics Serum Electrolytes Other tests Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Diagnostics Serum Electrolytes Sodium = 139 meq/L Potassium= 3.3 meq/L Others Amylase = 126 U/L ↑ Lipase = 96.56 U/L ↑ Lactate = 50.52 mg/dL ↑ Creatinine = 0.64 mg/dL ↑ NGAL = 225.2 ng/mL ↑ Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Enzymes: Amylase, Lipase • Slightly elevated amylase and lipase levels • Not definitive for pancreatitis (requiring three-fold increase) Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Neutrophil Gelatinase-associated Lipocalin (NGAL) • Biomarker for acute ischemic renal injury • Expressed by neutrophils and other epithelia (e.g. renal proximal tubules) • Measured in urine or serum Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Physical Examination Hospital Day 1 • • CNS: GCS 11, sedation with Midazolam CVS: •BP: 75/40 to 150/70, tachycardic hypotensive episodes •On dopamine and/or norepinephrine drip •(+) Trop T, elevated CK enzymes, anterior wall ischemia on → ECG •Given Enoxaparin (Clexane), 0.6 ml every 12 hours Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Drugs Enoxaparin • Anticoagulant • Binds to anti-thrombin III and accelerates activity, inhibiting thrombin and Factor Xa (low molecular weight heparin) Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Physical Examination Hospital Day 1 • Respiratory: •Oxygen saturation = 98% •+ Ronchi bilaterally •+ Rales on the right base • IDS •Febrile •On Linezolid and Imipenem • Unremarkable GI, GU and Endocrine findings Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Acute Respiratory Failure • Syndrome of failure in one or both gas exchange functions (oxygenation and/or carbon dioxide elimination) • PaO2 < 60mmHg (type 1) or PaCO2 > 50mmHg (type 2) Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Assessment • Acute respiratory failure secondary to septic shock secondary to ascending cholangitis s/p ERCP • Hypertension Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Plan • Close monitoring • Maintain hemodynamic stability • Administration of Linezolid and Imipenem • Mechanical ventilation Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Laboratory Objective Hospital Day 3: ICU Cultures: CNS: GCS 11 (E4VtM6) with episodes of agitation on Midazolam 5 ml/hr Hemoglobin = 83 g/dL Hematocrit = 0.25 Platelets = 119 WBC = 15.4 Bands = 0.02 Neutrophils = 0.85 Lymphoctes = 0.08 Monocytes = 0.04 Eosinophil = 0.01 Hypochromic Stent and blood: Klebsiella pneumoniae Bile: Heavy growth of Escherichia coli Stent: Proteus mirabilis *All organisms sensitive to Ceftriaxone and ampicillin •Serum Creatinine = 1.68 (↑ from 0.6) Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Antibiotics Ceftriaxone and Ampicillin • Culture guided antibiotics • Mechanism of action... • Coverage... • For Mimi Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Acute Kidney Injury • Broad spectrum of sublethal injury to tubular and other renal cells • Occurs in 1% to 25% of ICU patients • Cause ICU of mortality (Hoise et al.) RIFLE F 26.3% mortality RIFLE I 11.4% mortality RIFLE R 8.8% mortality Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Acute Kidney Injury – Rifle Criteria Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Anemia • Deficiency in red blood cells, hemoglobin, or in total volume • Gastrointestinal bleeds: manifest as melena, hematochezia, hematemesis • Most common etiologies: ulcers (3159%), varices (7-20%), Mallory-Weiss tears (4-8%) Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Assessment • Acute Respiratory Failure secondary to Septic shock secondary to ascending cholangitis s/p ERCP • Acute kidney injury • Anemia probably secondary to upper GI bleed Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Plan • • • • • • Close monitoring For blood transfusion Ulcer prophylaxis Potassium correction For step-down antibiotics - Ceftriaxone and ampicillin (culture guided) Possible mechanical ventilation weaning (extubation on hospital day 6) Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Hospital course • Day 4: creatinine at 0.67 • Day 5: extubated, well-tolerated • Day 6: transfer to the floors • Day 11: discharged Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Principles of Management Septic Shock • Close monitoring (vital signs, I/O) • Hemodynamic support with IV fluids and vasopressors • Identify underlying cause for sepsis Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Principles of Management Ascending Cholangitis • ABC assessment • IV fluid resuscitation with crystalloids (e.g. plain NSS) • Parenteral antibiotics • Biliary decompression (severe cases) • Extracorporeal shockwave lithotripsy (ESWL) for choleliths Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Acute Cholangitis Severe Mild Monitor with reassessment Improvement ICU ERCP No improvement Elective ERCP with definitive therapy of bile duct stones within 24-48 hrs Source: http://emedicine.medscape.com/article/774245-media Improvement Elective ERCP with definitive therapy (if not previously done) No improvement Percutaneous drainage Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Ascending Cholangitis Prognosis • • • Depends on the following: •Early recognition and treatment of cholangitis •Response to therapy •Underlying medical conditions of the patient Mortality rate: 5-10% (higher in patients who require emergency decompression or surgery) Good response to antibiotics = good prognosis Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Ascending Cholangitis Complications • • • Liver failure, hepatic abscess, microabscess Acute renal failure Bactermia, sepsis (gram-negative) Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Septic Shock Prognosis • • Depends on the following: •Severity of illness •Co-morbidities •Age Response to antibiotics Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Septic Shock Complications • • • • • Acute respiratory distress syndrome (ARDS) Renal dysfunction Disseminated intravascular coagulation (DIC) Mesenteric ischemia Myocardial ischemia and dysfunction Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Preventable gallstones? 2004 5 million Filipinos with gallstones 2010 5.4 Filipinos estimated to have gallstones Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Risk Factors Diet Medications Obesity Weight cycling Smoking Genetics Sedentary lifestyle Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Risk Factors More trans fat High glycemic index > 36 inches Increased risk Arch Intern Med. 2005 May 9;165(9):1011-5 Am J Clin Nutr. 2008 Mar;87(3):627-37 2x risk for cholecystectomy Gut. 2006 May; 55(5): 708-14 15/1000 smokers Sedentary lifestyle Increased risk Am J Epidemiol. 2009 Jan 15;169(2):153-60 Increased risk Ann Intern Med. 1998 Mar 15;128(6):417-25. Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong call-an-jee-tis Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Role of Practitioners Policy Stop trans fat use Surveillance of harmful dietary substances Education at the school level Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Healthcare Availability 12 days x Php 44,000 / day Php 488,000 Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong How many Filipinos can afford the same healthcare? ? that! Fewer50% 10% 30% 5% than Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Facts Earns: Spends: Savings: Php 206,000 Php 176,000 Php 30,000 Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Facts 16 years to pay Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Average income Number of families Average income per bracket Average expenditure per bracket P250,000 and above 3,264,000 471,000 361,000 P100,000 – P249,999 6,271,000 157,000 143,000 P60,000 – P99,999 4,122,000 79,000 77,000 P40,000 – P59,000 2,355,000 50,000 52,000 P40,000 and below 1,392,000 30,000 33,000 Total families: 17,403,000 (2006) http://www.census.gov.ph/data/sectordata/2006/fies0608r.htm http://www.census.gov.ph/data/sectordata/2006/fies0602r.htm Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong PhilHealth Case B Hospital discount: Php 33,600 Private Tertiary Hospital Php 488,000 to 454,400 Government/Public Tertiary hospital 1/3 of private costs: Php 162,000 The PhilHealth Member would pay only Php 128,400 Grandrounds: Shockingly Painful Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong Shockingly Painful A Case Presentation Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong December 22, 2010 Medicine Clerkship Rotation The Medical City