clinical case

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Here's a case I wanted to share thoughts on:

Pt hx: Lower GI bleed (associated with rectal tube/hemorrhoids), ESRD

Dialysis MWF

assess: AA0x2, temp 35.5, lungs slightly coorifice, 95% on 2LNC, HR 80's, B/p 60's/30's, +2pitting edema in arms/legs, good pulse arms, weak pulses feat, MAE, bowel sound present, abd nontender, anuric, large gel-like bowel movements with bloody clots.

access: triple lumen to R groin (old-maybe infected)-removed after blood products infused, new 3L to l groin placed

Pertinent labs:

Hgb: (4am)9.4, (8am) 8.4, (post transfusion 2 u PRBCs and 2 plts) 10.4

hct 28-30ish

na 135

k (am)3, (post-transf.) 3.1 (pt then got 20meq KCl IV)

bun/creat: 35, 5

alb 1.5 (?)

pt received liter and a half of NS, blood products, and continuous NS at 50/hr afterward, B/P still 70's/30's with MAPs in 40's. (temp now normal 36.9-37.2 with warming blanket) Started on Levo at 5mcg/min.... B/P came up a bit 80's-90/40, MAPs in 50's-60. Levo down to 2mcg/min. B/P dropped again after about hr to 70's/30's with MAP in 40's. HR up to 100's now. Levo turned up to 15mcg. MAP finally 65, diastolic pressures still low 30s. HR 120. NO access for a CVP.

pt still AAO, no other pasing of lg blood clots.

dr. finally agrees to give more fluids. bolus over an hour of NS.

Maybe hetastarch or albumin better? What other ideas do you guys have for the case?

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Specializes in ICU/Critical Care.

Is the patient septic as well or just a GI bleed? Seems like it could be possible if the patient had an old triple lumen. Were any blood cultures done? Albumin might help. It does help expand the circulating blood volume. But given the fact that the BUN/Cre are elevated, it might cause fluid overload.

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Specializes in Cardiac.
Started on Levo at 5mcg/min.... B/P came up a bit 80's-90/40, MAPs in 50's-60. Levo down to 2mcg/min. B/P dropped again after about hr to 70's/30's with MAP in 40's.

Why was the Levo turned down with the MAP in the 50's? Sometimes, people titrate too quickly and the pt just needs some time to perfuse a second.

What was his lactate?

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Specializes in ICU/Critical Care.
Why was the Levo turned down with the MAP in the 50's?

True. Should have left the levo alone. Should keep the MAP above 60

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Specializes in Cardiac.
True. Should have left the levo alone. Should keep the MAP above 60

Yeah, and leave it there for a bit. Let the man's organs get some blood!

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Specializes in ICU/Critical Care.
Yeah, and leave it there for a bit. Let the man's organs get some blood!

I don't know how long the levo was infusing but there's no rush to bump it down from 5mcg. Its not that much levo. Plus don't increase levo then half hour later turn it down, can cause rebound hypotension.

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Specializes in Cardiac.

access: triple lumen to R groin (old-maybe infected)-removed after blood products infused, new 3L to l groin placed

Did you send the tip for culture?

Also, was the rectal tube still in place?

I'd pan culture him,( I would have sent them in light of his temp and BP) ask for a random cortisol level and stat lactate.

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signs of sepsis: low temp, hypotensive, hr eventually went up (could have been other issues...) gathering from the fact that she has +2 pitting edema, seems like capillaries were leaking--3rd spacing. the Levo was turned back to 2mcg from 5 after having above adequate map>60 for a while (per orders). 2 sets of blood cultures were sent (old line and from new line). old catheter tip was sent for culture. it will be interesting to see how that turns out! rectal tube was gone prior to admit to ICU from floor.

With the cortisol level--are you thinking addisonian crisis?

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Specializes in ICU/Critical Care.
signs of sepsis: low temp, hypotensive, hr eventually went up (could have been other issues...) gathering from the fact that she has +2 pitting edema, seems like capillaries were leaking--3rd spacing. the Levo was turned back to 2mcg from 5 after having above adequate map>60 for a while (per orders). 2 sets of blood cultures were sent (old line and from new line). old catheter tip was sent for culture. it will be interesting to see how that turns out! rectal tube was gone prior to admit to ICU from floor.

With the cortisol level--are you thinking addisonian crisis?

Did they do a cortisol stimulation test? Sometimes patients with sepsis have adrenal insufficiency so the docs usually will start hydrocortisone. Had a patient with a low diastolic BP. It was 20-40. Docs suspected adrenal insufficiency, did the stim test, started hydrocortisone. Patient got four doses total, DBP came back up.

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I'm thinking sepsis AND (resolving) GI bleed: low temp, hypotensive, 2+pitting edema (capillaries leaking--3rd spacing), and eventually tachycardia, lungs were slightly coorifice.

the Levo was weaned from 5 to 2 mcg after pt had above adequate MAP for a while (Map 70-80's).

blood cx were sent from old line and new line. tip from old line sent for cx.

rectal tube removed at some time prior to coming to unit from floor.

cortisol, good thought---were you thinking along the lines of addisonian crisis?

Thanks for the replies : )

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Specializes in ICU/Critical Care.

No, adrenal crisis. Patients with adrenal crisis present with hyper or hypothermia, unexplained shock refractory to fluid resuscitation.

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Medical diagnosis of the "adrenal crisis" in which there is an insufficiency is Addisonian Crisis, girl! : )

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