Inter Hospital Conference

Inter-hospital
Conference
RAMATHIBODI HOSPITAL
Inter-Hospital Conference Jan,2014. Panvilai T.
O 29
O CC : 2
O 4
2

8/10
Question

O 4
( )
O 2


O .
O
.
O
O 4 pack-year
O Social Drinking
O 1
O

O Temp 37.1 C (axillar), BP 109/55 mmHg, PR
O
O
O
O
O
97/min, RR 24/min
GA : Alert, not pale, mild jaundice
HEENT : not injected tonsil and pharynx
Heart : normal S1S2, no murmur
Lung : clear
Abd : Active BS, soft, tender RUQ and
epigastrium, voluntary gaurding, no rebound,
Murphys sigh
PR : yellow feces
Question
Problem list and Differential

Diagnosis
Problem list and Differential

Diagnosis
O Acute RUQ pain and fever
O Acute cholecystitis
O Acute cholangitis
O Systemic Infection
Investigation
U
10
Ultrasound
Bedside
-GB wall 1 cm
- no GS
- no pericholecystic fluid
- Sonographic Murphys
sign +
11
CBC
O WBC
O 8,640 ( N79, L7, AL 11)
O HCT
O 57% (Hb 18.7)
O PLT
O 20,000
12
Chemistry
O Electrolyte
O Na 122, K 5.68, Cl 86, CO2 11.4

O Renal function
O BUN 21/ Cr 0.93
O Liver Function
O AST 9979/ ALT 4707, ALP 323/ GGT 454
O DB 1.8/ TB 3.1, Alb 35/ TP 67
O Pancreatic enz.
O Amylase 131
O Lipase 92
13
Coagulogram
O PTT
O PT
O INR
O TT
145.2
22.7
1.84
13.9
(22-33)
(10-13)
(10-13)
14
Ultrasound Report
O Diffuse thickening wall of gallbladder with
positive sonographic Murphys sign and

pericholecystic free fluid but no gallstone
or distension of gall bladder, suggestion
for acute gangrenous choecystitis
15
Differential Diagnosis, Further

Management and
Investigation
16
Differential Diagnosis, Further

Management and
Investigation
O Acute gangrenous Cholecystitis with DIC
O Severe Dengue Hemorrhagic Fever
O Severe Systemic Infection (Leptospirosis)
O Viral Hepatitis with Impending liver failure
O Toxic Hepatitis with Impending liver failure
17
At ER 2hr after Pt arrive

O Pt look agitation, PR 100/min, BP 110/90
O
O
O
O
mmHg, RR 24/min, Osat RA 94%

On Oxygen canular 3 LPM
NSS 1,000 ml IV load 500 ml in 15 min
then 150 ml/hr
Consult Medicine
Consult Surgeon
18
Managment
O Investigation
O Repeat CBC
O DIC panal
O Dengue Titer
O Hepatitis Profile
O Acetaminophen level
O Med
O ABG
O Anti-HAV
O Sx
O UA
O Plt 8 U IV
O Tazocin 4.5 g IV
O Losec 40 mg IV
O CT Whole
Abdomen
O Ceftriazone 2 g IV
O Metronidazole 500 mg IV
O 7.5% NaHCO3 1 amp IV
O FFP 4 U IV
19
Managment
O Investigation
O Repeat CBC
O DIC panal
O Dengue Titer
O Hepatitis Profile
O Acetaminophen level
O Med
O ABG
O Anti-HAV
O Sx
O UA
O Plt 8 U IV
O Tazocin 4.5 g IV
O Losec 40 mg IV
O CT Whole
Abdomen
O Ceftriazone 2 g IV
O Metronidazole 500 mg IV
O 7.5% NaHCO3 1 amp IV
O FFP 4 U IV
20
Repeat CBC
O WBC
O 13,730 ( N55, L15, AL 7, Band 5)
O HCT
O 50% (Hb 16)
O PLT
O 6,000
21
Dengue Titer
O Dengue virus NS1 antigen
O negative
O Dengue virus antibody IgM

O negative
O Dengue virus antibody IgG

O negative
22
ABG
O pH
O pO2
O pCO2
O HCO
7.32
133
19
10.4
23
Acetaminophen Level
O < 2.5 ug/ml
24
Hepatitis profile
O HBsAg
negative
O Anti-HCV negative
O Anti-HAV IgM
negative
O Anti-HIV
negaitive
25
Urinalysis
O SpGr
O Protein
O Ketone
O Blood
O WBC
O RBC
O Sq
1.015
3+
+
+++
0-1
>100
0-1
26
DIC panal
O D-dimer
O Fibrinogen level
1,049 (0-275)
167 (164-400)
27
CT Whole
abdomen
28
29
30
31
CT Whole abdomen
O Diffuse gall ladder wall thickening,
bilateral pleural effusion and ascites.
32
Differential Diagnosis
33
Radiologist consultation
O Reticular
Gallbladder Wall
Thickening : the
main feature of
plasma leakage
(Mostly Dengue
infection or
systemic infection)
34
Diagnosis
O Severe Dengue Hemorrhagic Fever with
impending Liver Failure

O Admit ICU at 30 hours after arrival
35
Repeat Dengue Titer

O Dengue virus NS1 antigen
O Positive
36
Progression
O Management at Ward
O 27/9/56
O 5%D/NSS IV 60 ml/hr
O FFP 2 U IV
O NAC IV protocal
O Pt on BiPAP, Lasix + Albumin, Viral
18
O 28/9/56
O CPP 10 U IV
37
Progression
29/9/56
O Hct 57 -> 50 -> 39 -> 29 -> 26 (no clinical
bleeding)
O PRC 1 U IV
O Pt Osat RA 90%
O
ABG Osat 99%

O Methemoglobin level = 8.7%
O Work up for anemia -> Drak Urine

O PBS + schistocyte
O G6PD Defficiency +
O Aclkalinization of Urine
38
Progression
O 1-4/10/56
O Supportive alkalinize Urine
O D/C
O HM. Folic 1*!
39
Dengue Hemorrhagic Fever
40
Dengue Hemorrhagic fever

O Diagnostic Test
O Specific Laboratory Finding
O Ultrasound Finding
O Management
O Adult with Dengue Infection
41

O Diagnostic Test
O Management
42
Specific Laboratory
Investigation
1. viremia
2. RNA genome Reverse
Transcription-Polymerase Chain Reaction (RT-PCR)
3.
43
3.
O primary infection
5
O secondary infection
2-3
44
False Negtive
O dengue IgM 2
90
60
O Rapid test IgM

IgM test
Flavivirus
O NS1-based assays : antigen detection in the acute stage of
secondary infections can be compromised by pre-existing

virusIgG immunocomplexes
45
46

O Diagnostic Test
O Management
47
Role of Ultrasound in DHF

O Ultrasound techniques have been used for
the evaluation of adults and children

suffering from dengue. Depending on the
diseases severity, the ultrasonographic
findings may vary from mild ascites,
hepatomegaly and thickening of
gallbladder walls in Stage I-II to these
findings and pleural effusion, pancreatic
enlargement, peri- or para-renal
collections and pericardial effusion in
Stage III-IV.
48
O 88 serologically positive cases

O 32 patients underwent ultrasound on
second to third day

O gall bladder wall thickening and
O pericholecystic fluid
O 56 patients ultrasound was done only on
fifth to seventh day

49
O Daily ultrasound examinations of the
abdomen and right thorax were performed in

158 suspected dengue cases
O Detected in DHF cases starting from 2 days
before defervescence and was detected in
some cases within 3 days after fever onset
O Pleural effusion was the most common
ultrasonographic sign of plasma leakage (62%
of DHF cases one day after defervescence
O Thickening of the gallbladder wall and ascites
were detected less frequently (43% and 52%
of DHF cases respectively)
50
O Ultrasound detected plasma leakage in 12
of 17 DHF cases who did not meet the

criteria for significant hemoconcentration.
51
52
53

O Diagnostic Test
O Management
54
55

.. 2556
O
O
O
O (laboratory
diagnosis for acute dengue infection)
O /
(Warning signs in severe dengue infection:
WHO 2009)
O
O
(plasma leakage)
56

.. 2556
57

.. 2556
58
59

.. 2556
60

.. 2556
61

.. 2556
62
63

.. 2556
O End point Target :
O pulse pressure > 20 mmHg, Urine
sp gr 1010-1020
O Keep urine output
O 0.5-1.0 ml/Kg/hr,
O Hct~40-45%
O Limitation: leakage syndrome
pleural effusion, ascites, crepitation
64
/
pulse pressure < 20 mmHg
O IV isotonic crystalloid 0.9%saline RLS
5-7 ml/kg/hr x1-2 hr

O clinical parameter 3-5
ml/Kg/hr x 2 -4 hr
2-3 ml/Kg/hr
O clinical parameter /
7-10 ml/Kg/hr 1-2 ( 2-4 )
( 2-4 )
65

O IV isotonic crystalloid 0.9%saline RLS
10-20 ml/kg/hr ( 500-1000 ml )x 1-2 hr

O clinical parameter 5-7
ml/Kg/hr x 1-2 hr
O clinical parameter /
colloid solution 5% albumin,
Dextran, FFP 10 ml/kg/hr x 1 hr (
)
crystalloid solution
66
crystalloid
solution
O severe bleeding, metabolic
acidosis, severe sepsis, pneumothorax

O (vasopressor)
norepinephrine 0.1-0.2 mcg/kg/min
10-15 (max dose 1-2 mcg/kg/min )
O
67

.. 2556
O
O 1.

O 2.

(grade III IV)
(intravenous fluid)
Hct

O 3. liver transaminase

2 AST/ALT

68

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Inter-hospital

Inter-Hospital Conference Jan,2014. Panvilai T.

Inter-Hospital Conference Jan,2014. Panvilai T.

Inter-Hospital Conference Jan,2014. Panvilai T.

Inter-Hospital Conference Jan,2014. Panvilai T.

Inter-Hospital Conference Jan,2014. Panvilai T.

Inter-Hospital Conference Jan,2014. Panvilai T.

Inter-Hospital Conference Jan,2014. Panvilai T.

Problem list and Differential

Inter-Hospital Conference Jan,2014. Panvilai T.

Problem list and Differential

Inter-Hospital Conference Jan,2014. Panvilai T.

Inter-Hospital Conference Jan,2014. Panvilai T.

Inter-Hospital Conference Jan,2014. Panvilai T.

O Na 122, K 5.68, Cl 86, CO2 11.4

Inter-Hospital Conference Jan,2014. Panvilai T.

positive sonographic Murphys sign and

Inter-Hospital Conference Jan,2014. Panvilai T.

Differential Diagnosis, Further

Inter-Hospital Conference Jan,2014. Panvilai T.

Differential Diagnosis, Further

Inter-Hospital Conference Jan,2014. Panvilai T.

At ER 2hr after Pt arrive

mmHg, RR 24/min, Osat RA 94%

Inter-Hospital Conference Jan,2014. Panvilai T.

Inter-Hospital Conference Jan,2014. Panvilai T.

O Dengue virus antibody IgM

O Dengue virus antibody IgG

Inter-Hospital Conference Jan,2014. Panvilai T.

Inter-Hospital Conference Jan,2014. Panvilai T.

Inter-Hospital Conference Jan,2014. Panvilai T.

Inter-Hospital Conference Jan,2014. Panvilai T.

Inter-Hospital Conference Jan,2014. Panvilai T.

Inter-Hospital Conference Jan,2014. Panvilai T.

Inter-Hospital Conference Jan,2014. Panvilai T.

Inter-Hospital Conference Jan,2014. Panvilai T.

bilateral pleural effusion and ascites.

Inter-Hospital Conference Jan,2014. Panvilai T.

Inter-Hospital Conference Jan,2014. Panvilai T.

Inter-Hospital Conference Jan,2014. Panvilai T.

impending Liver Failure

Inter-Hospital Conference Jan,2014. Panvilai T.

Repeat Dengue Titer

Inter-Hospital Conference Jan,2014. Panvilai T.

O Hct 57 -> 50 -> 39 -> 29 -> 26 (no clinical

ABG Osat 99%

O Work up for anemia -> Drak Urine

Inter-Hospital Conference Jan,2014. Panvilai T.

Dengue Hemorrhagic Fever

Inter-Hospital Conference Jan,2014. Panvilai T.

Dengue Hemorrhagic fever

Inter-Hospital Conference Jan,2014. Panvilai T.

Dengue Hemorrhagic fever

Inter-Hospital Conference Jan,2014. Panvilai T.

Inter-Hospital Conference Jan,2014. Panvilai T.

Inter-Hospital Conference Jan,2014. Panvilai T.

O NS1-based assays : antigen detection in the acute stage of

secondary infections can be compromised by pre-existing

Inter-Hospital Conference Jan,2014. Panvilai T.

Dengue Hemorrhagic fever

Inter-Hospital Conference Jan,2014. Panvilai T.

Role of Ultrasound in DHF

the evaluation of adults and children

O 88 serologically positive cases