Presented by: Dr. Ayman Bukhari Under supervision of : Prof. Hassan Abdul-Jabbar Dr. Faisal...

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Transcript of Presented by: Dr. Ayman Bukhari Under supervision of : Prof. Hassan Abdul-Jabbar Dr. Faisal...

  • Slide 1
  • Presented by: Dr. Ayman Bukhari Under supervision of : Prof. Hassan Abdul-Jabbar Dr. Faisal Kashgari
  • Slide 2
  • MR NO. 664144 A 24 y.o single Chadian lady was brought to E.R on 28/01/2009 at 08:34 P.M with a complain of: P-V bleeding confusion for 3 days generalized fatigue
  • Slide 3
  • The first assessment : Case was first referred to ICU department as the patient was vitally unstable BP=62/41 P=99RR=24T= 35.8O2SAT=100%
  • Slide 4
  • ICU DOCTOR ASSESSMENT IN E.R Hx : moderate PV bleeding..3 days duration LMP: 16 week ago No clots, Dizziness for 1 day Palpitation No nausea,, vomited once
  • Slide 5
  • cont. ICU DOCTOR ASSESSMENT IN E.R O/E : BP = 50/40 P=100RR= 24-30 conscious, oriented S1+S2+0 RESP. : EAE, CLEAR ABDOMEN : distended but lax Suprapubic mass ?? bladder
  • Slide 6
  • cont. ICU DOCTOR ASSESSMENT IN E.R No neck regidity No L.L oedema.. No DVT signs At 09:00 PM : 1 L N.S I.V bolus At 10:45 PM : BP= 70/55 P=100 O2SAT= 100% Pregnancy test was sent>>>> Positive Impression : shock for D.D : hypovolemic, ?? septic
  • Slide 7
  • cont. ICU DOCTOR ASSESSMENT IN E.R Plan : keep MAP of 65 mmHg UOP >= 0.5 Ml/kg/hr Give IVF challenges & monitor Pt. Response & tolerance O.B.GYN consultation CXR, ABG, U&E, Coag. Profile, CBC, serum lactate level Recontact ICU after the results are shown
  • Slide 8
  • At 01:25 AM : Pt is not responding to IVF well ABG : severe metabolic acidosis PH= 7.1 HCO3= 3.8 PCO2=1.61 PO2=17.99 Hb= 7.1 WBC= 44 PLT= 32 Pt= 35.5 Ptt=117 INR- 3.4
  • Slide 9
  • BG: B Positive Na=133 K=3.5 Cl=96 BUN- 4.3 CRTN= 242 Ca= 2.04 L.A= 17.2
  • Slide 10
  • Plan: Dopamine infusion was started Trace rest of results,, Sickling test>>> Negative NAHCO3 50 Ml I.V D-D, Fibrinogen, Perepheral Bl. Film & hematology referral
  • Slide 11
  • At 5:30 AM : Gyne. On-Call review 22 YO single, medically ? Aneamia Amenorrhea 14-16 W LMP= Not sure P-V BL. Mild to moderate for 3 days Hx of fever, chills at home but not documented
  • Slide 12
  • Cont. Gyne. On-Call review Denied any Hx of pregnancy or attempting to abort nor instrumentation Gave Hx of vaginal infection & took supposatories?? Came to ER in shock, most likely Dx >> Septic shock
  • Slide 13
  • Cont. Gyne. On-Call review O/E : P/A: soft, distended, No tenderness, No Guarding Around 12 w GA uterus P/V: only inspection : minimal bleeding Impression: pt is in sepsis,,,, to R/O septic abortion Plan: urgent U/S
  • Slide 14
  • At 05:30 AM : U/S result: small RPOC ( hyperechoic structure ) 3.2 x 2.7 cm,, No gestational sac,, no fetal pole moderate ascites Repeated Labs : Hb= 6.6WBC= 38.7HCT= 22.2 PLT= 25 Pt= 23.5Ptt= 84.7 L.A = 13.1 Serology was sent >> negative
  • Slide 15
  • At 05:45 am : BP = 100/59P=125 so the plan was to wean the Dopamine pt is conscious, oriented, no PV bleeding D/W consultant On-Call: to repeat U/S, QBHCG & discuss with head of department about D&C
  • Slide 16
  • At 06:30 am : Pt is deteriorating with Dopamine BP= 70/55 Plan : consultant is on the way for D & C The pt is admitted to MICU Arrangement for ER D&C.. Anaesthesia.. Will not start untill FFP & blood is ready
  • Slide 17
  • At 07:40 am : FFP is ready + 2 U of PRBC in OR fridge Calling for the patient to be transferred to OR from MICU At 08:50 am : pt was transferred to O.R Procedure: evacuation of RPOC for case of septic abortion, septic shock Uterus= 14 W, hymen not intact
  • Slide 18
  • During O.R : Under U/S guidance: moderate amount of tissue attached to the uterine wall with offensive smell removed and sent to histopathology>> multiple fragments of tissue composed of blood clots and decidua,, final diagnosis : POC
  • Slide 19
  • During O.R : EBL= 1 L 6 U FFP 5 U PRBC 2 Packs in Vagina Pt was shifted back to ICU
  • Slide 20
  • At 11:45 am... Back to ICU Pt was received in MICU from OR as a case of : Septic shock DIC multiorgan dysfunction due to septic abortion( post evacuation & curettage)
  • Slide 21
  • Upon arrival to MICU Intubated & ventellated Sedated on propafol infusion BP= 121/82 P=132 On Norepenepherin 40 Mg/min
  • Slide 22
  • Upon arrival to MICU Chest was clear Sinus tachycardia Abdomen: mild distension 2 packs in vagina.. Still bleeding Plan: CBC, PT, PTT Q6hrs LFT, U&E, D-D, Fibrinogen, Peripheral Bl. Film & blood culrue
  • Slide 23
  • Cont. Upon arrival to MICU Hb = 9.6 WBC= 40 PLT= 28 PT= 20.5 PTT= 62.5 Fbrinogen= 193.8 D-D = no reagent INR= 1.8 L.A = 13.8
  • Slide 24
  • Cont. Upon arrival to MICU 6 U FFP,, 6 U Cryoprecipitate Keep 10 U FFP stand by 4U PRBC stand by Pt is on : Pip/Taz, Gentamycine, Ranitidine
  • Slide 25
  • On 30/01/2009 Pt is intubated in ICU,, FiO2 45% PEEP + 5 BP= 80/70 T= 38.5 Intake=200cc/h UOP= 200 cc/h
  • Slide 26
  • Hb= 8.3 WBC=35.6 PLT= 18 PT= 17.9 PTT = 51.6 L.A= 6.4INR= 1.7 Plan : cont. Ab remove vaginal pack>> minimal clots & beeding
  • Slide 27
  • On 31/01/2009 Pt is on assisted mechanical ventilation Minimal bleeding On Norepenipherine 14 mcg/h On Vasopressin 2.4 U/h UOP= 100cc/h,,, positive balance 2019 Ml BP= 115/80 Lax abdomen No incidence of CNS insult
  • Slide 28
  • Cont. IN MICU ON 31/01/09 Inv : PH = 7.3PCO2= 45.4PO2= 83.1HCO3=23.2 Hb= 6.9 WBC= 43.1 INR=1.3PTT= 50.8 PLT= 35 Na= 141K=3.1CL-105Mg= 0.9 BUN= 6.7 CRTN= 128Ca= 1.94 PO4=0.88 AST= 1078S. Lactate= 7.1
  • Slide 29
  • Plan : 1 U PRBCs I.D referral NGT feeding ECHO
  • Slide 30
  • On 01/02/09 MICU Day 3 Still sedated,, on Propofol 1 Mg/Kg/h Pt is on vasopressin, Norepenipherin stopped On NGT GCS : 8 /15 ECHO >> EF = 40 %, severe T.R & Pulm. HPN
  • Slide 31
  • Investigations Hb =7.8 WBC = 37 PLT= 35 PT= 13.4 PTT= 42.8 BUN= 7.8 CRTN= 108 INR= 1.3
  • Slide 32
  • On 02/02/09 MICU No much change.. Blood culture : + Candidiasis, Diphthroid species & Staph. Epideremedies Infection team : started Amphotericin B on top of Gentamycine & Pip/Taz
  • Slide 33
  • On 03/02/09 MICU Pt is still intubated..rate = 12 BPM, FiO2= 30% Bp= 95/56 T= 36.8 P=97 Hb= 8.4 WBC= 34.4 PLT= 44 INR=1 PT= 11.7 (N)PTT= 35.8 (N)
  • Slide 34
  • On 04/02/09 MICU EXTUBATED Agitated,, Psychiateric episodes Psychiatry consultation >> Lorazepam, Olanzapin Was clinically improving,, minimal PV bleeding No much change on the day after
  • Slide 35
  • On 06/02/09 11:00 pm MICU BP= 100/60 P= 112 T= 37.8 RR= 37 Hb = 9.1 WBC= 32.9 PLT= 73 PT=12.3PTT=40.9INR= 1 BUN=4.7CRTN= 74 D-D = 4084 L.A= 1.6 (N)
  • Slide 36
  • ?? Pelvic Thrombophlebitis Heparin prohylactically was already started at same day Switched to Heparin Infusion 1000 u / h Doppler U/S L.L C-T Pelvic Venography to R/O pelvic thrombophelibitis Ordered Spiral C-T
  • Slide 37
  • Next Morning 07/02/09 Pt is conscious, oriented T=37 BP=110/70RR=24 Chest: clear, EAE Doppler >>> DVT both Distal Common Femoral Veins Hb= 9.5WBC=21.1PLT= 101 BUN= 4.8CRTN= 60 PT= 11.5PTT=51.8 INR=1
  • Slide 38
  • On 09/02/09 P=94 BP= 108/69 RR= 23-30 T= 37.6O2 Sat=100% PV bleeding stopped Chest is clear Abdomen was soft & Lax
  • Slide 39
  • Spiral C-T : confirmed the Dx of PE Bilateral segmental pulmonary emboli PLAN: to continue heparin infusion, to keep INR within therapeutic range
  • Slide 40
  • After 2 weeks in MICU Pt was progressing well with heparin infusion Was vitally stable On 12/02/09 : Warfarrin 10Mg po started On 13/02/09 : BP= 106/49P=89 T=36.5 O2Sat=100% Hb=10.6 WBC=8.7 PLT=359 INR=2 PTT= 93PT=22.6
  • Slide 41
  • On 14/02/09 MICU Pt has improved a lot BP= 100/64 P=79 T=36.5 Hb=10.7WBC= 9.5PLT= 464 PT= 25.5 INR= 2.3 BUN & CRTN >> 4.6 & 68 ( N)
  • Slide 42
  • On 15/02/2009 Pt is vitally stable, in a good shape BP=101/70P=83RR= 20 T= 36.9 Hb=10.7WBC=9.5 PLT=464 On warfarin.. INR= 2.3 PT=23.2 PTT=52.9 Blood Culture>>> No Organisms Identified
  • Slide 43
  • Plan : to discharge from Gyne site to transfer to F.M.U Pt is on : Gentamycine, Ranitidine & Warfarrin 10 Mg D/C Pip/Taz D/C Olanzapine & Lorazepam D/C Amphoterecin B
  • Slide 44
  • After 18 days MICU stay.. Plan to transfer the Pt to Female Medical Ward in a stable condition Stayed under observation for 3 days in F.M.W Gentamycin was stopped in the 2 nd day
  • Slide 45
  • On 18/02/2009 : BP=122/80 P=71RR=20 T= 37.2O2Sat= 99 % INR=2.8 Pt=29.2 Ptt= 53.4 LFT & U/E >> N
  • Slide 46
  • Cont. On 18/02/2009 : discharge day.. After 3 days observation in F.M.W Pt looks very well Plan: Discharge on : Warfarrin 10 Mg P.O O.D O.P.D 1/12 >> Medical & Hematology ECHO as an out patient
  • Slide 47
  • Thank You
  • Slide 48
  • Case 2 MR NO. 636979 A 42 y.o Burmese lady Un booked G16 P14 + 1 GA= 36 w K/C of chronic hypertension for 12 yrs on medications Previous 2 C/S due to PET.. First C/S >>outside & the second one was an emergency C/S done in our hospital on 28/01/2008>>severe PET, Left Parieto- Occipital infarction >> 2 days ICU admission
  • Slide 49
  • On 19/01/2009 at 01:08 A.M patient presented to E.R with a chief complain of CONVULSION one time at home and brought by her relatives Vitals in triage at 01:15 A.M : BP=121/101 P=98T=36 C RR=22O2 sat= 97%
  • Slide 50
  • At 1:50 A.M : E.R Gyne doctor assessment: G16 P14 + 1, 36 w, prev. 2 C/S due to severe PET cof convulsion one time. Tonic-clonic. Hx of H/A & blurred vision No other complaints
  • Slide 51
  • Cont. E.R Gyne doctor assessment: manual BP= 147/109 urine dip stick +3 protein P/A: soft, Lax & fundal hieght = date Doppler F.H = 147 P/V: os = 1-2 cm
  • Slide 52
  • Blood taken for PET profile,CBC,U&E,LFT & cross match Foleys catheter Magnesium sulfate loading dose 4 g Paediatrics were informed Pt. was admitted to Labor room at 02:30 A.M
  • Slide 53
  • In L & D at 02:35 A.M Pt is semi concious B/P= 147/105 Urine protein +1 Bed-side U/S >> lateral placenta, positive F.H
  • Slide 54
  • Pt is on MgSO4 maintenance dose 2 g / hour CTG>>no uterine contractions,no decelerations, base line 118 BPM, decreased variability Plan: to do C-T brain and after the result>> C/S
  • Slide 55
  • At 03:30 A.M : Pt was sent for C-T with the MgSO4 infusion At 04:30 A.M : pt was recieved back from C-T BP=136/100P=96T=36.8RR=23 O2SAT = 98%
  • Slide 56
  • C-T result: Old infarction at the left fronto-parietal and parieto- occipital lobes. No active infarcts nor intracranial bleeding.
  • Slide 57
  • Lab results: AT 02:12 A.m PRBC X-Matching : A positive RBS:5.0 PT= 10.6 PTT= 27.5 FIBRINOGEN=470.5 D-D= 260.2 INR= 0.9 ALBUMIN=24 ALP= 122 ALT=25 AST= 26 GGT= 12 TBIL= 3
  • Slide 58
  • Cont. WBC= 8.0 Hb. = 10.1 Hct= 30.6 Platelet = 255 Na = 135 K= 3.6 Chloride = 101 Urea = 2.7 Creatinine = 70 Calcium= 1.94 Mg= 0.77 (N)
  • Slide 59
  • At 05:15 A.M: anaesthesiologist reviewed the pt and they refused to start unless if there was a SICU bed available At 06:00 A.M: pt was pushed to O.R & emergency C/S was done under S. A.. BP= 144/104
  • Slide 60
  • A straight forward C/S with a baby girl delivered at 06 :55 am with good APGAR score wt>> 3.1 kg and EBL= 600 cc
  • Slide 61
  • At 09:00 A.M : Post OP : Pt was having heavy PV bleeding in recovery area Examination : BP= 99/76 P=100T=36 P/A: Lax uterus Diagnosis of uterine atony was made Pt is on : zenacif, ferrus & caltirate
  • Slide 62
  • Plan : prepare blood and to take the pt for O.R a subtotal hysterectomy was done EBL = 2.5 L >> received 4 U PRBCs, 6 U FFP & 6 U cryoprecipitate
  • Slide 63
  • Surgery finished at 11:15 A.M and pt was intubated BP=187/119 P=123 T=36.8 RR=28 O2SAT= 90% Pt was transferred to SICU
  • Slide 64
  • Lab results at 09:30 A.m INR= 2.8 PT= 29.8 FIBRINOGEN= 80.9 D-D = 18749 APTT= > 2 min. WBC= 8.1 Hb.= 5.1 HCT= 13.1 PLT= 122 ALB = 7 ALP= 38 AST = 12 ALT= 16 GGT=7 Tbil=4 Na= 139 K= 3.6 CL= 111 BUN= 1.8 CRTN= 41
  • Slide 65
  • IN SICU : Pt stayed for 4 days. To continue MgSO4 infusion 24 hr Propofol infusion.. Centeral line B/P = 170/100 upon admission to ICU Hydralazine 5 Mg I.V was given
  • Slide 66
  • SICU DAY 1: 19/01/2009 Pt. Was intubated DROWSY BP = 133/92 158/98 T = 36 S1+S2=0 Clear chest, abdomen :soft and lax, tender to touch LAB works: Hb= 9.1 Wbc=8.2 Mg= 1.42 CXR>> N
  • Slide 67
  • Medications given : CEFUROXIME PANTAPRAZOL DEXAMETHAZONE HEPARIN AMLOR ATENOLOL I.S.S ASA
  • Slide 68
  • SICU DAY 2-4 : 20-22/01/2009: After overnight observation, unable to extubate due to probable laryngeal oedema ( difficult airway at time of surgery & multiple attempts) IV steroid was given Day 3 patient was extubated Fully concious. BP= 160/108 P=71 afebrile UOP= 3240 cc Portovac= 410 cc bloody on day 2 Otherwise, uneventful ICU stay.
  • Slide 69
  • Lab works-day 2 IN SICU : WBC=11.4Hb.= 9.4HCT= 28 PLT=169 Na=136K= 3.6CL=101 BUN= 1.5CRTN=63 CALCIUM= 1.9Mg= 1.32Phosphate= 1.41 Albumin= 18
  • Slide 70
  • Lab works-day 3 IN SICU : WBC= 10.2Hb.= 8.5PLT= 166 Hct= 26.8 INR= 0.8 Na= 138K= 4Cl= 101 BUN= 2.7CRTN= 69Calcium= 2.06 Mg= 1.01 Phosphate= 1.73 Albumin= 17
  • Slide 71
  • At discharge from SICU-Day 4 Condition at discharge: stable Medications on discharge : Cefuroxime 1.5 g Q8(19/01) x 5 days, Pantoprazole 40 mg iv od Atenolol 50mg OD Heparin 5000 U S.C BID Amlodipine 10 mg OD ASA 81 mg OD
  • Slide 72
  • BP = 116/80 P=74 RR= 18 O2Sat= 98% Urine : clear
  • Slide 73
  • Lab works Hb = 9.1 Wbc=10.2 PLT= 212 PT=10.1 APTT=35.7 Na=131 K =131 Mg=1.01 Crtn=69 Urea= 2.7 Ca= 2.06 Ph=1.73 Albumin= 17
  • Slide 74
  • 23/01/09 : in O.B ward : BP=118/81 P=66 RR=18 T =36 O2Sat=98% Clear chest, s1 + s2 + 0 Portovac = 20cc in 24 h not removed serouse UOP= 2400cc/24 h No PV bleeding
  • Slide 75
  • On discharge : Pt was discharged on 25/01/2009 in a good condition Portovac was 5 cc>> removed BP=120/75 P = 82 afebrile WBC= 8.3Hb= 10.3 PLT= 420INR= 0.9 ENT OPD 6/52 GYN F/U 6/52
  • Slide 76
  • Thank You