A Kortgen1, W Lindemann, M Bauer. 1. Klinik für Anaesthesiologie und Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg/Saar. aiakor@uniklinik-saarland.de
Abstract
HISTORY AND ADMISSION FINDINGS: A 45-year old man with diabetes mellitus and arterial hypertension was transferred with fever of unknown origin, suspected diabetic angiopathy and sepsis. On admission the patient presented all signs of septic shock. Livid coloured injuries on his right hand and petechial bleeding in distal extremities were observed. INVESTIGATIONS: A different origin of sepsis was not found in transesophageal ultrasound cardiography and computed tomography of cranium, chest and abdomen. DIAGNOSIS, TREATMENT AND COURSE: Immediately after admission early goal-directed therapy was initiated. Apart from calculated antibiotic therapy intensive insulin therapy and hydrocortisone substitution was begun. The patient presented a multiple organ dysfunction syndrome. Plasma disappearance rate of indocyanine green (PDR (ICG)) on admission was 20,4 %/min (normal range > 18 %/min) and fell to 6,8 %/min within 12 hours, while central venous oxygen saturation remained normal. Despite therapy according to current guidelines for severe sepsis, the patient deteriorated. Surgical debridement was performed suspecting necrotizing fasciitis and application of recombinant human activated protein C (rhAPC) started. PDR (ICG) rapidly raised to normal values; the patient recovered and was discharged after 9 days. CONCLUSIONS: Monitoring of PDR (ICG) allows for improved bedside evaluation of liver perfusion of the critically ill and is not only able to predict prognosis but may help in decision making for supportive therapies.
HISTORY AND ADMISSION FINDINGS: A 45-year old man with diabetes mellitus and arterial hypertension was transferred with fever of unknown origin, suspected diabetic angiopathy and sepsis. On admission the patient presented all signs of septic shock. Livid coloured injuries on his right hand and petechial bleeding in distal extremities were observed. INVESTIGATIONS: A different origin of sepsis was not found in transesophageal ultrasound cardiography and computed tomography of cranium, chest and abdomen. DIAGNOSIS, TREATMENT AND COURSE: Immediately after admission early goal-directed therapy was initiated. Apart from calculated antibiotic therapy intensive insulin therapy and hydrocortisone substitution was begun. The patient presented a multiple organ dysfunction syndrome. Plasma disappearance rate of indocyanine green (PDR (ICG)) on admission was 20,4 %/min (normal range > 18 %/min) and fell to 6,8 %/min within 12 hours, while central venous oxygen saturation remained normal. Despite therapy according to current guidelines for severe sepsis, the patient deteriorated. Surgical debridement was performed suspecting necrotizing fasciitis and application of recombinant human activated protein C (rhAPC) started. PDR (ICG) rapidly raised to normal values; the patient recovered and was discharged after 9 days. CONCLUSIONS: Monitoring of PDR (ICG) allows for improved bedside evaluation of liver perfusion of the critically ill and is not only able to predict prognosis but may help in decision making for supportive therapies.
Authors: Magnus F Kaffarnik; Johan F Lock; Hannah Vetter; Navid Ahmadi; Christian Lojewski; Maciej Malinowski; Peter Neuhaus; Martin Stockmann Journal: Crit Care Date: 2013-10-31 Impact factor: 9.097