Critical Care Morning Report

1. Critical Care Morning Report Michael Schweizer Kyle Hogarth

2. MKSAP Question A 52-year-old woman is evaluated after a screening CT colonography detected a 3-mm nodule in the right lower lobe of the lung. A tortuous colon prevented complete screening colonoscopy. CT scan of the chest showed no additional nodules and was otherwise normal. The patient has never smoked; she works in the home and has not been exposed to potential carcinogens. She has not had a chest radiograph or other imaging procedure, except mammography. Her medical history includes only hyperlipidemia, and her only medication is simvastatin. Her family history is unremarkable. On physical examination, vital signs are normal. Examination of the skin is normal; there is no lymphadenopathy, and the lungs are clear.

3. Which of the following is the most appropriate next step in the management of this patient? A. Chest radiograph in 3 months B. CT scan of the chest in 3 months C. CT scan of the chest in 6 months D. CT scan of the chest in 12 months E. No follow-up

4. Studies of chest CT screening have shown that 25% to 50% of patients have one or more pulmonary nodules detected on the initial CT scan. • Even with a relatively high risk for lung cancer, the likelihood a small nodule is malignant is low (<1%). • the risk of malignancy is about 0.2% for nodules smaller than 3 mm and 0.9% for nodules 4 to 7 mm. • The Fleischner Society recommendations include no follow-up for low-risk patients with nodules 4 mm or smaller and follow-up CT at 12 months for patients who are at risk for lung cancer. More frequent follow-up is not recommended for nodules of this size. • This small nodule is not likely to be visible on chest radiograph, and, therefore, such imaging would not be helpful.

5. The Case 35 y/o male s/p cholecystectomy ‘07 p/w RUQ pain.

6. ROS 2 days of RUQ abd pain Similar to pain he had with prior cholecystitis Decreased UOP and dark urine No F/C No N/V No diarrhea, constipation, hematochezia, or melena

7. Past History PMHx Cholecystitis, Choledocholithiasis (6/07) Morbid obesity OSA PSHx ERCP x 4 (6/07 - 10/07) 2 prior and 2 after cholecystectomy Cholecystectomy (6/07) • Allergies • Clinda • Family Hx • Mother deceased; cervical CA • Father deceased; unknown cause • Social Hx • 3 cigarettes/day since ‘95 • Occasional binge drinking • Marijuana use • Medications • None

8. Physical Exam T 38.5, HR 102, RR 20, BP 141/77 HEENT: No scleral icterus, dry mucous membranes, no LAD. CV: Tachy, regular, no m/r/g, no JVD. Resp: CTA B. GI: Soft, +RUQ tenderness with +murphy’s sign. Neuro: AAO x 3. Skin: No rash, no jaundice, several tattoos.

9. Murphy’s Sign • Pain and arrest of inspiration when fingers are hooked under the right costal margin during deep inspiration • Classically a physical exam feature of acute cholecystitis • Positive LR 2.8 (95% CI 0.8 to 8.6)

10. DDx for abd pain

12. Initial workup?

13. Labs 9.3 17 8.7 4.7 141 100 10 145 184 7.5 3.0/1.9 4.9 3.7 25 0.9 534 421 126 Lipase 39 MCV 88 Blood cultures- pending

14. CXR

15. CXR Linear atelectasis/scarring present No infxn

16. RUQ US Hepatomegaly Highly echogenic which may be 2/2 fat infiltration Post cholecystectomy Normal caliber to biliary tract

17. CT abd/pelvis Post cholecystectomy Mild central biliary prominence No evidence of choledocholithiasis Possible fatty liver

18. Management At this Point?

19. Case cont… Initially given cipro/flagyl in ED Defervesced Spiked temperature to 39.3 and began rigoring Became altered O x 1

20. V/S cont…

21. How do you approach the patient?

22. V/S cont…

23. Additional Labs INR 1.4 --> 2.2 Lactate 2.4 --> 4.1 ABG 7.22 | 47 | 109 | 96 on 2L NC

31. Case cont… Switched to zosyn when v/s became unstable. Defervesced and MS improved greatly. Lactate cont to rise, however. ERCP done the next morning. Choledocholithiasis with obstruction and signs of cholangitis. Evidence of Mirizzi syndrome 2 common hepatic duct stents placed.

32. Mirizzi Syndrome Common hepatic duct obstruction caused by extrinsic compression Type I: Stone impacted in the cystic duct or gallbladder neck Type II: Fistula of the common duct Type III: Hepatic duct stenosis due to a stone at the confluence of the hepatic and cystic ducts Type IV: Hepatic duct stenosis as a complication of cholecystitis in the absence of a stone

33. Acute cholangitis Charcot’s triad Fever, RUQ pain and jaundice Reynold’s pentad Also includes mental confusion and hypotension Mortality rate 50% when pentad present Usually treat with urgent biliary tree decompression

34. Acute cholangitis cont… RUQ US Sensitive for detecting bile-duct stones is low: 27-49% Highly specific: 99-100% Normal bile duct size does not exclude choledocholithiasis. MRCP Increased sensitivity over US: >90% ERCP Gold standard in diagnosing bile-duct stones Advantage of being able to procede with therapeutic ERCP if needed

35. Causative organisms Cultures obtained from bile, stones and blocked stents are positive 90% of cases B cx positive 20-60% of cases Bacteria usually colonic origin Gm Neg: E. coli (25-50%), Klebsiella (15-20%), Enterobacter (5-10%) Gm Pos: Enterococcus (10-20%) Anaerobes Usually present as mixed infection Bacteroides and Clostridia species most often seen

36. Treatment of acute cholangitis No consensus on a given abx regimen Cipro/flagyl Zosyn or amp-sulbactam 3rd gen cephalosporin (eg ceftriaxone) and flagyl Imipenem Modify abx choice based on culture data

37. Treatment cont… 80-90% respond to conservative therapy with broad-spectrum abx Can then have ERCP electively Indications for emergent biliary decompression: Persistent abdominal pain Hypotension despite adequate resuscitation Fever >39 C Mental confusion

38. Treatment cont… ERCP is superior to surgical decompression Mortality rate: 4.7 - 10% vs 10-50%

39. Patient Follow-up Pan-susceptible Klebsiella oxytoca from blood culture. VRE from bile fluid culture. D/C’d on IV zosyn

40. Take home points Aggressive early management of sepsis leads to better outcomes Still need to consider cholangitis in patients that have had a cholecystectomy Mortality rate of severe cholangitis is very high

41. References N Engl J Med, Vol. 345, No. 19 N Engl J Med 2003;348:1546-54 Best Practice & Research Clinical Gastroenterology Vol. 20, No. 6, pp. 1139-1152, 2006 Anesthesiology. 89(6):1313-1321, December 1998 Crit Care Med 2006 Vol. 34, No. 6 JAMA 2003;289(1):80-86 Chapter 14. Abdominal Pain, Fauci, et al: Harrison's Principles of Internal Medicine UpToDate

42. MKSAP Revisited A 71-year-old woman is brought to the emergency department from a nursing home because of confusion, fever, and flank pain. Her temperature is 38.5 °C (101.3 °F), blood pressure is 82/48 mm Hg, pulse rate is 123/min, and respiration rate is 27/min. Mucous membranes are dry, and there is costovertebral angle tenderness, poor skin turgor, and no edema. Hemoglobin concentration is 10.5 g/dL (105 g/L), leukocyte count is 15,600/µL (15.6 × 109/L); urinalysis reveals 50 to 100 leukocytes/hpf and many bacteria/hpf. The patient has an anion gap metabolic acidosis. A central venous catheter is placed, and antibiotic therapy is started.

43. Which of the following additional interventions is most likely to improve survival for this patient? A. Aggressive fluid resuscitation B. Hemodynamic monitoring with a pulmonary artery catheter C. Maintaining hemoglobin concentration above 12 g/dL (120 g/L) D. Maintaining PCO2 below 50 mm Hg

44. The patient has severe sepsis presumptively from pyelonephritis. Aggressive fluid resuscitation with resolution of lactic acidosis within 6 hours would have a beneficial effect on this patient’s survival. Timing of resuscitation matters to survival. In a landmark study by Rivers and colleagues, early goal-directed therapy that included interventions within the first 6 hours to maintain a SCVO2 of greater than 70% and to resolve lactic acidosis resulted in higher survival rates than more delayed resuscitation attempts. Over the first 72 hours, patients in the control arm received the same quantity of fluid for resuscitation, but they had a significantly higher likelihood of dying by discharge or at 60 days.