Moderator EMEDPA Posted August 7, 2018 Moderator Share Posted August 7, 2018 Ok, A lot of firsts for me here. Let's play find the dx: 60 yr old male brought in by ambulance for aloc, gradually worsening over 1 week. normally completely functional VS: P 73(NSR), bp 136/74, R 18, sao2 98% RA, T 36.1 CBG from ems 95, GCS 11. no report of trauma. Looks ill from door. moaning, jaundiced. responds to sternal rub with moans and occasional "hey, whatcha doin!" EMS unable to start IV with many attempts. ditto rn staff. Go! what hx and physical exam would you like? what interventions and labs? you can have a single somewhat confused elderly family member for hx 2 hrs after pt arrives via ems. Link to comment Share on other sites More sharing options...
jk5142 Posted August 7, 2018 Share Posted August 7, 2018 A-seems to be protecting for the moment B-satting ok, no mention of labored respirations or other specific patterns of breathing C-appears hemodynamically stable Hx: comorbid conditions, known liver disease, EtOH hx, drug user, meds/APAP use, onset of jaundice, any belly pain or GI sx, any other neuro sx, increased edema, recent weightloss Exam: Neuro/HENT- look for head trauma, scleral icterus, neuro deficits, mvmt of extremites, mallampati score Neck-JVD? CV-usual Lungs-usual Abdomen: pain? RUQ tenderness? ascites? Extremities- edema? asterixis? pulses? Skin: other stigmata of chronic liver disease? bruising? Request>>> ABG, lactate, EtOH level, ammonia, Utox CBC, CMP, aPTT/INR Intvn: monitor MS/airway IV access- US if needed to place peripherals CT brain wait for labs to come back Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted August 7, 2018 Author Moderator Share Posted August 7, 2018 1 hour ago, jk5142 said: A-seems to be protecting for the moment B-satting ok, no mention of labored respirations or other specific patterns of breathing C-appears hemodynamically stable Hx: comorbid conditions, known liver disease, EtOH hx, drug user, meds/APAP use, onset of jaundice, any belly pain or GI sx, any other neuro sx, increased edema, recent weightloss RECENT UTI, DID NOT TAKE ABX BECAUSE THEY MADE HIM DIZZY. 7 SHOTS VODKA/DAY, JAUNDICE OVER LAST WEEK, WORSENING DAILY Exam: Neuro/HENT- look for head trauma, scleral icterus, neuro deficits, mvmt of extremites, mallampati score NO TRAUMA, + ICTERUS, MOVES EXTERMITIES, MALLAMPATTI 3 Neck-JVD? NO CV-usual NL Lungs-usual NL Abdomen: pain? RUQ tenderness? ascites? LG LIVER Extremities- edema? asterixis? pulses? NL PULSES, + ASTERIXIS Skin: other stigmata of chronic liver disease? bruising? DIFFUSE BRUISING Request>>> ABG NL , lactate 2.3 , EtOH level 0 ammonia 36 , Utox BENZOS CBC NL, CMP BILI 12, CR 4, BUN 80, AST400/ALT 800, ALK PHOS 250 INR 1.6 Intvn: monitor MS/airway DONE IV access- US if needed to place peripherals: IO X 2 DONE, IJ DONE CT brain NL wait for labs to come back FOLEY PLACED, WBC 20-30 ON CATH SPECIMEN Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted August 8, 2018 Share Posted August 8, 2018 Further tx? IVF, IV abx (Rocephin), NG tube & lactulose? CT abd w/o contrast? Hope the ICU isn't capped. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted August 8, 2018 Author Moderator Share Posted August 8, 2018 yes, this is urosepsis with hepatorenal syndrome(multisystem organ failure). 30 cc/kg fluids, rocephin 2 gm IV, narcan given without effect on arrival, Vitamin C sepsis protocol(1st for me). Ammonia not high enough for lactulose. ICU admit https://en.wikipedia.org/wiki/Hepatorenal_syndrome https://www.google.com/imgres?imgurl=http://rebelem.com/wp-content/uploads/2017/03/The-Marik-Protocol-Meds-1024x640.png?x49676&imgrefurl=http://rebelem.com/the-marik-protocol-have-we-found-a-cure-for-severe-sepsis-and-septic-shock/&h=640&w=1024&tbnid=mlP6n8kfVhL-wM:&q=vitamin+c+sepsis+protocol&tbnh=160&tbnw=256&usg=AFrqEze7-BuTobO1azS43vSbk0vf6wCD9A&vet=12ahUKEwi_srvFrNzcAhUVCDQIHXy2AVoQ9QEwAHoECAoQBg..i&docid=WSHtuSd5gTAT0M&sa=X&ved=2ahUKEwi_srvFrNzcAhUVCDQIHXy2AVoQ9QEwAHoECAoQBg Link to comment Share on other sites More sharing options...
jmj11 Posted August 8, 2018 Share Posted August 8, 2018 Great case. Just got home and put the thinking cap on to work on this, and then your answer came in. How would you differentiate this from hepatic encephalopathy (10% with normal ammonia), induced by an acute (septic) renal failure? Or, are you saying the same thing? What is the mechanism of cognitive changes? I didn't see a (quantitative) benzo level. Hyperreflexia / clonus? Link to comment Share on other sites More sharing options...
jk5142 Posted August 8, 2018 Share Posted August 8, 2018 It does sound like his encephalopathy could be multifactorial (UTI, HE despite normal ammonia, uremia assuming BUN is up along with that Cr) The AKI (?CKD) could be HRS but I believe HRS is usually a dx of exclusion. Workup AKI with renal US, FENa/FEUrea. Check urine sediment for ?ATN. See response to IVF boluses from ED. Hope he makes urine. To me this sounds more like an undiagnosed cirrhotic now presenting with decompensation. Not quite convinced he is septic (no fevers, no leukocytosis, BP stable, breathing ok) although would definitely still keep the abx on board while sorting everything out. CT a/p or at least RUQ US. I would assume there would be cirrhotic morphology noted, and if ascites, dx para to r/o SBP. -would definitely want to work this up to distinguish between decompensated cirrhosis vs ALF from acute infection/ingestion (he does have coagulopathy and encephalopathy). -would probably start him on lactulose -call GI/hepatology who seem to like ordering acute hepatitis panel (A,B,C), APAP level, salicylates, check for titers for HSV/VZV, ceruloplasmin. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted August 8, 2018 Author Moderator Share Posted August 8, 2018 did not have clonus. no hyper-reflexia. did have some intermittent flexion of both wrists potentially c/w asterixis. I did not consider hepatic encephalopathy in the setting of near nl ammonia(nl 32, this pt 36). I was not aware of that 10% stat, thanks. I did not give lactulose, but was planning to do so if ammonia elevated via ng. will be intertesting to see what the intensivist does with this. no quantitative benzo level available. pt was very dehydrated. 3500 cc in, 400 cc very dark urine out foley. did not require pressors for me, but all my consultants thought they likely would soon. apparently mortality with this constellation of sx is 40-60% within 1 month. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted August 8, 2018 Author Moderator Share Posted August 8, 2018 20 minutes ago, jk5142 said: It does sound like his encephalopathy could be multifactorial (UTI, HE despite normal ammonia, uremia assuming BUN is up along with that Cr) The AKI (?CKD) could be HRS but I believe HRS is usually a dx of exclusion. Workup AKI with renal US, FENa/FEUrea. Check urine sediment for ?ATN. See response to IVF boluses from ED. Hope he makes urine. To me this sounds more like an undiagnosed cirrhotic now presenting with decompensation. Not quite convinced he is septic (no fevers, no leukocytosis, BP stable, breathing ok) although would definitely still keep the abx on board while sorting everything out. CT a/p or at least RUQ US. I would assume there would be cirrhotic morphology noted, and if ascites, dx para to r/o SBP. -would definitely want to work this up to distinguish between decompensated cirrhosis vs ALF from acute infection/ingestion (he does have coagulopathy and encephalopathy). -would probably start him on lactulose -call GI/hepatology who seem to like ordering acute hepatitis panel (A,B,C), APAP level, salicylates, check for titers for HSV/VZV, ceruloplasmin. BUN was 80. deep dive in the chart shows neg hep a/b/c within the last year done by pcp. I work at a little rural hospital without GI or most other specialties for that matter. we have a family medicine hospitalist I didn't even bother calling. transferred to the big city for work up. Sounds like I probably should have started the lactulose despite essentially nl ammonia level. live and learn. for the sepsis dx, I figured source plus altered mentation and evidence of volume depletion with lactate > 2. also considered that this all started with the cipro causing a renal insult. this may very well be hepatorenal syndrome + uti with dehydration without sepsis. family arrived later to tell us he has not eaten in 6 days. Link to comment Share on other sites More sharing options...
jk5142 Posted August 8, 2018 Share Posted August 8, 2018 definitely didn't sound like one could r/o sepsis (especially if he looked sick and there was worry he was on the verge of decompensating). Interested to see if he does end up with dx of HRS. But I would guess/hope he responds to fluids and renal function improves. -In my limited experience, I think the ED starts lactulose if pt is a known cirrhotic/home med and presents with fairly obvious HE. But as encephalopathic as the pt sounded, not sure if the ED would be eager to shove an NG down (with ?any varices present if he's suspected to be a cirrhotic) to start lactulose with the risk of causing GI upset/vomiting/bleeding/aspiration >>> airway. With the pt. in the ED>> resus/stabilization and appropriate dispo (in the midst of the fog of war with limited info and severe time constraints). ICU/medicine>> gets the luxury of time/more information/ability to see response to previous interventions to then monday morning QB the ED, which I don't believe is fair at all. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted August 8, 2018 Author Moderator Share Posted August 8, 2018 thanks. pt known to be alcoholic, but no prior mention of cirrhosis, varices, or ascites. this was all fairly acute over the last 7 days. bottom line is the family dropped the ball by sitting on him and watching him decompensate for almost a week before calling 911. I opted not to intubate as he was maintaining his airway just fine and had a gcs of 11, but I think he probably has an elective intubation and maybe dialysis in his near future, maybe some pressors too if he starts to tank his pressure. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted August 8, 2018 Author Moderator Share Posted August 8, 2018 Looks like final working dx at this point is stage 2-3 HE with essentially nl ammonia (I admit I have never seen HE with nl ammonia before) triggered by a UTI +/- sepsis and dehydration in a chronic alcoholic +/- withdrawal sx with a fairly abrupt onset of hepatorenal syndrome. Pt doing somewhat better with aggressive ICU care. has not required pressors or dialysis yet. should get more info in a week or 2. Westhaven criteria for HE: https://www.mdcalc.com/hepatic-encephalopathy-grades-stages Link to comment Share on other sites More sharing options...
polarbebe Posted August 26, 2018 Share Posted August 26, 2018 On 8/7/2018 at 11:30 PM, EMEDPA said: pt was very dehydrated. 3500 cc in, 400 cc very dark urine out Interesting case. Bili 12: Elevated bilirubin (or rhabdo) can also darken urine besides hypovolemia Hepatorenal, agree that it is a diagnosis of exclusion, usually see portal hypertension and a FENa < 1% (unless they are on diuretics for their cirrhosis) Link to comment Share on other sites More sharing options...
CAdamsPAC Posted August 26, 2018 Share Posted August 26, 2018 On 8/7/2018 at 3:04 PM, jk5142 said: A-seems to be protecting for the moment B-satting ok, no mention of labored respirations or other specific patterns of breathing C-appears hemodynamically stable Hx: comorbid conditions, known liver disease, EtOH hx, drug user, meds/APAP use, onset of jaundice, any belly pain or GI sx, any other neuro sx, increased edema, recent weightloss Exam: Neuro/HENT- look for head trauma, scleral icterus, neuro deficits, mvmt of extremites, mallampati score Neck-JVD? CV-usual Lungs-usual Abdomen: pain? RUQ tenderness? ascites? Extremities- edema? asterixis? pulses? Skin: other stigmata of chronic liver disease? bruising? Request>>> ABG, lactate, EtOH level, ammonia, Utox CBC, CMP, aPTT/INR Intvn: monitor MS/airway IV access- US if needed to place peripherals CT brain wait for labs to come back Palpable liver? size? Hang a Banana Bag while labs are pending after giving 100 mg Thiamine. Link to comment Share on other sites More sharing options...
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