【持续性肾脏替代治疗crrt英文精品课件】necrotizing fasciitis

Necrotizing Fasciitis,History,66 y female PMH : DM , HTN , IHD , Hypothyroidism Pernicious anemia , ETOH Med: Atenolol , ASA , Nitrospray , Thyroxin , B12 & Atrovastatin,History,Presented to Seven Oaks Hospital 1/12 SOBE , Anasarca & decreased UOP 1/7 angina & melena ( 2 minimal ) No orthopnea , PND , wheeze , cough No palpitation , LOC No heartburn , vomiting or hematemisis No blood in urine,History,In ER : hemodynamicaly stable Sat 94% RA A & O Generalized edema No chronic liver disease signs ? Hypovolemic Chest : clear DRE +ve blood,History,WBC 2.1 poly 1.3 Hb 65 MCV20 INR 1.7 PTT 54 Creat , BUN & lytes N AST 110 ALT 70 Albumen 20 Billirubin total 70 direct 40 UA 0.3- 1 protein NO active sediment,History,Admission Dx pancytopenia ? Malignancy Rx PRBC , FFP & HAS Within hours of admission Fever , SOB & Hypotension No response to IVF , Bronchodilator,History,Transferred to ICU Worsening work of breathing On 15 l O2 NRBM PH 7.3 PCO2 33 PO2 76 HCO3 16 Intubated , Neosenphrine Swan Ganz septic CXR Lt effusion,History,Pleural tapping LDH 2995 Glucose 0.3 Protein 38 Transferred to ICM St.B Shock , Acute renal failure Craet 200 Lactaic acidosis 13 Melena Rhabdomyolysis Myogolbin 5000 ACS TnT 0.05 t wave inversion,Hospital Course,In ICM Seen by 3 services on the same time (reading the chart together) ID meropenem & Vanco Renal CRRT GI were scoping the pateint next door they didnt mind scoping this patient !,Hospital Course,Pleural fluid & Blood C/S Group C Beta strept Abx switch to Penicillin G continuous infusion Cortisol 1750 Not candidate for activated protein C,Hospital Course,Upper GI scope diffuse gastritis started on pantprazole Not candidate for activated protein C Recovered from shock Transferred to medicine,Group C Strept.,G +ve cocci , facultative anaerobes Vast majority are pathogenic Uncommon cause of bacteremia Predisposition old age , animal exposure , immunosupression,Group C Strept.,Dx hemolytic pattern on blood agar medium In case in the absence of overt focal disease& +ve Blood C/S search for an abscess, endocarditis or a suppurative process in an obscure area Usually it is part polymicrobial infection it is important for the microbiology lab to identify all species in a specimen from a closed space or bacteremic process.,Group C Strept.,5 y retrospective study GCBHS caused 0.05 / 1000 admissions Data from 10/13 patients primary bacteremia (4 cases), pneumonia (2cases), endocarditis (2 cases) meningitis, intraabdominal infection and 1 S. zooepidemicus Diagn Microbiol Infect Dis. 1992 Feb,Group C Strept.,8 y retrospective study in 5 hospitals 78 cases 16 bacteremia sources primary bacteremia, cutaneous , meningitis and pneumonia Higher rates of underlying diseases, ETOH abuse, liver diseases, and cutaneous infections, and lower rates of exposure to animals or raw products Morbidity and mortality were 20% to 30% Arch Intern Med. 1995 Jun,Group C Strept.,Exquisitely susceptible to penicillin MIC should be performed in life-threatening infections meningitis, brain abscess, endocarditis An aminoglycoside, for synergy,Group C Strept.,In penicillin allergic patients clindamycin & macrolide In high resistance or immunocompromised patients vancomycin Drainage of abscesses is essential,IVIG & GCBHS,Multicenter randomized Plc control Jan 1999 May 2001 streptococcal toxic shock syndrome STSS pateints Patients could be included before lab confirmation site of infection or family history strept infection Rapid antigen test from throat or skin CID 2003,IVIG & GCBHS,IVIG 1mg/kg day 1 & 0.5 mg/kg day 2&3 or Albumen 1% All patients received clindamycin 600mg TID & Penicillin 12 gm / day Primary outcome 28 days mortality Secondary outcomes time to shock resolutio