A 65-year-old male is admitted to your intensive care unit from the haematology ward with hypotension and diarrhoea (1.5L/day). He received an allogeneic stem cell transplant 18 days ago as part of his treatment for multiple myeloma.
On arrival to the ICU he is febrile, tachypnoeic, with a tachycardia and hypotension and a distended abdomen, which is diffusely mildly tender.
Blood results on ICU admission are as follows:
Parameter |
Patient Value |
Normal Adult Range |
|
Sodium |
137 mmol/L |
135 – 145 |
|
Potassium |
4.8 mmol/L |
3.5 – 5.0 |
|
Chloride |
99 mmol/L |
95 – 105 |
|
Bicarbonate |
16 mmol/L* |
22 – 32 |
|
Urea |
21 mmol/L* |
3.0 – 8.5 |
|
Creatinine |
146 micromol/L* |
40 – 90 |
|
Albumin |
19 G/L* |
36 – 52 |
|
Bilirubin |
33 micromol/L* |
0 – 18 |
|
Alanine Aminotransferase (ALT) |
49 IU/L* |
0 – 30 |
|
Aspartate Aminotransferase (AST) |
140 IU/L* |
0 – 30 |
|
Alkaline Phosphatase (ALP) |
120 IU/L* |
30 – 100 |
|
Gamma Glutamyl Transferase (GGT) |
225 IU/L* |
0 – 35 |
|
Haemoglobin |
84 G/L* |
115 – 165 |
|
Platelets |
12 x 109/L* |
150 – 400 |
|
White Cell Count |
0.1 x 109/L* |
4 – 11 |
|
Neutrophils |
0.0 x 109/L* |
2.0 – 7.5 |
|
FiO2 |
0.4 |
||
pH |
7.37 |
7.35 – 7.45 |
|
PCO2 |
28 mmHg* |
35 – 45 |
|
PO2 |
108 mmHg |
||
HCO3 |
16 mmol/L* |
24 – 31 |
|
Base excess |
-8 mmol/L* |
-3 – +3 |
|
Lactate |
8.1 mmol/L* |
< 2.2 |
|
Glucose |
6.2 mmol/L |
3.0 – 7.8 |
|
Calcium |
1.24 mmol/L |
1.2 – 1.3 |
a) Outline your management priorities.
b) List the likely causes of diarrhoea in this patient.
NB: Important points in bold.
a)
This is a critically ill, immunocompromised patient with febrile neutropenia following a stem cell transplant. There is evidence of septic shock with evidence of organ dysfunction (lactic acidosis, renal, hepatic and bone marrow dysfunction)
Management priorities: resuscitation, determination of relevant history, appropriate investigations and definitive therapy.
i. Resuscitation
Assessment of work of breathing & NIV, if required.
Assessment of volume status/responsiveness & cardiac output, IV access and fluid resuscitation, invasive central venous and arterial lines with platelet cover, vasoconstrictor/inotrope therapy aiming for appropriate goals.
Early antibiotic therapy.
ii. Relevant history
Organ specific symptoms.
Information about transplant, related chemotherapy, current medications.
Prior infections/colonisations.
Consideration of non-infectious causes - e.g. pancreatitis .
iii. Investigations
Detailed clinical examination, source of sepsis.
Blood cultures-peripheral and through existing central lines, urine, stool cultures, removal of existing lines if likelihood of infection and tip for culture.
Investigation for diarrhoea- stool for ova, cysts, parasites, C diff toxin, P/R examination, proctosigmoidoscopy (caution due to thrombocytopenia).
Erect AXR – rule out perforated viscous and surgical review, if indicated.
Other relevant imaging based on history and examination- chest x-ray, abdominal ultrasound/CT.
iv. Therapy
Empiric antibiotic therapy within an hour- either based on existing cultures or colonisation, allergies, recent antibiotic use, local antibiograms. Otherwise established febrile neutropenia protocol - Antipseudomonal, anti-staphylococcal and antifungal therapy. Dose adjustment for organ function.
Source control where possible, removal of existing lines, catheters.
Management of diarrhoea- fluid and electrolyte correction, loperamide if cultures negative.
G-CSF (haematology guidance), platelet transfusion if < 20,000 or active bleeding/pre-procedure.
Management of symptoms- pain, nausea, mucositis.
Establishment of nutrition- Parenteral nutrition if severe mucositis or diarrhoea, trace element supplementation.
b) Possible causes of diarrhoea:
Infectious
o Bacterial- Clostridium difficile, salmonella, shigella, E coli including ESBL.
o Viral - CMV, rotavirus, adenovirus, norovirus.
o Parasitic – cryptosporidium, microsporidia, giardia.
o Fungal- candida.
Non-Infectious
o Acute Graft versus Host Disease.
o Neutropenic enterocolitis (Typhilitis).
o Drugs- antibiotic related, opioid withdrawal, promotility agents, tacrolimus (thrombotic microangiopathy), chemotherapy conditioning regime for stem cell transplant.
o Severe hypoalbuminaemia .
a)
This question is broadly about the resuscitation of sepsis, but the patient has specific issues which need to be addressed, and one would not do well if one simply applied an algorithmic approach.
The issues are:
A structured approach:
Immediate management:
A) - assessment of the urgent need for intubation
B) - Support of oxygenation with NIV or high flow nasal prongs
C) - Hemodynamic control:
D) - Adequate analgesia
E) - Correction of electrolyte abnormalities
F) - Monitoring of urine output and renal function; CRRT support as indicated
G) - Nutritional support (ideally, enteral)
H) - Haematological interventions:
I) - Early administration of broad-spectrum antibiotics
Investigations:
b)
Infectious |
Non-Infectious |
Viruses
Bacteria:
Parasites
Fungi
|
Immunosuppressant therapy
Consequences of BMT
ICU therapy
|
Timothy A. Woods. "Diarrhea." Chapter 88 in: Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990.
Cox, George J., et al. "Etiology and outcome of diarrhea after marrow transplantation: a prospective study." Gastroenterology 107.5 (1994): 1398-1407.