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SICU research meeting

SICU research meeting. Intern 粘展瑋 2007-01-21. Patient Profile. Name: 徐 X 光 Gender: male Age: 64-year-old Chart No.: 5046353 Bed No.: 4B1 07. Past History. Systemic disease: DM(-), HTN(-), CAD(-) Op history: Bilateral hip replacement 5 years ago

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SICU research meeting

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  1. SICU research meeting Intern 粘展瑋 2007-01-21

  2. Patient Profile • Name: 徐X光 • Gender: male • Age: 64-year-old • Chart No.: 5046353 • Bed No.: 4B1 07

  3. Past History • Systemic disease: DM(-), HTN(-), CAD(-) • Op history: Bilateral hip replacement 5 years ago • Smoking: 2~3 PPD for many years • Allergy: Denied

  4. Brief history I • 9505 Blood-tinged sputum, 恩主公H, Cytology: SCC CT: right hilar and subcarinal LAP and obstructive pneumonia of RUL. • 9506 NTUH, T4N2M0, stage IIIb Received CCRT( Taxotere+Cisplatin followed by 45Gy/25fx R/T ) • 9510 CT: encasement of right bronchus, pulmonary a., compression of SVC PET: residual malignancy at RUL • 951028 Operation: Right lung pneumonectomy+ SVC, RA, LA tumor excision+ SVC reconstruction+ temporal pacemaker

  5. Brief history II • 9511 Reintubation due to bronchospasm Extubation on 11/07 • 951109: Postero-lateral thoracotomy to repair of RMB stump for SC emphysema • 951128 Tracheostomy • 951206 K 6.3, acute renal failure CPR4min→ROSC, s/p CVVH • 951219 MDRPA ID: keep ABx, colistin + CMZ if S/C(+) • 950109 HSV infection in perianal and scrotum area • 950114 RUL stump repair for air leakage

  6. Lab data Platelet WBC

  7. HSV-related Thrombocytopenia

  8. Thrombocytopenia • Definition: PLT < 150,000/microL However, 2.5 % normal population have a platelet count lower than this. Clinical symptoms were rarely found unless PLT < 100,000/microL. • Life span of platelets 8 to 10 days • Production of platelet 35,000 to 50,000/microL/per day This value can be increased up to eight-fold during times of increased demand

  9. Cause of thrombocytopenia • Decreased platelet production Viral infections (ex. rubella, mumps, varicella, parvovirus, HCV, EBV), C/T or R/T, Bone marrow aplasia or hypoplasia, Alcohol toxicity, VitB-12 or folic acid deficiency • Increased platelet destruction ITP, SLE, Alloimmune destruction (posttransfusion, neonatal, post- transplantation ), DIC, TTP-HUS, HELLP syndrome, Antiphospholipid syndrome, Certain drugs (heparin, quinine, quinidine, and valproic acid), Infections (eg, infectious mononucleosis, CMV, HIV) ,Physical destruction of platelets during (CABG, IABP, huge aortic aneurysm) • Dilutional or distributional thrombocytopenia • Splenomegaly • Pseudothrombocytopenia

  10. Dilutional thrombocytopenia • Massive transfusion with packed RBC • Usual platelet count 47K~100K/microL after 15U PRBC in 24 hr 25K~ 61K /microL after 20U PRBC in 24 hr • Suggest giving platelet concentrates when patients receiving more than 20U PRBC in 24hr.

  11. Thrombocytopenia in the ICU • Infection, sepsis, septic shock • Use of heparin • Disseminated intravascular coagulation (DIC) • Massive blood transfusion • Post-transfusion purpura • Cardiopulmonary resuscitation • Cardiopulmonary bypass • Adult respiratory distress syndrome • Pulmonary embolism • Use of intravascular catheters • Solid organ allograft rejection • Use of drugs associated with thrombocytopenia

  12. Study • Predictors of thrombocytopenia developing Evolution of DIC Cardiopulmonary resuscitation Signs of organ failure • Septic shock, a higher APACHE II score, and a 30 % decrease in platelet counts were significant risk factors for ICU death Crit Care Med 2002 Aug;30(8):1765-71

  13. Our patient • Infection, sepsis, septic shock • Use of heparin • Disseminated intravascular coagulation (DIC) • Massive blood transfusion • Post-transfusion purpura • Cardiopulmonary resuscitation • Cardiopulmonary bypass • Adult respiratory distress syndrome • Pulmonary embolism • Use of intravascular catheters • Solid organ allograft rejection • Use of drugs associated with thrombocytopenia

  14. HSV-induced thrombocytopenia • Pathogenesis Tend to infect cells of ectodermal origin. After retrograde axonal flow from neurons at the viral point of entry and local replication, the viral genome becomes latent. • HSV viremia Immunocompromised population is most common Immunologically healthy individuals can occur, especially in pregnancy Disseminated infection can result in hepatitis, esophagitis, pneumonitis, encephalitis, and adrenal necrosis. • HSV hepatitis Leukopenia, thrombocytopenia, and disseminated intravascular coagulation E-medicine

  15. HSV hepatitis • Lab picture Marked elevation of liver transaminase values Slight increase in the bilirubin level Leukopenia and thrombocytopenia • Kaufmam et al, in their review, found a WBC count of <5,000/mm3 in 43% of patients. • Aboguddah et al, found a mortality rate of 81%; of cases reported between 1969 and 1980, 88% were fatal, and of cases reported from 1981 to 1989, 78% were fatal Clin Infect Dis 1997; 24:334-338 J Rheumatol 1991; 18:1406-1412

  16. South Med J 93(12):1212-1216, 2000

  17. In our patient 1/14: Transfusion PLT: 24U PRBC: 2U for operation 1/20 & 1/21 : PRBC 2U for Hb↓ r/o GI bleeding

  18. Diagnosis • Clinical picture Skin lesion • CT of liver Multiple low-density lesions • Liver biopsy is gold standard Of 52 reported cases, the correct diagnosis was made before death in only 23%. Clin Infect Dis 1997; 24:334-338

  19. Treatment • Acyclovir A review of the clinical experience with acyclovir in the treatment of HSV hepatitis shows that 13 of 21 patients survived. Transplantation 1995; 59:145-149

  20. Infection • Antibiotics for Pseudomonas aeruginosa Colistin(1221~) Fortum(1221~) Metronidazole(12/25~) Fortum was discontinued on 1/15

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