Presentation on theme: "Facilitators: Dato Dr. Sree Raman Dr. Lim Chew Har Dr. Ho Bee Kiau"— Presentation transcript:
1 Facilitators: Dato Dr. Sree Raman Dr. Lim Chew Har Dr. Ho Bee Kiau Case Management 2Facilitators:Dato Dr. Sree RamanDr. Lim Chew HarDr. Ho Bee Kiau
2 26/6/08 Klinik Kesihatan FEMALE 60 year old C/O: Fever for 3 daysDizzy and lethargyJoint pain and myalgiaNausea but no vomitingPMH: DM and HPT. Not on treatmentO/E:T=38 CBP=120/70
3 Cont.. Fever ? Cause Treatment: Paracetamol Cefaclor 375mg bd Q1: What is your comment on the casemanagement?
4 Answer Q1:Page 16A Stepwise approach on outpatient management of dengue infection is importantStep 1: Overall assessment1. History2. Physical examination3. InvestigationsStep 2 : Diagnosis, disease staging and severity assessmentStep 3 : Plan of management
5 27/6/08 (Day 4 of fever) Klinik Kesihatan Patient came back to KK the next day, still c/o fever with diarrhea, vomiting and epigastric pain, feeling lethargy.Seen by MA, O/E T=38.5 C, BP 110/65, PR 100/min, hydration fair, PA: soft, mild epigastric tenderness.Diagnosis: AGE with gastritis TRO DFFBC: Hb 10.3, Platelet count 120 (HCT 41.5%)TCA cm to repeat FBCQ2: a) What are the warning signs?b) Would you have admitted this patient?
6 Answer Q2(a): WARNING SIGNS Warning signs Abdominal pain or tenderness Page 17WARNING SIGNSAbdominal pain or tenderness• Persistent vomiting• Clinical fluid accumulation (pleural effusion, ascites)• Mucosal bleed• Restlessness or lethargy• Liver enlargement > 2 cm• Laboratory : Increase in HCT concurrent with rapiddecrease in platelet
7 Answer Q2(b): CRITERIA FOR HOSPITAL REFERRAL / ADMISSION Page 18The decision for referral and admission should depend onthe Total Assessment:1. Symptoms :• Warning signs• Bleeding manifestations• Inability to tolerate oral fluids• Reduced urine output• Seizure2. Signs :• Dehydration• Shock• Bleeding• Any organ failure
8 3. Special Situations :• Patients with co-morbidity e.g. diabetes, hypertension,ischaemic heart disease, coagulopathies, morbid obesity,renal failure, chronic liver disease, COPD, haemoglobinopathy• Elderly (<65 years old)• Pregnancy• Social factors that limit follow-up e.g. living far from healthfacility, no transport, patient living alone4. Laboratory Criteria:Rising HCT accompanied by reducing platelet count
9 28/6/08 (Day 5,10:00 am- Saturday)Ambulance call. Brought to KK at 12:05pmSeen by MAH/o:Fever 5 days, still has diarrhea and vomitingHeadache and joint painEpigastric pain for 2 dayDark sticky stool 2/7O/E:BP unrecordable. Alert consciousPulse: fast and small volume
10 Treatment: IVD- Hartman’s 3pint via 2 IV lines DIAGNOSIS : UPPER GIT BLEED WITH SHOCK SECONDARY TO DHF OR PEPTIC ULCERIx: RBS=21.4mmol/LTreatment: IVD- Hartman’s 3pint via 2 IV linesWrote a referral letterReferred to hospital and accompanied byJMQ3. What could have been done by thehealth provider at KK?
11 Answer Q3: The BP, Pulse monitoring must be continued while in Page 18The BP, Pulse monitoring must be continued while inthe ambulance and patient must be accompanied by MO/MA
12 At 12:35pm, the patient was transferred to Hospital A (as requested by the family because one of their family member worked at Hospital A and she was on follow up for DM there)Arrived at Hospital A at 12:55pmJM went to the casualty and showed referral letter to the counter staff at casualty. Case was not accepted because no bed availableCase was sent to General Hospital
13 (Day 5,1.30PM – 2 hours defervescence): A+E General Hospital(Day 5,1.30PM – 2 hours defervescence):C/O:- Fever x 5/7. Settled today- Diarrhoea (5x/day) & black tarry stool for 2 days- Vomiting with epigastric pain- Giddiness, lethargic, myalgia- No hematemesisNeighbour admitted for dengue, still in wardPMH: Diabetes Mellitus and HypertensionDH: Metaprolol 50mg bd and ramiprilGlicazide 80mg bd and simvastatin 20mgTook NSAIDS for shoulder pain & myalgia
14 Q4. What is your diagnosis? Examination:Wt 55kgPink, alert and consciousBP:90/68mmHg PR:65/min T:37’CSPO2:98-100% Cold peripheries. No rashCapillary refill time > 2secCVS: S1S2 ESM at left sternal edgeLungs : clearAbdomen: soft, mild epigastric tendernessPR: malenaGlucometer :14.9mmol/lQ4. What is your diagnosis?
15 Answer Q4: Dengue Shock syndrome ( Grade 3) with upper GI bleed. Underlying uncontrolled DM
16 Q5. Comment on the management Diagnosis :1) Hypotension secondary to AGE2) Uncontrolled DM3) UGIT bleedManagement:- Admit general ward- Given 1pint Hartman fastInvestigations:FBC, BUSE , RBS, Stool C&SQ5. Comment on the management
17 Answers Q5Plan for fluid therapy should be documentedThis patient should be admitted to HDW or ICU for close monitoring and management
18 Day 5 (1630) ( 4 hours defervescence ) BP:94/73mmHg PR:101/minT:37’C SPO2 97%G/M:17.9mmol/lCVS: DRNMLungs :clearAbdomen: soft,non tenderPR: yellowish stool,no malenaTwbc:4.6 x109Hb:15.4g/dl HCT:46.5Plt:4 x109Urea 13mmol/l Na 125 K 4.1INR APTT 59ECG: Normal
19 Diagnosis:1) Fever with severe thrombocytopeniaDengue haemorrhagic fever Grade III (CriticalPhase)2) DM uncontrolledMx:- Start iv dopamine 150mg in 50cc run 5cc/h- SC Actrapid 10 u tds- IV fluid 6 pint N/S over 24 h- to transfuse 4 u platelet- monitor I/O
20 Q6.Explain why Hb and HCT in this patientwas not as low as expected.Comment on the use of dopamine at this stage.
21 Answers Q6Hb and HCT were relatively high (inappropriate) considering patient had GIT bleed.Her high HCT was due to hemoconcentration as a result of plasma leakage during this critical phase.It was expected that Hb and HCT would drop once IV fluid therapy being given and hemoconcentration improved.The use of inotropic/vasopressor support at this stage( when the patient is still hypovolaemic) may further worsen the tissue hypoxia, due to vasoconstriction effect of the dopamine.
22 Q7: Do you agree with the fluid therapy and platelet transfusion?
23 Answers Q7The IV fluid regime was inadequate. IV fluid therapy should be initiated with resuscitation regime as patient was in shock.Resuscitation rate : 10-20ml/kg fast with crystalloid for the first 2 cycles then colloid if hemodynamically not improved.Meanwhile packed cell should be made available as patient was bleeding. Other blood products such as platelet and FFP may be given
26 Answers Q8 Fluid resuscitation was inadequate as evidenced by persistently raised HCT and severe metabolic acidosis.The patient had ongoing plasma leakage with pleuraleffusion and further fluid resuscitation would most likelylead to worsening of respiratory function so intubation wasindicated.The patient should have been referred to intensive care unitfor consideration of ICU admission.
27 Early recognition and treatment of shock is essential Management of DSS is a medical emergency andrequires prompt and adequate fluid replacementEarly and effective replacement of plasma lossesresults in a favorable outcome, so consider early referralto ICUSevere metabolic acidosis is a sign of prolonged shockand tissue hypoxiaIn general, respiratory support should be considered earlyin a patient’s course of illness and should not be delayeduntil the need arises.
28 Treatment: IV lasix 40mg stat IV cocktail stat & 50ml NaHCO3 Reduce IV drip to 4pints/24 hours Insulin infusion 3u/hr CVP attempted x 2 but failed
29 Q9 : Would you have attempted central line insertion ?
30 Volume resuscitation does not require a central venous Answer Q9Volume resuscitation does not require a central venouscatherisation (CVC) if sufficient peripheral intravenousaccess can be obtained.When CVC is indicated it should be inserted by askilled operator, preferably under ultrasound guidanceif available.Subclavian vein cannulation should be avoided as faras possible.
31 Day 6 (0810am) ( 20 hours defervescence) On dopamine 4cc/h. Tailing down doseExamination:Alert GCS 15/15 RR 22/min,pink,no jaundiceBP:178/83mmHg PR:110/min T:37’CLungs: crepitation at the basesAbdomen: tenderness at the epigastriumBleeding at venepunctureUrine output –anuric since 12 midnightIx:ABG:PH: HCO3: PO2:98BUSE:17.7/134/.6.9/106
33 Diagnosis:1) Dengue shock syndrome with sepsis2) Acute renal failure secondary to (1)3) Persistent hyperkalaemia-cocktail x 24) Thrombocytopenia6) Uncontrolled DM
34 Mx:- Add Fortum 1g od- Iv Azithromycin 500 mg od- IV fluid 1pint/24 hours- Increase insulin to 4 u /h -1H g/m (aim 6-8mmol/l)- iv sodium bicarbonate 50cc over ½ h- iv cocktail stat kiv hyperkalaemia –for dialysis- iv ranitidine 50mg tds- Put on HFMO2 10L/min
35 1030am ( 22 hours defervescence) : BP dropping to 98/28mmHgMx:Started on iv noradrenalin 8 mg in 50cc D5% run at 2cc/h12 noon ( 24 hours defeversence)Reviewed ABG:PH : HCO3:7.5CBD: urine 10cc onlyPatient :acidotic breathingCase noted to specialist:- to transfused platelet 4 u than proceed with peritoneal dialysis- refer anaest
36 Patient then desaturated o/e:- Tachypnoeic,gasping- Emergency intubation- BP recordable after started on tripple inotropic agent:81/53mmHgpulse rate:154/min-weakcold peripheries- Pupil dilated and non reactive
37 Pt asystole thenCPR done-3 ampoules of atropine and adrenalin given but not reverted.Confirmed death:2.30pm ( 26 hours defervescence)Cause of death:septicaemic shock
38 Result / date28/629/6PT/ APTTINR:2.48Ratio:3.84ABGpH:7.31HCO3:11.7PO2:99.9PCO2:23.7pH:7.29HCO3:9.7PO2:48.6PCO2:20.5pH:7.196HCO3:7.5
39 BFMP:negativeTyphoid test :negativeLeptospira serology:non reactiveCreat:288Indirect bilirubin:23Direct:13ALT:4190AST:6439ALP:551LDH:4464Plasma lactate:10.4mmol/lBlood C+S:no growthMeiloidosis serology :pendingDengue serology: IgM detectedStool occult blood:negativeCK:1143CXR(discuss with radiologist)right pleural effusion with fluid in the oblique fissure,may represent chest infection