1 / 49

R4 王建中 /VS 吳允升 Apr, 11 st , 2014

R4 王建中 /VS 吳允升 Apr, 11 st , 2014. Critical Combine Conference. A 49-year-old man with left upper abdominal pain for about 3 months. Patient Profile. Systemic disease:

terah
Télécharger la présentation

R4 王建中 /VS 吳允升 Apr, 11 st , 2014

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. R4 王建中/VS 吳允升Apr, 11st, 2014 Critical Combine Conference

  2. A49-year-old man with left upper abdominal pain for about 3 months

  3. Patient Profile • Systemic disease: • Gastric adenocarcinoma, cT4bNxM1, inoperable and metastatic, pancreas invasion and peritoneal seedings/carcnomatosis with ileus, stage IV • Obstructive uropathy with hydronephrosis due to cancer • Operation: • 2014/02/17: Port-A implantation, echo-guided • Allergy: NKA • Personal history: • Smoking & alcohol use: Nil • Education:Junior high school • Marital status: Married

  4. Patient Profile • Occupation:服務業 • Drug history: • Nexium (40) 1 tab QD • Strocain 1 tab TID • Gascon (40) 1 tab TID

  5. Family History No HTN, CAD, Autoimmune Disease HX 77 y/o 49 y/o 49 y/o 20 y/o 19 y/o

  6. Past History 2013 • Left upper abdominal sharp pain • Not correlated to oral intake • Easy satiety and abdominal distention •  Visit 新泰 hospital: EGD : gastric ulce Dec • Persistent abdominal pain • Weight loss about 9kgs in one months • Bowel habit change was noted. •  新光 H: • EGD : one large ulcer about 1.5~2cm with elevated • margin and folds convergence in the angle to the • LC/posterior wall of lower body, suspected • malignancy •  Biopsy performed • CT scan : gastric cancer with peritoneal seeding 2014 Jan, 21

  7. Past History 2014 • Laparoscopic appentectomy was done for suspicious of acute appendicitis • Peritoneal seeding was noted during surgical intervention  Pathology: metastatic adenocarcinoma Jan, 21 Jan, 21 NTUH • MRI : infiltrative tumor with involvement of stomach and pancreas, probably arising from gastric cancer and directly invading the pancreas; multiple regional lymph nodes Feb, 12

  8. Abdominal MRI (2014.02.12) Infiltrative gastric tumor with involvement of stomach and pancreas; multiple regional lymph nodes

  9. Physical Examination BH: 170cm BW:68.7Kg BMI:23.77 HEENT Conjunctiva: not pale, Sclera: icteric (-) Pupil: isocoric, 4mm/4mm, midposition Light reflex: R/L +/+, promptly Oral thrush(-), oral ulcers(-) Neck Supple, tightness(-), JVE(-) , LAP(-), goiter(-) Kernig’s sign (-), Brudzinski’s sign(-)

  10. Chest Symmetrically expanded, axillary LAP(-) Breath sound: clear over bilateral lower lung fields Heart PMI displacement (-),RHB, thrill(-) Murmur(-), distant heart sound (-) Abdomen Distended, normoactive bowel sound, Tenderness(+, epigastric area) Hepatosplenomegaly (-), Extremity Petechiae(-), purpura(-), cyanosis(-), cold (-) Leg edema(-), clubbing finger(-) Physical Examination

  11. CXR 201402/17

  12. ECG (2014.02.14)

  13. Past History 2014 • Port-Ainsertion • Initiate TPN Feb, 17 • EGD:Advanced gastric cancer, Bormann type 3, angle to the LC-PW of lower body, s/p biopsy • Pathology: adenocarcinoma, poorly-differentiated Feb, 19 • Double J (Tumor stent) insertion • for left hydronephrosis Feb, 22

  14. Past History 2014 • HDFL C1D1 • NG decompensation: more than 2000ml gastric juice drained out per day • Keep TPN and keep I/O balance Feb, 25

  15. Laboratory Data 2/27: Cl:93 mmol/L

  16. Urine exam 2014/02/24 FENa =1.8% > 1%

  17. Renal Echography (2014.02.27) • Right • Size : normal 13.6 cm • Shape : regular • Cortical echogenecity : • increased chogenecity • Cortical thickness : • Normal: 2.0 cm • Central echo : mildly • seperated • Cystic lesion(s): Nil • Solid lesion : Nil • Left • Size : normal 12.1 cm • Shape : regular • Cortical echogenecity : • increased echogenecity • Cortical thickness : • Normal: 1.8 cm • Central echo : mildly • seperated • Cystic lesion(s): Nil • Solid lesion : Nil IMPRESSION : 1. Bilateral parenchymal renal disease 2. Moderate right hydronephrosis 3. Renal cyst, right 4. Engorged right renal vessels, r/o renal vein thrombosis

  18. Acute kidney injury Hypovolemia Decreased cardiac output Decreased effective circulating volume: -Congestive heart failure -Liver failure Impaired renal autoregulation: NSAIDS, ACEI/ARB, cyclosporin Prerenal Gluomerular: acute glomerulonephritis Intrinsic Tubules and interstitium Vascular: vasculitis, malignant hypertension, TTP-HUS Bladder outlet obstruction Bilateral pelvoureteral obstruction (or unilateral obstruction of a solitary functioning kidney) Postrenal Harrison's Principles of Internal Medicine, 18e

  19. Past History 2014 • Increased O2 demand suddenly • NG decompression: about 2600-3300ml/day • Suspected septic shock Mar, 04 Mar, 05 Mar, 05 Mar, 05 • Consult nephrologist; transfer to MICU? • DNR(+) • Family decided to discontinue inotropic agents • Passed away Mar, 06

  20. Final Diagnosis • Gastric adenocarcinoma, cT4bNxM1, stage IV, inoperable and metastatic, pancreas invasion and peritoneal seedings/carcnomatosis with ileus • Severe metabolic alkalosis secondary to hydrogen ion loss from vomiting (obstructive GI tract) • Acute kidney injury, AKIN stage 3 • Septic shock, suspected IAI related • Obstructive uropathy with hydronephrosis due to cancer

  21. Discussion-- Metabolic alkalosis The rule of dialysis for treatment for severe metabolic alkalosis

  22. Metabolic alkalosis

  23. F. John Gennari, Am J Kidney Dis, Vol 55, No 6 (June), 2010: pp 1130-1135

  24. F. John Gennari, Am J Kidney Dis, Vol 55, No 6 (June), 2010: pp 1130-1135

  25. F. John Gennari, Am J Kidney Dis, Vol 55, No 6 (June), 2010: pp 1130-1135

  26. HSD11B2 gene KCNJ1 gene SCNN1B gene F. John Gennari, Am J Kidney Dis, Vol 55, No 6 (June), 2010: pp 1130-1135

  27. Metabolic alkalosis • (1) Abnormal chloride losses • (2) In states of mineralocorticoid excess • (3) Renal ion transport disrupted by genetic abnormalities that lead to stimulation of collecting duct sodium reabsorption through ENaC (eg, Liddle syndrome) F. John Gennari, Am J Kidney Dis, Vol 55, No 6 (June), 2010: pp 1130-1135

  28. Metabolic alkalosis • Surreptitious vomiting or diuretic abuse should always be considered • Both aldosterone and renin levels should be increased • Apparent mineralocorticoid syndrome • Liddle syndrome • HSD2 deficiency • Hypertension • Hypokalemia • Metabolic alkalosis • Low aldosterone levels • Genetic analysis: gold standard • Aldosterone antagonist: for 11HSD2 • deficiency; no effect to Liddle syndrome • Amiloride: blocks ENaC directly, • treatment for Liddle syndrome F. John Gennari, Am J Kidney Dis, Vol 55, No 6 (June), 2010: pp 1130-1135

  29. Clinical course of a patient with CHF and metabolic alkalosis

  30. Aldo J. Peixoto, Am J Kidney Dis. 2013;61(5):822-827

  31. Case Present • 68 y/o M, transferred to ICU: Af and pulmonary edema s/p intubation • HTN, CAD,CHF with preserved systolic function, obesity • Persistent signs of volume overload but received only intermittent doses of furosemide • Three days prior to transfer, developed more overt signs of CHF, prompting more aggressive use of furosemide (40-80 mg intravenously [IV] twice daily) Aldo J. Peixoto, Am J Kidney Dis. 2013;61(5):822-827

  32. Case Present • Remained volume overloaded and developed pulmonary edema requiring intubation during an episode of rapid Afib • Echocardiogram: atrial dilatation, moderate AR and MR, LVEF: 50% with mild posterobasal hypokinesis, and impaired diastolic filling • IV furosemide with gradual improvement in congestion  progressive alkalemia and severe hypokalemia over the ensuing 5 days Diagnosis: CHF; metabolic alkalosis due to heart failure and loop diuretic use; hypokalemia due to loop diuretic use and secondary hyperaldosteronism from decompensated heart failure Aldo J. Peixoto, Am J Kidney Dis. 2013;61(5):822-827

  33. Aldo J. Peixoto, Am J Kidney Dis. 2013;61(5):822-827

  34. Metabolic alkalosis of CHF • Diuretic therapy: chloride loss, decreased effective circulating volume, activation of the renin-angiotensin-aldosterone system • CHF: system sympathetic overactivity  increased renal adrenergic tone  activation of the sodium/hydrogen ion exchanger in the proximal tubule Aldo J. Peixoto, Am J Kidney Dis. 2013;61(5):822-827

  35. Aldo J. Peixoto, Am J Kidney Dis. 2013;61(5):822-827

  36. IV acetazolamide (250 mg every 6 hours for 24 hours or as a single dose of 500 mg) Ex: 70 kg*0.5*10 mEq; infusion should not be faster than 0.2 mEq of hydrogen per 1 kg of body weight per hour; F/U e-/ABG Q1-2H Aldo J. Peixoto, Am J Kidney Dis. 2013;61(5):822-827

  37. The rule of dialysis for treatment for severe metabolic alkalosis

  38. Case Present • A 69-year-old woman, ESRD (secondary to hypertensive nephrosclerosis); invasive SCC of the left pinna and ear with neck metastasis • Presented with confusion, lethargy, and low oxygen saturation (80%) • These symptoms preceded for several days of severe and profuse vomiting • Abdominal CT: proximal small-bowel dilatation measuring up to 3.3 cm in diameter, with a transition point noted in the left hemipelvis (narcotic use) Lu Huber, Am J Kidney Dis. 2011;58(1):144-149

  39. Case Present • Admitted to ICU: • NG insertion, pantoprazole therapy • Dialysis: urgently for 3 hours without ultrafiltration: using dialysate: • Potassium : 4 mEq/L (4 mmol/L) • Calcium(ionized): 5 mg/dL (1.25 mmol/L) • Bicarbonate: 30 mEq/L (30 mmol/L) Lu Huber, Am J Kidney Dis. 2011;58(1):144-149

  40. NG 4700ml iHD iHD 2hours Lu Huber, Am J Kidney Dis. 2011;58(1):144-149

  41. Lu Huber, Am J Kidney Dis. 2011;58(1):144-149

  42. + Lu Huber, Am J Kidney Dis. 2011;58(1):144-149

  43. Lu Huber, Am J Kidney Dis. 2011;58(1):144-149

  44. Vomiting and GI hydrogen ion loss • High grade gastric distension due to outlet obstruction causes cholinergic activation  Increased gastrin secretion, decreased somatostatin secretion  Increased hydrogen ion secretion and gastric fluid volume • When stimulated, gastric fluid has a hydrogen ion concentration of 100-170 mmol/L (pH 1.0) • No stimulated: hydrogen ion concentration 10 mmol/L • One millimole of bicarbonate is generated in body fluids for each millimole of hydrogen ion lost in emesis Lu Huber, Am J Kidney Dis. 2011;58(1):144-149

  45. Hemodialysis for severe metabolic alkalosis • Severe metabolic alkalosis (serum bicarbonate concentrations > 50 mEq/L): • Hemodialysis with a reduced bath bicarbonate concentration is a safe and effective intervention • Bicarbonate decreased to the lowest level available • No increase calcium concentration • Hydrochloric acid infusion is not an acceptable treatment alternative in patients without kidney function (large volume of fluid) Lu Huber, Am J Kidney Dis. 2011;58(1):144-149

  46. Lu Huber, Am J Kidney Dis. 2011;58(1):144-149

  47. Take Home Message • Severe metabolic alkalosis (bicarbonate cncentration >50 mEq/L) + (all these severe case reports) with impairment of kidney function (due to volume loss) Hemodialysis may be considered ! • For metabolic alkalosis, treatment the underlying disease is most important

  48. Thank you for your attention!

More Related