Death presentation

By kalkidan S ( ECCM R2)

Moderator: Dr Abeselom( Internist, Critical care fellow)
July 7, 2023
outline
• History and physical examination
• Investigation results summary
• Management done
• AKI and pregnancy
• Options of Renal replacement therapy and metabolic acidosis
• Limitations faced and recommendations
identification
• Name:
• Age: 32
• Address: Elugela
• MRN: 1161057
• Date of presentation: 22/09/15
History
• A 32 years old GIV paraIII mother presented with a compliant of
generalized body swelling of 2 weeks duration which started from her
face and involved her lower extremity progressively with associated
decreased urine output for the past 1 week.
• In addition she also had history of productive cough of whitish
sputum, SOB for the past 1 weeks but no orthopnea or PND
• Had history of vomiting which was coffee ground in appearance with
associated watery diarrhea of 2 days duration
• Was told to have renal disease 2 years back but not specified

• Had history of bilateral flank pain of 1 year duration but no pain

during urination, frequency or urgency of urine

• For the above compliant, she visited ambo hospital diagnosed with
multi parous+ 3rd TM Px + AKI 2to ?+ severe anemia where she was
transfused with 1 units of blood and referred here for dialysis and
better management
• Is from malaria endemic area and previously treated a year back
• No history of fever, chills or rigor
• No history of abnormal body mov’t or LOC
• No history of any medication use
• No history of rash, joint pain
• No history RUQ pain, jaundice or headache
• No history of vaginal bleeding
• No hx of cough or hemoptysis
Investigations at referral
• HCT: 13%
• Creatinine: 18
• PLT: 114 x 103
• PICT: NR
• Abdominopelvic ultrasound: normal
Initial physical examination
• BP: 100/70 PR: 74 RR: 20 PS02: 95% with atm air
• HEENT: pale conj, NIS
• Chest: clear and resonant bilaterally
• CVS: S1 and S2 well heard no m or gallop
• Abd: 32 week gravid uterus, longitudinal lie FHB: +ve, +ve signs of
fluid collection
• GU: no CVAT
• MSS: no edema
• CNS: conscious, OTPP
• DX: 3rd TMPX+ MP+ unknown date+ severe anemia 2to+ AKI 2to ?HUS
investigations
• CBC: WBC:7.7 k Hgb:4.3 HCT: 11.6 PLT: 114k
• Creatinine: 14.8 urea: N/A Na: 144. K: 6.2 Ca: 1.43
• Abd U/S: bilateral echogenic kidneys
• U/A: trace albumin, blood + 2, LDH: 2286
• ECG: sinus rhythm
On 23/09/15
• BP: 110/70 PR: RR: T0:36
• HEENT: pale conj NIS
• Chest: in respiratory distress, deep and labored breathing
• CVS: S1& S2 well heard no murmur or gallop
• Abdomen: 32 week gravid uterus with + ve signs of fluid collection
• MSS: no edema or discrepancy
• CNS: fully conscious and cooperative
Done:
• Renal & hematology side communicated
• Started on shifting therapy
• 1 cycle of dialysis
• Started on Vitamin B12 and folic acid
• Planned for dialysis
• Transfused with 2 units of PRBC
• Transferred to the HDU
On 24/09/15
• LUST CS was done for maternal indication: impending RF 2to metabolic
acidosis EBL: 250ml
• B: RR:34-40 deep and labored breathing chest: good and comparable air
entry
• GCS: 12/15 ( E3 V4 M5) had 2 episodes of seizure
• On MF UOP: 700ml/24hrs Balance:
• K 5.3 Na+ 153
• Uremic encephalopathy+ atypical preeclampsia with Severity features
considered
• Loaded with phenytoin
25/09/15
• Transferred to the ICU
• Airway: patent protected by ETT
• B:on MV AC/PCV mode TV: 300 PSo2: 90-92%
• RR: 22 chest: clear and resonant bilaterally
• C: BP: 85-90/55-60 PR: 130 feeble: started on adrenaline
0.05mcg/kg/min
• D: on sedation RAAs: -2 RBS: 136mg/dl
• GI: direct tenderness over suprapubic area
• GU: no UOP
On the 2nd DOA to the ICU
• Developed septic shock of chest focus+ GU focus
• Decreased air entry over left lower 1/3 of the chest
• U/A: leukocyte esterase +ve Urine culture: E.coli sensitive to
meropenem only
• On renal adjusted dose of vancomycin, ceftazidime
• Transfused with 1 unit of blood
• Took a session of dialysis
Assessment
• 3rd POD after LUST CS done + type II RF 2to metabolic acidosis+ septic
shock with sepsis of chest+ GU focus + AKI 2 to septic ATN+ partial
HELLP syndrome r/o CKD+ severe anemia 2to MBA

• Total of 5 dialysis sessions done

• Transfused with total of 4 units of blood
• Continued with the same management
On 28/09/15
• Airway : patent and protected
• B: RR: 20 Ps02: 99% with FIO2 of 40% PEEP: 5
• C BP: 103/64 PR: 108
• CNS: GCS: 10 T Pupil: mid size and reactive bilaterally
• Persistently febrile: To: 39.9
On 29/09/15
• 5th post op day + AKI 2to ? + severe anemia 2to MBA + 5th post
intubation day for the indx of type II RF+ Partial HELLP syndrome+
abdominal hematoma
• Gyni side communicated and hematoma evacuated
0n 01/10/15
On 02/10/15
• Had recurrent episodes of seizure
• Given diazepam and loaded with phenytoin
• GCS dropped to 3T
• BP was dropping to MAP of 20-60: vasopressor requirement
increased : put on noradrenaline and adrenaline

• Diagnosis: same+ status epilepticus

On 03/10/15
• A: airway protected by ETT
• Minimal secretion
• B: on MV AC/VCV FIO2 of 40 PEEP:8 RR:14
• Chest: decreased air entry over bilateral lower 1/3 of chest
• BP: 66/30 on adrenaline PR: 110 later 90, 87
• On cardiac monitor: had recurrent PVCS and peaked T wave
• Started on shifting therapy and loaded with calcium gluconate
• CNS: GCS:3T, had recurrent hypoglycemia
Periarrest on the same day 7:20 DLT
• Developed Ventricular tachycardia and cardioverted 3x with 100, 150,
200J but it was refractory

• CPR was not done

• Cause of death: refractory septic shock+ refractory hyperkalemia+

poorly controlled status epilepticus
BP 108/69. 106/64 112/73 109/80
PR 108 110 93 95
Ps02 98 99 98 99
RBS 140 150 200 140
Investigations summary
Date 23/09/15 24/09/15 26/09/15 29/10/15 30/10/15 01/10/15 02/10/15
WBC 7.94 9.05 12.3 9.3 7.46 12 18.75
N 83.7 94.2 92.2 81.1 91.4 92 93.1
L 11. 2.7 4.4 11.8 6.5 7.1 4.7
Hgb 4.3 6.2 7.3 8.9 9.6 9.2 9.4
MCV 112 102 100.6 90.6 88 90.5 90.1
PLT 114k 100k 116 105k 111k 45k 8
RDW 15.6 16.7 17.3
creatinine 14.82 12.3 10.86
urea 168 200
T bilrubin 0.92 1.5 3.6
D bilrubin 0.523 1.02 2.9
ALT 17.5 17.4 425 166 129
AST 39 40.6 N/A 134 N/A
ALP 132 149 155
date 23/09/15 24/09/15 26/09/15 29/09/15 30/10/15 01/10/15
Na 144 153 163 152 159
K 6.2 5.12 2.92 4.2 4.38
cl 104.5 116 109 121 126
Ca 1.43 1.52
Serum LDH 2286 1501 1221 1160
Albumin 2.43
PT
PTT 35.7
INR 1.31
T3 0.729
13.97
TSH 0.438
• Viral markers: negative
• Urinalysis: trace protein and albumin
• Trace leukocyte esterase, Wbc: 0-5

• Peripheral morphology: macrocytic normochromic RBCS

Arterial blood gas analysis
• PH: 7.12 po2/FI02: 191mmhg
• PCO2: 19.6mmHg
• PO2: 86mmHg
• Na: 141
• K: 4
• Cl: 129
• HC03act: 6.2mmol/L
• HC03 Std: 10.1mmol/L
• Lactate level: 1.98mmol/L
Interpretation?
• Non anion gap hyperchloremic metabolic acidosis

• Any DDX?
Abdominal ultrasound
• Gall bladder sludge
• Kidney, liver, spleen has normal size and echogenicity

• Echocardiography: normal study

Abdominal CT with contrast
• GB hydrops
• Persistent corticomedullary phase 2to AGN + mild splenomegaly
• Small intraluminal hematoma
• Circumfrential urinary bladder wall thickening with contrast
enhancement likely from cystitis
• Mild to moderate simple ascites
• Bilateral lower lung dependent atelectasis
Questions for analysis
• What are possible causes of AKI for this patient?
• Potential contributors of metabolic acidosis:
• Treatment modalities of metabolic acidosis: RRT, NaHCO3
• Metabolic acidosis vs. septic shock
AKI and pregnancy
• Severe preeclampsia
• Severe preeclampsia with HELLP syndrome
• TTP/HUS
• Acute fatty liver of pregnancy
• ATN or acute cortical necrosis associated with hemorrhage
• AKI associated with NSAIDS
Uncommon causes include
• Acute pyelonephritis
• Acute tubulointersitial nephritis
• Acute glomerulonephritis
• Urinary tract obstruction
Preeclampsia with or without HELLP
For Against

Late pregnancy Not hypertensive

Elevate liver enzymes

AKI

Low platlet count

Severe anemia Peripheral smear not suggestive of

hemolysis
Elevated LDH level Unresolved signs and symptoms of
HELLP
Trace proteinuria
Thrombotic thrombocytopenic purpura or
HUS
FOR AGAINST

Severe AKI Absence of schistocytes on

Peripheral blood smear
Neurologic findings including seizure No signs of DIC early in the course

fever Clinical presentation

Acute fatty liver of pregnancy

For against

Nausea, vomiting Absence of jaundice

Mildly elevated liver enzymes Failure of symptoms to resolve

after delivery

AKI Absence of signs of DIC

encephalopathy No recurrent hypoglycemia

AFLP…..continued
• Swansea criteria
• Abdominal ultrasound findings?
Renal tubular acidosis
• Type of metabolic acidosis
• Urinary PH
• Potassium abnormalities?
What additional tests/ investigations would
you like to do:
• Urine sediment
• Autoimmune serology
• 24 hour urine protein
• Renal biopsy??
• Brain CT
Potential contributors of metabolic acidosis
• Renal failure
• Lactic acidosis resulting from tissue hypoxia, epinephrine use
• Untreated sepsis
• Hyperchloremic acidosis: resulting from large volume resuscitation
Treatment of metabolic acidosis and renal
failure in this patient
• Modalities of RRT: continuous vs intermittent
Metabolic acidosis vs sepsis with septic
shock
• Effects of metabolic acidosis on cardiovascular system
•

• Types of arrhythmias in metabolic acidosis: PVC, ventricular

tachycardia, ventricular fibrillation
Place of sodium bicarbonate administration
Limitation faced in the management of this
patient
• Antibiotic coverage: meropenem sensitive urine culture results
• Thus sepsis was not fully treated
• Unavailability of sodium bicarbonate
• Unable to update some important investigations due to cost issue
• AKI with non-recovery can cause end stage renal disease (ESRD)
directly; usually when superimposed on significant chronic kidney
disease (CKD), or, more rarely due to bilateral renal cortical necrosis.
recommendations
• Continuous monitoring of fluid responsiveness in patients with septic
shock
• Follow up of patients with metabolic acidosis
• Use of sodium bicarbonate for metabolic acidosis with clear
indications
• High risk patients for contrast induced AKI need adequate hydration
prior to the procedure
• RRT options: SLED, CRRT