Critical Appraisal of Mortality case Discussion

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1. Critical Appraisal Case 1 19th October 2012 Dr. Saptharishi L G 2. Points of discussion Diagnostic work up & evaluation Antibiotic therapy rationale Queries…
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  • 1. Critical Appraisal Case 1 19th October 2012 Dr. Saptharishi L G
  • 2. Points of discussion Diagnostic work up & evaluation Antibiotic therapy rationale Queries Lacunae in clinical management Management of respiratory complications
  • 3. Diagnostic work up & evaluation • • • • • • • • • Infant with admission weight – 2.7 Kg Birth weight of 3 Kg Admission for acute gastro-enteritis @ 2 mo age Episode of Pneumonia @ 3 months age Previous blood transfusion Hepatosplenomegaly Persistent lobar collapse Multiple radiological features – suggestive of CF Greenish pus at intubation – Pure growth of Pseudomonas aeruginosa from ET aspirate
  • 4. DIAGNOSTIC LABEL - ? CAP ? • Anything but routine – ‘garden variety’ of ‘COMMUNITY ACQUIRED severe PNEUMONIA’ – several oddities – Consideration for revision of emergency diagnosis? • Enough points to at least suspect underlying predisposing illnesses: – – – – Cystic fibrosis Cow’s milk protein intolerance Perinatally acquired CMV infection Galactosemia / Storage group of disorders
  • 5. Pointers towards CYSTIC FIBROSIS • Pseudomonas – Rarely causes disease in children without a predisposition (Nelson 19th Ed. Page 975) – Finding pure growth on culture of lower airways – strongly suggests CF (Nelson 19th Ed. Page 1490) • First ABG – Metabolic alkalosis – suggestive of CYSTIC FIBROSIS- though hyponatremia / Hypochloremia – not prominent
  • 6. Evaluation for Cystic Fibrosis • Considered by the general unit – Appropriately • Diagnostic work up for CF: – Role of sweat chloride test in infants • Quantitaive Pilocarpine Iontophoresis Technique (QPIT) • Children with CF – failure to thrive/ malnutrition – NOT UNcommon. Does it contradict sweat chloride testing? – Role of stool fat studies • Were these considered in the index case? – CFTR gene studies • Western data Vs. Indian data on CFTR Delta F 508 mutation • Work up sent by the managing team - AWAITED
  • 7. How could it have changed the management? • Pseudomonas in Cystic fibrosis – Usual colonization : MSSA  Ps. aeruginosa – Recommended management: • Airway clearance therapy • Antibiotic therapy – at least 2 agents ‘that cover Pseudomonas’ – as initial therapy + 1 agent that covers Staph aureus • Avoid GENTAMICIN – TOBRA/AMIKACIN preferred • Inhalational therapy with Tobramycin/ Colistin
  • 8. Anti-Pseudomonal antibiotics 3rd generation cephalosporins Cefaperazone, Ceftazidime 4th generation cephalosporins Cefepime Extended spectrum penicillins Piperacllin, Ticarcillin Carbapenems Imipenem, Meropenem Monobactams Aztreonam Quinolones Ciprofloxacin, Levofloxacin Aminoglycosides Amikacin, Tobramycin TAZOBACTAM – Not active against Pseudomonas Effective anti-pseudomonal combinations – SYNERGISTIC ACTION  Cephalosporin* + Aminoglycoside* WHY TWO ANTIBIOTICS FOR Antibiotic Basics for Clinicians. Alan R Hauser. First Edition. PSEUDOMONAS ?? 2009. Pg 131
  • 9. Reference
  • 10. Rationale of antibiotic therapy • PGI protocol: – Special situation: CYSTIC FIBROSIS – Anti staphylococcal + Anti-pseudomonal cover – Does Ampi/Gentamicin cover PSEUDOMONAS adequately? • Clinical worsening – Setting for suspicion of CF – Persistent UL collapse – Was the hike to Cefotaxime/ Amikacin after 72 hrs appropriate? Antibiotic choice? • Could have considered PSEUDOMONAL cover at this point..
  • 11. Subsequent antibiotic choice • Sequentially antibiotics upgraded to – Vancomycin / Imipenem / Piperacillin-Tazobactam / Cloxacillin – SIMULTANEOUS administration of 4 antibiotics – Rationale for this antibiotic combination?
  • 12. Monitoring of Blood Gases • ABG 0n 4/10/2012 7:20 pm (on Np CPAP) – pH  7.34 – pCO2  51 • 5/10 to 07/10 – No blood gas monitoring – Despite last ABG showing Acute resp. acidosis – Despite notes mentioning clinical deterioration on 6th in form of respiratory worsening on Np CPAP • Shifted to ward – 07/10/2012 1 pm • ABG on 7/10/12 @ 5 pm showed pH & pCO2 values of – 7.32/ 61 – 7.26/80 • Child intubated & put on IPPR i/v/o respiratory failure
  • 13. Management of Hypercarbia • Persistent collapse of RUL • Persistent severe respiratory acidosis – 7.14  7.048  7.099 7.066 – pCO2: 107, 92, 93 • Appropriate management – Physiotherapy – Positive pressure ventilation (Inability to provide PEEP) – Postural drainage • BRONCHOSCOPY could have helped  Setting of mucus plugging  Persistent collapse • Why was it not considered?
  • 14. Summary of Queries • Why diagnostic label of ‘CAP’ for initial 4 days despite so many oddities? • Why ABGs were not monitored for 3 days despite clinical worsening & last ABG showing respiratory acidosis? • Rationale for the 4-antibiotic regimen? • Failure to thrive Limitation of sweat chloride testing- yes; but Is it a contra-indication? (Delta F 508 mutation studies may actually be less useful in India)
  • 15. Summary of Queries • Why did we not consider ‘stool fat estimation’ in this child? Should we have started oral pancreatic enzyme supplementation? • Why BRONCHOSCOPY was not considered? No documentation reg. plan/feasibility • Rationale for keeping total fluids at 50-60% maintenance despite child being in shock (on 3 ionotropes)? • Management of FTT in the index case
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