SICU research meetingSICU research meeting

Intern Intern 粘展瑋粘展瑋 2007-01-212007-01-21

Patient ProfilePatient Profile

Name: Name: 徐徐 XX 光光 Gender: maleGender: male Age: 64-year-oldAge: 64-year-old Chart No.: 5046353Chart No.: 5046353 Bed No.: 4B1 07Bed No.: 4B1 07

Past HistoryPast History

Systemic disease: Systemic disease:

DM(-), HTN(-), CAD(-)DM(-), HTN(-), CAD(-) Op history: Bilateral hip replacement 5 yeaOp history: Bilateral hip replacement 5 yea

rs agors ago Smoking: Smoking: 2~3 PPD for many years2~3 PPD for many years Allergy: DeniedAllergy: Denied

Brief history IBrief history I 9505 9505 Blood-tinged sputum, Blood-tinged sputum, 恩主公恩主公 H, Cytology: SCCH, Cytology: SCC CT: right hilar and subcarinal LAP and obstructive pneumonia of RUL. CT: right hilar and subcarinal LAP and obstructive pneumonia of RUL. 95069506 NTUH, T4N2M0, stage IIIb NTUH, T4N2M0, stage IIIb Received CCRT( Taxotere+Cisplatin followed by 45Gy/25fx R/T )Received CCRT( Taxotere+Cisplatin followed by 45Gy/25fx R/T ) 9510 9510 CT: encasement of right bronchus, pulmonary a., compression of SVCCT: encasement of right bronchus, pulmonary a., compression of SVC PET: residual malignancy at RULPET: residual malignancy at RUL 951028 951028 Operation:Operation: Right lung pneumonectomy+ SVC, RA, LA tumor excision+ SVC reconRight lung pneumonectomy+ SVC, RA, LA tumor excision+ SVC recon

struction+ temporal pacemaker struction+ temporal pacemaker

Brief history IIBrief history II 95119511 Reintubation due to bronchospasmReintubation due to bronchospasm Extubation on 11/07Extubation on 11/07 951109: 951109: Postero-lateral thoracotomy to repair of RMB stump for SC emphysemaPostero-lateral thoracotomy to repair of RMB stump for SC emphysema 951128 951128 TracheostomyTracheostomy 951206951206 K 6.3, acute renal failure K 6.3, acute renal failure CPR4min→ROSC, s/p CVVHCPR4min→ROSC, s/p CVVH 951219951219 MDRPAMDRPA ID: keep ABx, colistin + CMZ if S/C(+)ID: keep ABx, colistin + CMZ if S/C(+) 950109950109 HSV infection in perianal and scrotum areaHSV infection in perianal and scrotum area 950114950114 RUL stump repair for air leakageRUL stump repair for air leakage

96/01/16

Lab dataLab data

Platelet WBC

HSV-relatedHSV-related

ThrombocytopeniaThrombocytopenia

ThrombocytopeniaThrombocytopenia Definition:Definition: PLT < 150,000/microLPLT < 150,000/microL However, 2.5 % normal population have a platelet count lower However, 2.5 % normal population have a platelet count lower than this. than this. Clinical symptoms were rarely found unless PLT < 100,000/microL.Clinical symptoms were rarely found unless PLT < 100,000/microL.

Life span of platelets Life span of platelets 8 to 10 days8 to 10 days

Production of plateletProduction of platelet 35,000 to 50,000/microL/per day35,000 to 50,000/microL/per day This value can be increased up to eight-fold during times of This value can be increased up to eight-fold during times of increased demand increased demand

Cause of thrombocytopeniaCause of thrombocytopenia

Decreased platelet productionDecreased platelet production Viral infections (ex. rubella, mumps, varicella, parvovirus, HCV, EBV), C/T or R/T, BonViral infections (ex. rubella, mumps, varicella, parvovirus, HCV, EBV), C/T or R/T, Bon

e marrow aplasia or hypoplasia, Alcohol toxicity, VitB-12 or folic acid deficiency e marrow aplasia or hypoplasia, Alcohol toxicity, VitB-12 or folic acid deficiency

Increased platelet destructionIncreased platelet destruction ITP, SLE, Alloimmune destruction (posttransfusion, neonatal, post- transplantation ), ITP, SLE, Alloimmune destruction (posttransfusion, neonatal, post- transplantation ),

DIC, TTP-HUS, HELLP syndrome, Antiphospholipid syndrome, Certain drugs (DIC, TTP-HUS, HELLP syndrome, Antiphospholipid syndrome, Certain drugs (heparinheparin, quinine, quinidine, and valproic acid), Infections (eg, infectious mononucleosi, quinine, quinidine, and valproic acid), Infections (eg, infectious mononucleosis, CMV, HIV) ,Physical destruction of platelets during (CABG, IABP, huge aortic aneus, CMV, HIV) ,Physical destruction of platelets during (CABG, IABP, huge aortic aneurysm)rysm)

Dilutional or distributional thrombocytopeniaDilutional or distributional thrombocytopenia SplenomegalySplenomegaly PseudothrombocytopeniaPseudothrombocytopenia

Dilutional thrombocytopeniaDilutional thrombocytopenia

Massive transfusion with packed RBC Massive transfusion with packed RBC

Usual platelet countUsual platelet count

47K~100K/microL after 15U PRBC in 24 hr47K~100K/microL after 15U PRBC in 24 hr

25K~ 61K /microL after 20U PRBC in 24 hr25K~ 61K /microL after 20U PRBC in 24 hr

Suggest giving platelet concentrates when patieSuggest giving platelet concentrates when patients receiving more than 20U PRBC in 24hr.nts receiving more than 20U PRBC in 24hr.

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

StudyStudy Predictors of thrombocytopenia developingPredictors of thrombocytopenia developing Evolution of DIC Evolution of DIC Cardiopulmonary resuscitationCardiopulmonary resuscitation Signs of organ failure Signs of organ failure

Septic shock, a higher APACHE II score, and a Septic shock, a higher APACHE II score, and a 30 % decrease in platelet counts30 % decrease in platelet counts were significant were significant risk factors for ICU deathrisk factors for ICU death

Crit Care Med 2002 Aug;30(8):1765-71 Crit Care Med 2002 Aug;30(8):1765-71

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

HSV-induced thrombocytopeniaHSV-induced thrombocytopenia PathogenesisPathogenesis Tend to infect cells of Tend to infect cells of ectodermal originectodermal origin. After retrograde . After retrograde axonal flow from axonal flow from

neuronsneurons at the viral point of entry and local replication, the viral genome bec at the viral point of entry and local replication, the viral genome becomes latent. omes latent.

HSV viremia HSV viremia Immunocompromised population is most commonImmunocompromised population is most common Immunologically healthy individuals can occur, especially Immunologically healthy individuals can occur, especially in pregnancy in pregnancy Disseminated infection can result in Disseminated infection can result in hepatitishepatitis, esophagitis, pneumonitis, , esophagitis, pneumonitis, encephalitis, and adrenal necrosis. encephalitis, and adrenal necrosis.

HSV hepatitis HSV hepatitis Leukopenia, thrombocytopeniaLeukopenia, thrombocytopenia, and disseminated intravascular coagulation, and disseminated intravascular coagulation

E-medicineE-medicine

HSV hepatitisHSV hepatitis Lab pictureLab picture Marked elevation of liver transaminase valuesMarked elevation of liver transaminase values Slight increase in the bilirubin levelSlight increase in the bilirubin level Leukopenia and thrombocytopenia Leukopenia and thrombocytopenia Kaufmam et al, in their review, found a WBC count of <5,000/mm3 iKaufmam et al, in their review, found a WBC count of <5,000/mm3 i

n 43% of patients. n 43% of patients. Aboguddah et al, found a mortality rate of 81%; of cases reported bAboguddah et al, found a mortality rate of 81%; of cases reported b

etween 1969 and 1980, 88% were fatal, and of cases reported from etween 1969 and 1980, 88% were fatal, and of cases reported from 1981 to 1989, 78% were fatal 1981 to 1989, 78% were fatal

Clin Infect Dis 1997; 24:334-338 J Rheumatol 1991; 18:1406-1412

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

In our patientIn our patient

1/14: Transfusion PLT: 24U PRBC: 2U for operation

1/20 & 1/21 : PRBC 2U for Hb↓ r/o GI bleeding

DiagnosisDiagnosis

Clinical pictureClinical picture

Skin lesionSkin lesion

CT of liver CT of liver

Multiple low-density lesions Multiple low-density lesions

Liver biopsy is gold standardLiver biopsy is gold standard

Of 52 reported cases, the correct diagnosis was Of 52 reported cases, the correct diagnosis was

made before death in only 23%.made before death in only 23%.

Clin Infect Dis 1997; 24:334-338

TreatmentTreatment

Acyclovir Acyclovir

A review of the clinical experience with acyclovir in the A review of the clinical experience with acyclovir in the treatment of HSV hepatitis shows that 13 of 21 patients treatment of HSV hepatitis shows that 13 of 21 patients

survivedsurvived..

Transplantation 1995; 59:145-149 Transplantation 1995; 59:145-149

InfectionInfection

Antibiotics for Antibiotics for Pseudomonas aeruginosa Pseudomonas aeruginosa Colistin(1221~)Colistin(1221~)

Fortum(1221~)Fortum(1221~)

Metronidazole(12/25~)Metronidazole(12/25~)

Fortum was discontinued on 1/15