1 Shock and sepsis pathophysiological analysis of cases MUDr. MSc. Michal Šitina, PhD. Department of pathological physiology, MUNI Department of anaesthesia and intensive care medicine, FNUSA Biostatistics, ICRC-FNUSA 2 • man 72 yo, up to now healthy, used no medication • admitted the day before to the urology department of local hospital for abdominal and back pain - suspected renal colic • partial improvement after analgetic treatment • abdominal US • normal kidneys • AAA of diameter 8 cm • immediately angioCT of abdomen • AAA 8 cm with signs of rupture, hematoma in surroundings • immediately transported to the vascular surgery of FNUSA, direct to the operating theatre C1 3 • on arrival stabil, P 105/min, BP 105/60 • Hgb 90 g/l, no coagulopathy • lactate 3.2 • in the OP theatre • CV and arterial catheter inserted, crystalloids infused • OTI, mechanical ventilation • 1 min after OTI severe BP drop, asystoly, CPR initiated • after 2 mins ROSC, high dose of NA • immediately operating field prepared and laparatomy performed • again asystoly, CPR, after 2 mins ROSC • aortic clamp above the aneurysm • fliuds, blood transfusions, huge dose of NA, with this „stable“ C1 4 • in the ICU • on admission hypothermia, high dose of NA, lactate 12 • further fluids, correction of coagulopathy, active warming • bleeding does not continue krvácení, hypovolemia corrected with help of US • persistent extreme dose of NA, very slow decrease of lactate • need of high FiO2, anuria • on the next day still high, but acceptable dose of NA, lactate 2.5 • return of diuresis, lower ventilatory support • urea 20, crea 250, thrombocytes 50, fever 38.5, CRP 320 • in the following days improvement of renal functions, decrease in CRP • persistent coma – after CRP, SIRS encephalopathy, influence of sedation? C1 5 • in the ICU • from the 6th day fever again, new increase in CRP, need of NA • on abdominal CT suspected retroperitoneal abscess • surgical solution impossible • ATB • very slow improvement • on the 10th day extubation • on the same day, however, need of re-intubation because od progressive hypercapnia • tracheostomy and slow weaning from mechanical ventilation C1 6 • summary: • hemorrhagic shock • initially compensated • decompensation after OTI • SIRS + MODS • after hemorrhagic shock and cardiac arrest • ischemia-reperfusion injury • septic shock (role of immunosupression?) • critical illness polyneuromyopathy C1 7 • man 50 yo, 4 weeks ago a fall with fracture of 2 ribs, used ibuprofen • progressive weakness and black stool for about 3 days • ambulance called for vomitting of blood (hematemesis) • at the first contact BP 80/50, P 130/min, CGS 15 • given crystalloids 1000 ml, transport to the ER FNUSA • on arrival BP 100/50, P 115/min • immediately gastroscopy • duodenal ulcer bleeding Forrest 1b • stopped after adrenaline injection into ulcer • Hgb 41 g/l, lactate 2.5 C2 8 • admitted to the ICU of the Department of internal medicine • 4 transfusions, fluids, stabilisation • on the 3rd day abrupt deterioration, prompt decrease in BP, need of NA • relapse of hematemesis • indicated immediate surgery • during OP extremely unstable, huge dose of NA • given 8 TU, fibrinogen, 6 TU of plasma, tranexam acid, 2 IU thrombocytes • bleeding was stilled with suture of duodenal ulcer C2 9 • return to ARK ICU at 4:30 am • further fluids, 4 TU, plasma, fibrinogen, correction of coagulopathy • gradual stabilisation, minimal dose of NA • 9:00 suddenly ventricular fibrillation, cardiac arrest, CPR initiated • 1x defibrillation resulting in asystoly, given 1 mg adrenaline • after 5 mins ROSC • afer ROSC shortly hypertension up to 280/140 (reaction to adrenaline) • etiology unclear • no blood from nasogastic tube • ECG, echocardiography – EF LV 50%, inferior wall hypokinesis • cardiologist did not indicate coronarography C2 Zápatí prezentace10 ECG 4:30 Zápatí prezentace11 ECG 8:15 12 • concluded as STEMI • prompt increase in NA • re-echocardiography – still good function of LK • mild decrease in Hgb, increase in lactate • sharp increase in NA dose • increase in abdominal volume • US – growing collection (character of hematoma) 12 cm in diameter in area of duodenum • acute surgical consultation – indicated oper. revision • after purge of NG tube large amount of blood is being drained • massive dose of NA C2 13 ECG on the next day 14 • during OP strong arterial bleeding in the area of previous suture found • re-suture, bleeding was stopped • return to ARK ICU • gradual stabilisation • anuria, on the 2nd day dialysis was initiated • lower ventilatory support • On the 7th day increase in CRP, fever, higher NA • new production of purulent sputum, susp. new infiltrate on chest-X ray • ATB administered C2 15 • summary: • hemorrhagic shock • initially compensated (slow anemisation) • decompensation with bleeding renewal • cardiogenic shock?? • why STEMI? • cause of the 2dn re-bleeding?? • nosocomial ventilator pneumonia – sepsis (immunosupression) C2