ICU Grand Round

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ICU Grand Round

• Case Presentation 3.10.2003
• Dr Rishi Mehra

2
Mrs AS

• 53 Year old lady
• Migrated from Philippines
• Past Medical History- Hypertension-
  Hypercholesterolaemia- Lung cancer -
  Adenocarcinoma

3
Mrs AS

• Adenocarcinoma- April 99 Presented to St
  Vincents Hospital - Chest pain dyspnoea -
  CXR -gt Lesion in left mid zone - Bronchoscopy
  biopsy - Adenocarcinoma- Left lower
  lobectomy at St Vincents in May 1999- Resection
  margin free of tumour 20x15x30mm lesion,
  moderately differentiated adenocarcinoma

4
Mrs AS

• Adenocarcinoma- Histology No evidence of
  malignancy in nodes, confirmed margins free of
  malignancy- Staging T1N0M0- 6 monthly review
  at St Vincents under thoracic surgeons

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Mrs AS

• Medications- Simvastatin
• NKDA

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Mrs AS

• Presented to AE on 4.9.2003- Gradual onset
  upper abdominal pain- Localised to right upper
  quadrant- Associated with nausea and vomiting-
  Nil diarrhoea- Nil dysuria- Nil fevers-
  Background of 2 weeks of loss of appetite and
  loss of weight clothes feel a bit loose

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Mrs AS

• One month of increasing dyspnoea- cough, clear
  sputum- No fevers- No travel hx/exposure
• ExaminationHR 90 reg / RR 20 / BP
  135/95 SpO2 96 Room air / T 37.4

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Mrs AS

• Chest Examination - Good AE RgtL, no creps
  heard
• Abdominal Exam- Tender in RUQ and epigastrium-
  Murphys sign Negative- BS present

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Mrs AS

• CXR Prominent right middle fissure-
  consolidation in right middle zone
• FBE 12.6 / 9.7 / 331 Neut 7.5- Film left
  shift with neutrophilia
• UE NormalCr 0.06
• LFTs Bilirubin 12 / ALT 120 / ALP 105/
  GGT 207 Albumin 38

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Mrs AS

• Amylase 81, Lipase 36, CRP 11
• Discussed with ED senior
• Impression right middle lobe pneumonia
• Rx Ceftriaxone 2g, oral roxithromycin
• LMO letter organised
• Pt discharged home

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Mrs AS

• Saw LMO that day
• LMO concerned about LFT abnormalities and RUQ
  pain
• Organised U/S that day- Thickened GB wall c/w
  cholecystitis- Commenced antibiotics -
  ?which??- Told to present to hospital if
  condition worsens significantly

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Mrs AS

• Pt returned to AE on 6.9.03 0511
• On arrivalBP 160/100, RR 24, HR 81 reg, T
  36.7Chest ClearAbdominal exam RUQ tenderness

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Mrs AS
14
Mrs AS

• U/S reviewed by radiologist- Thickened GB wall
  6mm- Nil dilation of CBD- Nil stones- Solitary
  Polyp- No comment on pericholecystic fluid

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Mrs AS

• Assessment Cholecystitis and pneumonia
• Admitted on 6.9.03- Triple antibiotics
  Gent/Amp/Metron.- Placed on ward
• 6.9.03 on ward- RMO called re wheeze- Sudden
  onset, given ventolin/atrovent nebuliser-
  Patient anxious? Given morphine

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Mrs AS

• 6.9.03 2330 Hrs- RMO called increasing
  dyspnoea- O/E RR 28/Min, SpO2 97 2L-
  Decreased AE right side- Nil creps/wheeze-
  JVPNE- Nil SOA

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Mrs AS

• 7.9.03 Pt reviewed twice by RMOs- Increasing
  dyspnoea- Decreasing U/O- ECG T wave
  inversion I,II, V4-V6- Fluid boluses for low
  U/O- 6L over 24 hours- Troponin lt 0.3- ?
  Overloaded - Diuresis

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Mrs AS

• 8.9.03 midnight - Medical registrar called-
  Rapid AF rate 130-150/min- ABG on high flow
  O2 - pH 7.37 - pCO2 34 - pO2 48 - BE
  - 6.1 - SpO2 83

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Mrs AS

• 8.9.03 Medical registrar notified ICU
• 8.9.03 0400 Pt admitted to ICU- issues1.
  Rapid AF2. Pulmonary oedema3. Thought to have
  acute cholecystitis

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Mrs AS

• 8.9.03- CXR Enlarged heart - ECG Rapid
  AFMx- Amiodarone infusion- CPAP / GTN
  infusion- Diuretics- Arterial line placed

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Mrs AS

• 8.9.03 Morning ward round- Discussion with
  relatives- Increasing dyspnoea over last 2
  weeks- Orthopnoea- Ankle oedema- Increasing
  abdominal pain, pt pointing to RUQ- ? Cardiac
  cause Urgent TTE organised

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Mrs AS

• 8.9.03 Pulsus paradoxus
• TTE performed

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Mrs AS

• 8.9.03 TTE- Large circumferential pericardial
  effusion- Tamponade- Pericardiocentesis
  performed- Blood stained effusion- Single lumen
  CVC placed into pericardial effusion for drainage

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Mrs AS

• 8.9.03- Immediate increase in BP- Pulsus
  paradoxus resolved- Pt reported feeling
  immediately better1200 ml effusion drained-
  Cytology- Microbiology

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Mrs AS

• Impression- Malignant pericardial effusion-
  Increasing in size- Worsening cardiac function-
  Poor LV function with pulmonary oedema- Poor RV
  function with hepatic congestion, abdominal pain,
  nausea and abnormal LFTs

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Mrs AS

• Outcome- Pericardial drain in for another 48
  hours- Repeated TTE minimal effusion present-
  Drain removed- Oncology referral made- Pt
  clinically improved oedema cleared, 2L O2 via
  nasal prongs
• Discharged form ICU 10.9.03

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Mrs AS

• Micro No bacteria/acid fast bacilli seenNil
  growth on cultures
• CEA on effusion 649
• Cytology malignant cells seen, poorly
  differentiated, consistent with metastatic
  adenocarcinoma

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Mrs AS

• Discussed with St Vincents Thoracic unit
• Discharged from TNH on 19.9.03
• Thoracic outpatients appointment on 23.9.03

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Pericardial Effusion

• Presence of abnormal amount of fluid in the
  pericardial space
• Normally 15-50 mls of fluid
• Function minimise friction between visceral and
  parietal pericardial layers
• Arises from visceral pericardium
• Essentially an ultrafiltrate of plasma

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Pericardial Effusion

• Clinical manifestations vary with rate of
  accumulation
• Rapid accumulation -gt elevated intracardiac
  pressure with 80mls
• Slow accumulation -gt elevated intracardiac
  pressure may not occur until 2 litres

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Pericardial Effusion

• Figures vary approximately 20-30 of autopsies
  on patients with malignancy show metastases to
  pericardium- Lung 37- Breast 22-
  Leukemia/lymphoma 17Braunwald E, ed Heart
  Disease A Textbook of Cardiovascular Medicine.
  Philadelphia WB Saunders Company 1997 1478-96.

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Pericardial Effusion

• Not all cancer associated effusions are
  malignant- Mediastinal lymphoma and Hodgkins
  disease associated with transient effusions-
  Though to arise from impaired lymphatic drainage

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Pericardial Effusion

• Causes- Infectious bacterial, viral, fungal,
  parasitic, TB, HIV related- Autoimmune
  connective tissue disorders e.g. rheumatoid
  arthritis, SLE- Trauma- Neoplastic-
  Radiation- Hypothyroidism

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Pericardial Effusion

• Causes cont.- Drugs- Uraemia

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Effusion Tamponade
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Pericardial Effusion

• InvestigationsCXR Enlarged cardiac
  silhouette -- Pericardial fat stripeCXR is
  unreliable in establishing or refuting diagnosis
  of pericardial effusionChong HH, Plotnick GD
  Pericardial effusion and tamponade evaluation,
  imaging modalities, and management. Compr Ther
  1995 Jul 21(7) 378-85

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Pericardial Effusion
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Pericardial Effusion

• Investigations- CT Chest may detect as little
  as 50mls of fluid- General data suggests fewer
  false positives than echocardiography-
  Disadvantage transport of pt to CT scanner
  especially if unstable

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Pericardial Effusion

• Investigations- MRI can detect as little as
  30mls- Transport and time taken to scan are
  major issues- ECG Classic findings low
  voltages, electrical alterans - Studies suggest
  ECG poor diagnostic tool
• Meyers DG, Meyers RE, Prendergast TW The
  usefulness of diagnostic tests on pericardial
  fluid. Chest 1997 May 111(5) 1213-21.

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Pericardial Effusion

• Echocardiography- Gold standard- Large
  effusions seen as echo free spaces between
  visceral and parietal pericardium- Large
  effusions -gt diastolic collapse of RA and RV,
  signalling tamponade- Large effusions are
  classified as gt 1cm on echocardiography-
  Increasingly used in combination with
  pericardiocentesis

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Pericardial Effusion

• Management- Pericardiocentesis - used commonly
  with agitated saline to determine if needle is
  in ventricle - Connection of ECG lead to
  needle Electrical activity seen on monitor
  when comes into contact with myocardium

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Pericardial Effusion
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Pericardial Effusion

• Complications of pericardiocentesis include
  ventricular rupture, dysrhythmias, pneumothorax,
  myocardial and/or coronary artery laceration, and
  infection.
• Recurrence rates within 90 days may be as high as
  90 in patients with cancer
• Maisch B Pericardial diseases, with a focus on
  etiology, pathogenesis, pathophysiology, new
  diagnostic imaging methods, and treatment. Curr
  Opin Cardiol 1994 May 9(3) 379-88

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Pericardial Effusion

• Subxiphoid pericardial window with
  pericardiostomy
• low morbidity, mortality, and recurrence rates.
• Can be performed under local anesthesia.
• Less effective when effusion is loculated.
• Can replace pericardiocentesis as initial
  treatment for stable pericardial effusions.
• A recent study suggests that this may be safer
  and more effective at reducing recurrence rates
  than pericardiocentesis. However, only patients
  who were hemodynamically unstable underwent
  pericardiocentesis, and no change in overall
  survival rate was observed.