Tuesday, April 11, 2017
The ER calls with an ICU admission as follows: 55 year old with ischemic cardiomyopathy EF 30% (but no chest pain) presenting with complaints of cough and shortness of breath. Vitals include a temp of 101, pulse of 90, bp 90/60, and pulse ox of 85%. The patient has significant increased work of breathing and was intubated in the ED. With the information given, determine what is wrong with the patient and determine what steps to take to stabilize this patient before you leave in three hours?
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The question assumes that there is no more history to be gained; therefore clinical investigations and medical acumen must be relied upon the elicit the etiology. I would begin by fleshing out a DDX: 1. is the patient in acute heart failure concomitant with sepsis or distinct from it? We know that we have a reduced EF, but little else, so imaging (CXR) may help us determine if pulmonary edema or infiltrate is present, physical exam (breath and heart sounds, edema) would also aide the cause. If emergent echo is available, I would welcome it. Laboratory (BMP, BNP, CBC troponins)) to determine renal function and any anemia, EKG to profile arrythmias or MI. A CT PE would be in order if renal function and allergy history supports it 2. Leukocytosis with the fever to accompany the hypotension would push us toward a sepsis response including fluids and broad spectrum ABX with Cultures and UA. The picture may be clouded by the penumbra of heart failure and require ajudication of the typical sepsis bundle if the patient cannot tolerate the fluid load. If that is determined soon; central venous access would be imperative to preserve vascular integrity with pressor support. Early goal Directed therapy for sepsis (EGDT) (Rivers, et al.November 8, 2001 N Engl J Med 2001) for sepsis has been accepted in theory but rebutted in the practice of a strict protocol of continuous CVP and ScvO2 monitoring does not appear to add any benefit. (Mouncey et al. for the ProMISe Trial Investigators. N Engl J Med 2015.)
ReplyDeleteIn short, I would evaluate for cardiac function and treat for sepsis including fluid/ pressor support with ventilation adjustments per body habitus and ABG results; temporizing as dictated by cardiology.
55yo with a Fever, Hypotensive, MAP of 70mmHg, Hypoxic at 85%. Intubated.
ReplyDeleteFirst I would make sure his O2 has improved while intubated, his TV would be calculate at 6 x Ideal Body Weight= TV. Start at a PEEP of 5. RR of 18. 100% FiO2 and order a stat ABG and wean down his FiO2 as he tolerates.
Do a Physical Exam.
Orders: CXR, CBC, BMP, BNP, CXR, EKG, ECHO, ABG, Lactic Acid and repeat q2hours if elevated, Procalcitonin q6 hours x 3, Sputum Culture (sounds like maybe pneumonia), Blood cultures, strep pneumo, Legionella, Mycoplasma, Flu (if season is right) I would start him on fluids, his MAP is already above 65, I would start him on NS depending on his weight I would start him on a certain Ml/Hr. If he becomes Hypotensive I would bolus him 30cc/kg fluid bolus and start LEVOPHED (choice of pressor in Septic Shock if his blood pressure drops) We would need to be careful due to CM with EF 30% however patient is now on the vent therefore giving fluids would be more important than not giving fluids. If the patient needs sedation I would start with pushes of Fentanyl and Versed because propofol would decrease his blood pressure even more than it already is.
The patient should be stabilized at this point, I would start broad spectrum antibiotics if I find that the patient is septic. If the patient is not septic and this is actually cardiogenic and the patient has heart failure I would be sure to stop my fluids and give the patients LASIX after reviewing his home medications and I would monitor his urine output and blood pressure.
If the patient is found to have acute decompensation heart failure I would not give fluids, I would give lasix. I would make sure the map remains above 65 if inotropic agents are needed I would choose dobutamine or milrinone. Then stabilize the patient through these measures.
In this scenario I believe this patient is likely septic and that I would need to stabilize the patient and be ready to treat septic shock but I would keep in mind that this could also be compensation heart failure and would follow up on labs, CXR, and ABG.
In addition to this.
DeleteInotropic Agents: Milrinone and Dobutamine
Vasopressor Agents: levophed and dopamine
There have been studies done for inotropes and vasopressor therapy and actually they were unable to find evidence to determine the clinical efficacy and safety of vasopressor therapy and inotropic therapy.
Inotropic therapy could be harmful in heart failure without a low output state. They increase your HR and Myocardial oxygen consumption which could in turn provoke ischemia particularly in patients with ischemic heart disease. It is also important to use caution with these drugs due to their potential to increase the risk of atrial and ventricular arrhythmias.
Obtaining a full medical history and examination is the most crucial to coming to a diagnosis. Basic labs, EKG and CXR would be primary testing to assist in forming a diagnosis, assuming these were done on presentation.
ReplyDeleteCHFrEF Exacerbation would be high on my list, however, the patient does meet SIRs criteria with the fever and tachycardia. I would look for a source of infection given that the patient is also hypotensive... they are currently maintaining a MAP >65 as stated by Dr. Patel, however, will they last? Are they in shock? This is a critical question if we are thinking CHFrEF vs Septic shock. If they develop shock, which would be the best option? Levophed given the sepsis or Dopamine given the heart failure? Actually, "a subgroup analysis showed that dopamine, as compared with norepinephrine, was associated with an increased rate of death at 28 days among the 280 patients with cardiogenic shock but not among the 1044 patients with septic shock or the 263 with hypovolemic shock." (NEJM 360) Given this, Levophed or Neo would be better choices.
Given that they are on the vent, I am less concerned for worsening fluid overload - fluid resuscitation will be important. UA and cultures can help assess for a source while a CXR will also support fluid overload or pulmonary congestion as the cause of symptoms. A central line would be beneficial to monitor CVP. Broad spectrum antibiotics would not hurt and can be deescalated as tests return negative.
Cardiology consult may be beneficial later in admission for placement of an AICD according to NEJM 360. This wouldn't need to be done until patient is on the following core measures: Loop Diuretic, Spironolactone (specifically for patient's with EF <35%), ACEI/ARB, BB. However, it is to note that it has been shown in recent studies patients with heart failure not caused by CAD, ICD implantation was not associated with significantly lower long-term rate of death.
From the information given, I would be more suspicious of an infectious cause to the patient’s symptoms, specifically because of the elevated temperature. With that consideration, it appears that the patient has septic shock. So, fluid resuscitation would be important going forward. Although, it would be nice to take a history, perform a physical and obtain a WBC, BNP, lactic acid, procal and imaging prior to any further treatment.
ReplyDeleteFluid resuscitation would ordinarily be NS 30ml/kg as initial therapy for sepsis, however with the patient’s decreased EF, 500cc boluses should be given with clinical and hemodynamic monitoring for the presence or absence of pulmonary edema following bolus administrations. If patient develops pulmonary edema, I would be more suspicious of fluid overload 2/2 to heart failure and begin diuresis and IV vasopressors. However, assuming that patient tolerates fluid boluses; obtain blood, sputum and urine cultures. Vanc and Zosyn would be the anitbiotics of choice based upon the limited information.
Initial review demonstrates a person in respiratory distress of unknown cause, requiring IPPV. Initially I would follow ABCs. The patient’s airway is secure, monitor breathing with ABGs and adjusting ventilator settings as appropriate. Circulation, currently hypotensive, venous access would need to be established with peripheral IVs for fluid resuscitation with 500ml-1L NS (depending on body habitus) and monitor for response.
ReplyDeleteInitial labs would be stat ABG with POC lactic acid, cbc, cmp, troponin, EKG, BNP, procal, blood urine and sputum culture. If between the months of October-March, I would obtain a flu swab as well. Stat portable chest xray for evaluation of pneumonia, pneumothorax, pulmonary edema or chronic bronchiolar thickening. Based on labs, chest xray, and patients response to fluid bolus would dictate the next intervention.
Patients history tells that the #1 differential diagnosis would be severe ADHF with hypotension sbp <85 or signs of shock such as cool extremities, narrow pulse pressure, low urine output, confusion. Up to date recommends starting inotrope and placing a-line for bp monitoring. Goal would be map of 70.
As the patient is in severe respiratory distress and clinically unstable so first of all, I will follow the ABC . Airway is protected and mechanical ventilation will be started to maintain the o2 saturation above 92 percent. After that I will do a quick respiratory exam to listen for decreased breath sounds, wheezing or nasal crackles to rule out Pneumonia, acute bronchoconstricton ,pneumothorax and pulmonary edema and cvs exam to listen for any murmurs specifically MS , MR and AS because all of these can result in pulmonary edema and hypotension. My next step will be to give Duonebs and IV solumedrol and emergent EKG and CXR to rule out acute MI and pulmonary edema . Although bp is 90/60 but map is 70 . So if the EKG is negative for any acute Changes and cxr negative for pulmonary edema , We will start IV NS @ 75 ml hour because patient is hypotension and loosing more fluids due to high temperature. Flu swab will be order and IV Levaquin will be started empirically for suspected pneumonia. CBC , BMP, Troponins, BNP , UA , D dimer will be ordered. Blood, urine and sputum cultures will be sent . We will continue monitoring patient vitals and oxygen saturation continuously. If the patient has signs of pulmonary edema and extremity edema , a dose of IV lasix will also be administered. Further management will depend on labs . Echocardiogram will done once patient is admitted to floors to check for more recent EF ,ventricular dyskinesia and valvular abnormalities.
ReplyDeletehttps://link.springer.com/content/pdf/10.1007%2Fs00134-017-4683-6.pdf
ReplyDeleteLink to the surviving sepsis guidelines