Septic_encephalopathy.pptVIP

Septic encephalopathy 報告人: 許希珍 Case report – 4C1 , 08-2 73 y/o , Female Underlying /c ?HTN , ? Parkinsonism , ? Chr. Headache /c analgesic use , ? DU + GU for 2 yrs /s tx CC in our ER (5/11) : severe abd. pain with abdominal distension Brief history (1) 5/8 : epigastralgia + fever to 38 → MKMH, UTI was told discharge after analgesic use 5/9-10 : poor oral intake , pain persisted 5/11 am: abdominal distension + severe abd. pain → NTUHER pale face , dyspnea in general looking T/P/R/BP=37 / 122 / 27 / 119/87mmHg cons. clear , conj pale , abd PE : soft ,distension , no muscle guarding periumbilical intermittent migral pain , BS : hypoactive Brief history (2) Bedside abd. echo: ascites(+) , tapping: turbid 12:00am BP drop: 97/77 mmHg ABG data: metabolic acidosis , r/o sepsis cons. became drowsy , on endo → Highly suspect hollow organ perforation → consult GS WBC=3.38 D/C : Band 39% , Seg 29% , CRP=28.6 Hb=9.3 →7.5 , plt=318 , alb=3.2 BUN/Cr=28.8/2.4 , lipase=64 Na =129 , K =6.0 ,Ca=3.35 ABG: pH=7.18 , pCO2=54.5 , pO2=188.3 HCO3-= 19.4 , BE= - 8.1 Brief history (3) 5/11pm: OP finding: huge ulcer with perforation at pre-pyloric area, massive turbid ascites Dx: PPU OP method :Antrectmoy with B-II reconstruction + duodenotomy + Jejunostomy SICU course Transferred to our 4C1 on 5/11 Cons. irritable /c mild sedation Inotropic agent was tapered gradually Intermittent high fever after operation Refractory infection control 5/16 poor cons. E2M4Vt, pupil:3/3 L/R:+/+ Head CT: no ICH, no brain swelling → R/o septic encephalopathy Duodenotomy leakage /c biliary content in RD Abd. w`d fascia dishiscence /c biliary discharge Impending MOF , DIC , expire on 614 Flumarin (5/11,5/12 ,5/13 ,5/14 ,5/15) PCN-G (5/13 ,5/14 ,5/15,5/16,5/17…..,5/26 ) D