Transcript MORTALITY AUDIT DENGUE SHOCK SYNDROME 12 OCTOBER …

CASE PRESENTATION - 4
26/M/F, university student, staying at Gombak
Came back to Kelantan on D2 of fever
S/B MA at A&E, DH
Day 3 onset of fever, 0730am
C/O: Fever-3 days
Nausea and vomiting
Myalgia.
O/E Comfortable Pulse 98/min BP= 98/60mmHg
T=37.5
Lungs -clear
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Given IV fluid 1pint N/S fast.
Repeat BP 102/60
Plan: FBC
Allow discharged (before review of FBC)
Q1: What is the pitfall in the
management ?
District Hospital
Day 5 (1430, 31 hours defervecence)
(Referral letter)
Admitted yesterday.
 C/O: fever for 4 days ,
vomiting and abdominal pain
headache and fainting episodes
No bleeding
No diarrhoea
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2 siblings also had fever. Still at home.
Cont…….
 Admitted for 24 hours.
BP =80-90/50-60mmHg,
HR=105/min
Leptospirosis TRO
dengue
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IV fluid 1pint N/S bolus
followed by 5 pint N/S
over 24 hours
IV C Penicillin 2.0 mega
6hourly
Referred for persistent
thrombocytopenia
IX (Day 5) 0830
IX
1730
WCC
7.8
Hb
Hb
14.5
13.2
Platelet
Platelet
56
7
Urea
Urea
9.0
12.0
WCC
Hct
Hct
8.3
44.0
38.4
Lactate
Lactate
1200
2200
7.1
8.9
16.6
14.1
50.0
42.0
13
5
11.2
INR
INR
1.8
APTT
APTT
112
Q2: Comment on the referral
letter?
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Q3: Comment on diagnosis
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Q4: How would you manage?
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Q5: What other investigations
would you request?
GH: Day 5 (1630,33 hours defervecence)
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Has PV bleed. 4 pads soaked today
Examination: Obese wt 79kg
Alert but restless Afebrile BP 80/60
PR 98/min RR 22/min SPO2:98% on O2 nasal
prong
Generalized macular rash
Lungs: clear
Abdomen: soft , mild tenderness
Hess test: POSITIVE
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Assessment : DSS
Fluid resuscitation: 10ml/kg bolus given for 2
cycles (1L N/S then 1L voluven). Continued
with 1.5 IV fluid maintenance.
ABG: PO2 105 PCO2 25 HCO3 15mmol/l
Day 5 (22.00, 37 hours
defervesence)
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More restless. BP 146/110mmHg
Pulse 105/min RR 25/min. SpO2 95% on HFL
Lungs: Rhonchi. Bilateral pleural effusion
Abdomen: Distended and tender. Ascites
present
Left ankle- bruises
Day 5 (22.30)
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Chest X ray: Bilateral
pleural effusion and
collapsed consolidation of
left lower lobe
ABG: PO2 130 PCO2 21
HCO3 13mmol/l
GXM -3 pint packed cell
6hourly FBC/BUSE
Blood C&S
Echocardiogram: good LV
function EF 68%
IX
IX
1730
1730
2200
2140
WCC
WCC
8.3
8.3
8.9
8.9
Hb
Hb
13.2
13.2
14.1
14.1
Hct
38.4
42.0
Platelet
7
5
Urea
12.0
Hct
Platelet
Urea
Lactate
Lactate
INR
38.4
7
12.0
1.8
INR
1.8
APTT
112
APTT
112
42.0
5
11.2
11.2
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Q6: Discuss on hemodynamic status of
this patient?
Q7: Would you transfuse blood and
blood products?
Day 5 (23.30)
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BP 82/60 Pulse 112/min RR 30/min
Treatment:
IVD 2 pints NS/2H (6ml/kg /hour)
2 pints packed cell transfused
Refferred to anesthetist: NO BED IN
ICU
Q7: How would you manage the
patient?
Day 6 (0230)
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More restless and
tachypnoeic
Ventilated in HDW
Urine output: 20ml/hour
Assessment: DSS with
ARF and acute liver
failure (transaminitis
and coagulopathy)
IX
1730 2140
D5
D5
0100
D6
WCC
8.3
17.8
Hb
IX
Hct
WCC
13.2
14.1
1730
38.4
8.3 42.0
13.0
2200
8.9 41
Platelet
Hb
7 13.2 5
14.1 7
Hct
Urea
Platelet
Creatini
38.4
12.0
7
42.0 13
Urea
Lactate
Lactate
INR
INR
APTT
APTT
12.0
8.9
5
11.2
1.8
1.8
112112
AST
1213
ALT
2303
11.2
300
Day 6 (0900)
Transferred to ICU
 Noted blood clots from the
ETT and RT-coffee ground
aspirate
 Bleeding from nasal and
oral cavity and from the
puncture sites
 BP=105/55 HR 98/min.
 Urine output (20ml/h)
 ABG: pH 7.096 pCO2 18.4
pO2 192.9 HCO3 5.5 BE 24.2
IX
2140 0100
D5
0600
D6
WCC
8.9
17.8
22.8
Hb
IX
Hct
WCC
14.1
13.0
1730
42.0
8.3 41.0
10.0
2200
8.9 28
Platelet
Hb
5 13.2 7
14.1 7
Hct
Urea
Platelet
Creatini
38.4 13
42.0 23
7
5
Urea
Lactate
Lactate
INR
INR
APTT
APTT
12.0
11.2
AST
1213
ALT
2303
1.8
112
300
11.2
480
11.3
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CVVHDF commenced
Blood transfusion: 4 pints PC, 4u
platelet, 4u FFP
Fluid therapy reduced to 500ml/24
hours
Referred to gastro team
Day 7 (0230)
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Assessment: DSS with
ARF and acute liver
failure (transaminitis
and coagulopathy)
IX
1100
D6
1500
D6
2200
D6
WCC
18.3
18.9
17.8
Hb
IX
Hct
WCC
12.0
12.1
11.0
1730
2200
34.4
42.0 8.9 33.1
8.3
27
25 14.1 27
13.2
Platelet
Hb
Hct
38.4
Urea
8.0
Platelet
Creatinine 7
Urea
Lactate
Lactate
INR
INR
APTT
APTT
12.0
7.8
42.0 6.5
5
4.0
1.6
1.8
71
112
AST
1713
ALT
1203
11.2
120
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Q9: Did you agree with the gastro
referral?
Q10: Why did you think the patient
deteriorated despite stable BP?
Day 8(Recovery phase:1000)
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BP:100/50mmHg on NA infusion. T 35C
HR 102/min. Temp=36C. Ventilated. Anuric.
CXR: worsening pleural effusion, ARDS
features
ABG: Ph 6.9, PCO2 58 P02 90 HC02 9
WCC 3.84 Hb 12.2 HCT 36.2 Platelet 16
Hematologist: 2 cycles DIVC regimes and
IV tranxanemic acid.
Day 8(1800)
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General condition deteriorating further:
BP lowish despite 4 max intropes
Bleeding from oral and nasal cavity, ETT
Generalized oedema, peripheral cyanosis
Pupils fixed and dilated
Confirm death at 2025h
Cause of death: DENGUE SHOCK
SYNDROME
Day 9 (0930)
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Dengue IgM: (D5)
borderline
Blood C&S:
D5: No growth
D7:Kleb Pneum
Urine C&S: D7
Kleb Pneum
TA C&S: Kleb Pneum
IX D8
0600 1000
1600
WCC
5.21
4.1
Hb
IX
Hct
WCC
11.6
12.1
1730
34.4
8.3 36.0
9.0
2200
8.9 27.1
Platelet
Hb
25 13.2 15
14.1 27
Hct
Urea
Platelet
Creatini
6.038.4 6.8
7
42.0 6.5
Urea
Lactate
Lactate
INR
INR
APTT
APTT
12.0
3.84
3.7
1.6
1.8
1.8
71 112 60
AST
1868
ALT
833
5
11.2
90
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Q9: Can you comment on borderline
Dengue IgM serology?
FINAL CAUSE OF DEATH
DENGUE SHOCK SYNDROME
WITH SEPTICAEMIA