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Morbidity-Mortality conference
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Patient identification
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Admit 29/3/58. HN : IX 9792
Chief complaint : *)JK+% 3 .+.
Present illness :
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27/3/58 Admit ICU ; Dx septic shock, Empiric : Tazocin 4.5 gm iv q 8hr
28/3/58 High grade fever + generalized tonic seizure
CT brain : no ICH, no brain edema
LP : OP 19 cmH2O, Protein 500, sugar 90, WBC 10
CSF ; PCR for TB neg
dDx ; Viral encephalitis or Septic encephalitis or Tetanus
On ETT c ventilator + empiric (Meropenem + Metronidazole + Acyclovir)
Control seizure : Dormigum iv drip
GCS ; E1VtM1 -> refer SNH
Past history : *+.+#&
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Physical examination : Comatoes stage, GCS:E1VtM1
Vital sign : Body temp 37C, Pulse rate 120 bpm, Respiratory rate 12 tpm, Blood pressure 120/80 mmHq
HEENT : Pink conjunctivae, anicteric sclerae, cervical and supraclavicular LN were impalpable, parotid glands
were not enlarged
Heart : PMI at 5th intercostal space mid clavicular line, normal S1S2, no murmur
Lung : Normal breath sound, no adventitious sound
Abdomen : Obese abdomen, soft, liver and spleen were impalpable, liver span 8 cm, negative splenic dullness
Extremities : no edema, no rash
Neurology : E1VtM1
Cranial N ; pupil 4 mm per right eye and 3 mm per left eye, slightly react to light both eyes
Stiffneck ; negative all direction
motor ; gr I all
Deep tendon reflex ; gr 2 all
BBK ; dorsiflexion both feet
Clonus ; negative both ankles
Investigation (29/11/58)
CBC : Hb 11.9 g/dL, Hct 37.3%, WBC 7400/uL, Plt 161,000/uL, PMN 82.1%, Lympho 11.8%, Mono 11.6%,
Eos 1.1%, Baso 0.9%, MCV 85.3, PT 13.8, INR 1.3, PTT 32
Blood chemistry : BUN 7.2 mg/dL, Cr 0.6 mg/dL, Na 141 mEq/L, K 3.3 mEq/L, HCO3 11.2 mEq/L, Cl 109
mEq/L, Ca 7.3 mg/dL, PO4 1.9 mg/dL, Mg 2.9 mg/dL, Alb 2.9 g/dL
Liver function test : Chol 179 mg/dL, TP 5.4 g/dL, Alb 2.9 g/dL, Glob 2.4 g/dL, TB 0.3 mg/dL, DB 0.1 mg/dL,
ALT 25 U/L, AST 41 U/L, ALP 101 U/L
Anti-HIV : non reactive
Hepatitis profiles : HBsAg ƒ Negative, HBsAb ƒ Negative, Anti-HCV ƒ negative
Serum Crypto-Ag : negative, VDRL : non reactive
Dengue Ag : negative, Scrub typhus Ag : negative
Thyroid function : FT3 1.29 (N), FT4 0.85 (N), TSH 0.488 (N)
Cortisol level : 29, Lactate 19.5
Arterial blood gas : pH 7.41, PaCO2 18.3 mmHg, PaO2 168 mmHg, BE -11 mmol/L, HCO3 11.5 mmol/L,
O2sat 99%
CT brain c CM : Acute diffuse white matter change, diffuse brain edema, impending uncal herniation
Impression : Meningoencephalitis c impending uncal herniation c shock
„„„„„„„„„„„„„„„„„„„„„„„„„„„„„„„„„„„„„„„„„„„„„„„
Management :
On V-CMV Vt 400, RR 16, PEEP 5, I:E 1:2.5, FiO2 0.4
Load 0.9% NaCl total 1500 ml
On levophed (4:250) iv drip 10 mcd/min titrate keep MAP > 65
On 0.9% NaCl 1000 ml add K2PO4 20 mEq iv drip 60 ml/hr
Empiric ATB
Ceftriaxone 2 gm iv q 12 hr
Acyclovir 500 mg iv q 8 hr
Consult neuro-Sx : no indication for decompressive craniectomy, suggest conservative Tx
Progression
30/3/58 GCS E1VtM1 pupil 4 mm both eyes
EEG : No epileptiform discharges, brain dysfunction
On levophed (4:250) iv drip 22 mcd/min
+L6 Polyuria (urine 3875 cc/8hr) Elyte : Na 160, K 2.7, HCO3 14.9, Cl 131
Urine osmole 121
Suspected ; central DI
Start DDAVP 1 mcg iv stat
6%@6 urine ,% (… 30-50 cc/hr ((,"+ 300-500 cc/hr)
Feed SW 250 ml x 6 feed
On 5% DW 1000 ml add K2PO4 60 mEQ iv 120 ml/hr
Access C-line -> CVP 6
K2PO4 10 mEq + 5% DW 100 ml iv drip in 1 hr X 2 doses
I/O : 6112/2816 -> + 3296
31/3/58 GCS E1VtM1
On levophed (4:125) iv drip 20 mcd/min
Elyte : Na 153, K 2.6, HCO3 14.5, Cl 124
K2PO4 10 mEq + 5% DW 100 ml iv drip in 1 hr
On 0.9% NaCl 1000 ml add K2PO4 60 mEq iv drip 80 ml/hr -> 100 ml/hr
Empiric ATB : Azithromycin 500 mg iv q 24 hr
I/O : 4257/2895 -> + 1362
1/4/58
GCS E1VtM1
On levophed (4:125) iv drip 32 mcd/min
Elyte : BUN 4.9, Cr 1.0, Na 154, K 4.8, HCO3 14.5, Cl 122
On 5% DNSS 1000 ml iv drip 120 ml/hr
2/4/58
GCS E1VtM1
Lab : BUN 6.6, Cr 1.1, Na 160, K 5.6, HCO3 20, Cl 132
On levophed (4:125) iv drip 34 mcd/min
++3(,
Add adrenaline (1:10) iv drip 5 mcd/min + wean levophed
Add hydrocortisone 200 mg iv drip in 24 hr
On 5%DW 1000 ml iv drip 60 ml/hr
3/4/58 GCS E1VtM1
Lab : BUN 16.6, Cr 2.2, Na 160, K4.2, HCO3 14.6, Cl 127
On levophed (4:125) iv drip 34 mcd/min
On adrenaline (1:10) iv drip 8 mcd/min
Feed SW 250 ml x 6 feed
5% DW 1000 ml iv drip 100 ml/hr
On hydrocortisone 200 mg/day
4/4/58 GCS E1VtM1
Lab : BUN 23.2, Cr 2.6, Na 142, K 5.1, HCO3 19.2, Cl 107
On levophed (4:125) iv drip 20 mcd/min
On adrenaline (1:10) iv drip 8 mcd/min
On 0.9% NaCl 1000 ml iv drip 40 ml/hr
On hydrocortisone 200 mg/day
On DDAVP 4 mcg iv stat then DDAVP 6 mcg sc OD
5/4/58
GCS E1VtM1
On levophed (4:125) iv drip 7 mcd/min
On adrenaline (1:10) iv drip 7 mcd/min
On 0.9% NaCl 1000 ml iv drip 40 ml/hr
On hydrocortisone 200 mg/day
Feed BD (1:1) ng drip 20 ml/hr
Advice to clarified brain dead -> "}"($
6/4/58
E1VtM1, no brain stem reflex
CSF PCR for HSV neg,ADA 2, PCR TB neg form private hospital
ANA positive,coarse speckle type,cytoplasmic pattern, 1:80
Antiphospholipid syndrome profile : neg
Advice prognosis
7/4/58
E1VtM1, no brain stem reflex
Advice prognosis, consult palliative care
8/4/58
advice Declare brain death
9/4/58
Declare brain death
Respiration
No respiration after withdraw ventilator
5 min from 10 min
PaCO2 78.7 from 53.1 mmHg (>60)
" Accept #& !#&
14.00 ")01 5
LP was done after permission
No brain biopsy nor autopsy
16.00 ")(: no CPR, no inotropic agents
22.00 HR 50 BP80/40 : " accept
10/4/58 8.00 HR 50 BP 46/20, EKG bradycardia
8.05 : EKG asystole >> " no CPR