Name:
A 63-Year-Old with a Sepsis
Description:
A 63-Year-Old with a Sepsis
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Duration:
T00H05M26S
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Upload Date:
2022-02-23T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
♪ (music) ♪
CATHY: Hi, welcome to Harrison's Podclass where we discuss important concepts in internal medicine. I'm Cathy Handy.
CHARLIE: And I'm Charlie Wiener, and we're coming to you from the Johns Hopkins School of Medicine. Welcome to Episode 30: A 63-Year-Old with Sepsis. The question reads: A 63-year-old man with a history of diabetes and myocardial infarction, eight years ago, is admitted to the medical intensive care unit, one day ago, with sepsis due to pneumococcal pneumonia with bacteremia. He was started on antibiotics immediately, but initially required high doses of noradrenaline and fluids to stabilize his blood pressure.
CATHY: Well, we're not off to a good start here.
CHARLIE: It gets better. His initial ECG showed sinus tachycardia and no acute changes, and the noradrenaline was weaned off approximately 12 hours ago. But, here it's going to get worse again.
CATHY: Uh-oh.
CHARLIE: Okay, so over the past two hours, he's had increasing abdominal pain, distension, and new onset bloody stools. His physical examination is notable for a blood pressure of 100/50, off vasopressors, a regular heart rate of 100 beats per minute, a respiratory rate of 22 breaths per minute, and an oxygen saturation of 93% on high-flow nasal cannula. He has a diffusely tender abdomen with no audible bowel sounds. An abdominal radiograph shows multiple small bowel air-fluid levels, and his ECG is unchanged, only showing sinus tachycardia.
CHARLIE: The question asks: which of the following is the most likely diagnosis? Option A is arterial embolus; option B is C. difficile colitis; option C is inflammatory bowel disease; option D is nonocclusive mesenteric ischemia; and option E is venous thrombosis. What do you think, Cathy?
CATHY: Of the choices listed, it sounds like he has intestinal ischemia, given the new onset bloody stools and clinical symptoms, along with the signs that you mentioned. C. difficile typically presents with non-bloody diarrhea, but it definitely can progress to life-threatening bloody diarrhea in the case of severe disease. This patient has only been on antibiotics and only in the hospital for one day, so while severe C. diff with complications is certainly a possibility, it wouldn't be highest on my differential, given the timing. I'm also going to eliminate IBD because there's no history given to suggest that, and there are many other things going on, so it seems unlikely that this is his first presentation of IBD when he comes in with such bad pneumococcal pneumonia.
CHARLIE: Okay, so option A - arterial embolus, option D - nonocclusive mesenteric ischemia, and option E - venous thrombosis can all lead to intestinal ischemia. How do you differentiate between those three, and which is your best answer?
CATHY: Alright, let's take them one by one. So, first, option A - arterial embolus, so that can lead to intestinal ischemia, and the risk factors here are generally the same as other acute arterial embolic states, such as stroke or a heart attack. So, these are typically acute and onset and are seen in patients with atrial fibrillation, a recent MI-- which he doesn't have-- valvular heart disease or recent cardiac or vascular catheterization. All of these can lead to embolic clots in the mesenteric circulation, but he doesn't have any of these risk factors, so I would put this not as the top thing on the differential.
CHARLIE: What about nonocclusive mesenteric ischemia?
CATHY: So that, I think, is the best option. It typically happens in patients with known risk of vascular disease, as in this patient who has a remote history of coronary artery disease and also has diabetes. The bloody diarrhea that you see in nonocclusive mesenteric ischemia is typically more insidious than in this case, but this could have been due to the vascular instability that he had, due to the sepsis and the use of vasopressors. So, in fact, this syndrome can be seen in any patient receiving high-dose vasopressor infusions, such as patients with cardiogenic or septic shock in patients with cocaine overdose.
CATHY: So, I would go with option D for this question.
CHARLIE: And just to be complete, why not mesenteric venous thrombosis?
CATHY: Well, it's much less common, and it's usually associated with the presence of a hypercoagulable state, like protein C or S deficiency, antithrombin III deficiency, polycythemia vera or cancer, and we don't have any history of that in this patient.
CHARLIE: So, you suspect this patient has nonocclusive mesenteric ischemia? What is the best therapy?
CATHY: Really supportive care, so you need to ensure adequate hydration, continue the antibiotics, follow his hemoglobin, and transfuse if necessary, and, if you can, minimize the vasopressor use. To improve the oxygen delivery, you'd minimize the metabolic acidosis and try and optimize his cardiac output. If the diagnosis of intestinal ischemia is being considered, consultation with a surgical service is definitely necessary because the decision to operate is usually made on a high index of suspicion from the history and physical exam alone, and the decision can be made even in the presence of normal laboratory findings.
CHARLIE: So, the teaching point of this case is to distinguish between nonocclusive mesenteric ischemia and other causes of intestinal ischemia. Particularly in a patient with known vascular disease in the presence of hemodynamic instability or vasopressors, be aware of nonocclusive mesenteric ischemia as a cause of new onset abdominal signs or symptoms.
CATHY: To read more about this, you can look at the chapter on Mesenteric Vascular Insufficiency within the Disorders of the Gastrointestinal System. ♪ (music) ♪
