D-dimer in diagnosing of PE

There were five trauma cases this morning in the ICU. The ICU 2 was admitted during the weekend. Another polytrauma case (without TBI), who developed acute respiratory failure and required ventilatory support. The injuries are fracture  right ribs from 2nd to 5th, lung contusion, open book fracture and fracture femur. The C-spine was cleared clinically. There were bilateral pulmonary infiltrates on both sides of the lungs. He has moderate increased in A-a gradient. I start to go thru few differential diagnoses in my mind which include fat embolism syndrome, PE, aspiration pneumonia, worsening lung contusions and finally TRALI. Suddenly I was distracted by the MO's comment: Since the D-dimer was positive, this patient has been treated for pulmonary embolism and 'they' have started him on fondaparinux...I asked, what was the next plan? She said, the orthopedic team is planning for ILN once this patient is more 'stable'..Actually, I raised few issues, first of all the safety of fondaparinux in this pelvic injury and secondly since when D-dimer was used as a confirmatory test for PE??

"D-dimer assays for the diagnosis of PE have been extensively studied. They are best characterized as having good sensitivity and negative predictive value but poor specificity and positive predictive value."

Sensitivity: D-dimer levels are abnormal in about 95% of all patients with PE when measured by ELISA, quantitative rapid ELISA or semi-quantitative rapid ELISA. This falls to about 90% when measured by qualitative rapid ELISA or quantitative latex agglutination, 86% measured by semiquantitative latex agglutination and 82% measured by erythrocyte agglutination. Among patients who have subsegmental PE, d-dimer levels are abnormal in only 50% when measured by quantitative latex agglutination.

Specificity: D-dimer levels are normal in only 40-68% of patients without PE, regardless of the assay used. This is a consequence of abnormal D-dimer levels being common among hospitalized patients, especially those with malignancy or recent surgery. The specificity decreases even further in the setting of severe renal dysfunction and increased patient age.

NPV: The ability of a normal or negative D-dimer assay to exclude acute PE  depends on both the type of D-dimer assay and the clinical pretest probability that a patient has acute PE.

Taken together, the evidence indicates that a D-dimer level less than 500ng/ml by quantitative ELISA or semiquantitative latex agglutination is sufficient to exclude PE in patients with a low or moderate pretest probability of PE.
source: uptodate.com



 

BLUNT AORTIC INJURY

Today, during the morning handover, there was a polytrauma case. Very interesting, since he has thoracic aorta dissection,, open book fracture of pelvis, liver laceration and fracture femur. Another striking findings were rhabdomyolysis and acute kidney injury. This is a very interesting case since there are a few possible causes of acute kidney injury which include hypovolemia, contrast induced nephropathy, rhabdomyolisis, and trauma to the genitourinary tract.

I asked the MO, was the dissection due to blunt aortic injury?? Well, she didn't have a clue.

Blunt aortic injury usually occur at the junction between the mobile arch and the fixed descending aorta, just distal to the origin of the left subclavian artery, as a result of severe deceleration injury. Less frequently, the ascending aorta or arch vessels are injured by direct trauma.

It is divided into two:
1. Significant aortic injury: with disruption of the intima and full thickness of the media. There is a high risk of rupture

2. Minimal aortic injury: with laceration limited to the intima and inner media.  Radiologically this manifests as an intimal flap< 1 cm with minimal periaortic hematoma. There is a low risk of rupture

Clinical signs include unequal upper limb pulses, pseudocoarctation or interscapular murmur. The aortic injury should be suspected if the mechanism of injury is suggestive of rapid deceleration such as high speed (greater than 90 km/hr) motor vehicle or motorcycle crashes or a pedestrian hit by a vehicle.
CT and transesophageal echocardiography have been used for screening and diagnostic purposes.
Limitation of TOE : it provides high diagnostic accuracy for aortic injury and also allows examination for blunt cardiac injury. Imaging of distal aorta, proximal arch and major branches are limited.

Chest radiograph signs of blunt aortic injury:
1. Signs of periaortic hematoma:
-Widened mediastinum > 8 cm at the level of aortic knuckle
-Obscured aortic knuckle
-Opacification of aortopulmonary window
-Deviation of trachea, left main bronchus or nasogastric tube
-Thickened paratracheal stripe

2. Indirect signs:
-left haemothorax
-Left pleural cap
-Fractured first or second ribs


Significant aortic injury requires prompt surgical or endoluminal stent repair. Surgery should be deferred sometimes indefinitely if severe associated injuries or comorbidities make the operative risk unacceptably high.
Options for surgery: direct repair (clamp and sew), endoluminal stent repair.
Conservative management includes antihypertensive therapy (B-blockers +/- vasodilators) and serial imaging to assess for expanding pseudoaneurysm that will require intervention.

reference: Oh's intensive care manual 5th edition pg 794













 

Tumor Lysis Syndrome

It is caused by massive lysis of malignant cells and leads to release of large amounts of potassium, phosphate and uric acid into the systemic circulation with secondary hypocalcemia. Acute kidney injury can result from precipitation of uric acid and/or calcium phosphate in the renal tubules.

Most commonly encountered after initial chemotherapy for

a) High grade lymphomas (particularly Burkitt subtype)

b) Acute lymphoblastic leukemia (mature B cell acute lymphoblastic leukemia)

c) May occur spontaneously in high grade lymphoma or ALL

d) May occur in other tumor types with a high proliferative rate, large tumor burden or high sensitivity to cytotoxic therapy.

Diagnosis: Cairo-Bishop Definition of TLS

Laboratory tumor lysis syndrome is defined as any 2 or more of the following metablic abnormalities and presents within 3 days before or 7 days after instituting chemotherapy.

a) Uric acid > 476 micromol/L or 25% increase from baseline

b) Potassium > 6 mmol/L or 25% increase from baseline

c) Phosphate > 1.45 mmol/L in adults (> 2.1 in children) or 25% increase from baseline

d) Calcium < 1.75 mmol/L or 25% decrease from baseline

Clinical TLS: is defined as laboratory TLS plus one or more of the following that was not directly or probably attributable to a therapeutic agent

a) Increased serum creatinine > 1.5 from the upper limit normal

b) Cardiac arrythmias/sudden death

c) Seizure

Treatment

Best management is prevention
 

1. Key components are

a) Aggressive fluid hydration prior to therapy in all patients at intermediat or high risk for TLS. Children and adult should initally receive 2 to 3 L/m2 per day of IV fluid (or 200ml/kg per day in children weighing less than 10 kg). Urine output should be monitored closely and maintained within a range of 80 to 100 ml/m2 per hour (2 ml/kg for both children and adults, 4-6ml/kg in children less than 10 kg). Diuretics can be used to maintain the urine output, if necessary but should not be required in patients with relatively normal renal and cardiac function.
 

b) Diuresis
 

c) Administration of hypouricemic agents

Purine catabolism results in the production of hypoxanthine and xanthine which are metabolized to uric acid via the enzymatic action of xanthine oxidase. Allopurinol inhibits xanthine oxidase: blocking  hypoxanthine and xanthine to uric acid. After two to three days, allopurinol therapy results in increased excretion of both hypoxanthine which is more soluble than uric acid and xanthine which is less soluble than uric acid. A marked increase in xanthine excretion can occur when allopurinol is given for prevention of TLS and may lead to acute renal failure or xanthine stones. Allopurinol does not reduce the serum uric acid concentration before treatment is initiated. Thus for patients with pre-existing hyperuricemia, rasburicase is the preferred hypouricemic agent. Urate oxidase (which in not present in human) oxidizes preformed uric acid to allantoin which is 5 to 10 times more soluble than uric acidin acid urine. When exogenous urate oxidase (rasburicase) is administered, serum and urinary uric acid levels decrease markedly within approximtely four hours.

 

d) Urinary alkalinazion: generally not recommended. Benefit in increasing uric acid excretion is unproven. Potential harms, particularly in the setting of hyperphosphatemia.

e) Indications for dialysis are oliguria, persistent hyperuricemia, hyperphosphatemia and hypocalcemia.

Indications for renal replacement therapy include:

-Severe oliguria and anuria

-Persistent hyperkalemia

-Hyperphosphatemia induced symptomatic hypocalcemia

PERCUTANEOUS TRACHEOSTOMY

Important summary of my presentation:

Since Ciaglia et al. described the percutaneous dilatational tracheostomy (PDT) in 1985, PDT has gained popularity over surgical  tracheostomy in the intensive care setting. Percutaneous tracheostomy (PCT) requires less time to perform, it is less expensive and it is typically performed sooner (because an operating room does not have to be scheduled).  In a meta-analysis of 17 randomized control trials, PDT offers several advantages such as decreased wound infections, decreased bleeding and mortality compared to surgical technique. Indications for PCT are the same as those for standard open tracheostomy. Established contraindications against PCT are unstable fractures of cervical spine, severe local infection of anterior neck and uncontrolled coagulopathy. Relative contraindications are high PEEP or oxygen requirements, difficult anatomy, proximity to extensive burns or surgical wounds, elevated intracranial pressure, haemodynamic instability and previous radiotherapy to the neck.  In experienced hands, PDT seems to be a safe procedure. The number of relative contraindications to PDT declines with increasing operator experience. Overweight patients have a five times higher risk of perioperative complications with PDT than normal weight patients.

Percutaneous tracheostomy using the dilator (or Ciaglia) technique is superior to other percutaneous approaches including the single-forceps (Griggs) technique. Several commercial kits are available for PDT. Eventhough procedure differs slightly with choice of kit, the basic steps remain common. No strong evidence supports one specific kit or technique. To minimize complications, it is recommended that each institution chooses one kit and gain familiarity to appreciate its advantages and drawbacks. With bronchoscope guidance, the operator can ascertain correct tracheostomy site, intratracheal guidewire placement, intratracheal dilator placement without tracheal damage, proper partial withdrawal of the endotracheal tube and placement of tracheostomy tube. If ultrasound machine is available, a skilled operator can evaluate the anatomy of major vessels and the thyroid gland in relation to tracheostomy site. It helps in localize the level of tracheal rings and indentify midline puncture, depth etc. Following PDT, a routine chest radiograph is probably unnecessary, provided the procedure had been uncomplicated. In a retrospective review of 60 patients undergoing tracheostomy with bronchoscopic guidance, a post-procedure chest radiograph was only useful in detecting complications following procedures deemed difficult by and experienced operator.

 

Vancomycin in ICU

I am writing this today because someone is confused on prescribing vancomycin in critically ill patients. I hope this comment is useful, at least for my revision.

 

Vancomycin is a glycopeptide antibiotic, used for suspected or proven gram-positive infections.  Vancomycin's primary route of elimination is by renal excretion of unchanged drug. The rate of elimination is directly related to creatinine clearance.

 

The rate of killing depends primarily on time of concentration exceeding the organism's MIC (concentration dependent with time dependence). The ratio of area under the time concentration curve  during a 24 hour period to MIC(AUC0-24h/MIC ratio) is the best predictor of efficacy in this model.

Adverse effects:

1. Red man syndrome: is anaphylactoid reaction during or immediately following rapid infusion of large doses of vancomycin. Flushing usually involves face and neck, but can affect the whole body. It may be eliminated by avoiding massive doses and prolonging the infusion time e.g. no more than 500mg/hour or a maximum of 15 mg/min should prevent most infusion related reactions.

2. Nephrotoxicity: in monotherapy is not fully understood since early preparations were associated with nephrotoxicity. Only 20 cases reported in the medical literature in the years 1956-1984 despite the incessant use. Most of these cases were complicated by concomitant aminoglycoside therapy and pre-existing renal problems as well as investigator discrepancies in interpreting serum levels. Renal insufficiency due to vancomycin administered concomitantly with an aminoglycosides is well established. The incidence of acute renal failure in this setting may be as high as 20 to 30 percent.

3. Ototoxicity: has been described but it is the incidence is < 2%. Only approximately 40 cases of oto- and nephrotoxicity were reported in medical literature in the years 1956-1984.

Dosing

Vancomycin doses of 15 to 20 mg/kg should be administered q12h in patients with normal renal function, not to exceed 2g per dose. In settings where rapid clearance is anticipated, the intervals may be increased to q8h. For rapid achievement of target concentrations in seriously ill patients, a loading dose of 25 to 30 mg/kg may be administered. This may be appropriate for patients with critical illness in the setting of high anticipated Vd (e.g. burns, fluid overload).

 

Vancomycin dosing is based on actual BW (even in the setting of obesity), and doses are rounded to the nearest 250 mg. In general, the drug should b infused over 0.5 hours for each 500mg increment (e.g. 500mg over 0.5 hours, 1g over 1 hour etc). In the setting of the red man syndrome, the rate of infusion may be reduced to 500mg over 1 hour.

 

In recent RCT of continuous infusion regimens have not shown substantial improvement in patient outcomes compared with intermittent dosing.

 

In obesity, to avoid individual doses greater than 2g, the total daily dse can be divided into 3 administrations (q8h). In patients with renal insufficiency, doses in the range of 15-20mg/kg (based on target trough concentration) rounded to the nearest 250mg should be administered at frequencies based on estimations of creatinine clearance.

 

Serum concentration monitoring

Troughs versus peaks: Trough concentrations are useful as surrogate to AUC and are generally considered the most accurate and practical method to monitor vancomycin. Therefore, optimal dosing is guided by knowledge of both susceptibility and trough concentration.

There is little role for the routine monitoring of peak vancomycin concentrations, given the concentration independent pd properties and lack of data correlating peak concentrations with either efficacy or toxicity. IDSA 2005 guidelines for endocarditis endorsed target peak of 30-45 mcg/ml, the opinion was based on animal models and invitro susceptibility data rather than clinical evidence.

 

Target trough

At least 10 mcg/ml, may reduce emergence of isolates with elevated MIC. In the setting of invasive infections (e.g. bacteremia, endocarditis, osteomyelitis, prosthetic joint infections, HAP, infections of CNS) aim trough of 15-20 mcg/ml. Such concentrations generally achieve an AUC/MIC of > 400 for isolates with vancomycin MIC < 1. If MIC is > 2 mg/ml, alternate therapies should be considered.

 

Timing of levels: trough concentrations should be measured within 30 minutes prior to infusion of the fourth or fifth dose following the inital dose or dose adjustment. Trough concentration monitoring should be performed in patients receiving vancomycin therapy longer than 3 days. Once target concentrations are achieved, the trough should be monitored at least weekly for patients who receive longer therapy.

Serum creatinine concentration should be determined daily until stable,the weekly. More intensive monitoring may be considered if renal function unstable, if nephrotoxic drugs are administered concomitantly.

For patients on RRT via the newer, more permeable high flux membranes, repeat vancomycin is often required following each session. Many favour supplemental doses of at least 500 mg following each hemodialysis session.

Whenever practical, serum concentrations assessed immediately prior to hemodialysis may be used to guide subsequent dosing.

 

Pulmonary Disease in Chronic Liver Failure

Portal hypertension is responsible for:
1. Gastrointestinal bleeding
2. Ascites
3. Portosystemic encephalopathy
4. Hepato-renal syndrome
5. Pulmonary disease:
    a. Hepato-pulmonary syndrome
    b. Porto-pulmonary hypertension

A. Hepatopulmonary syndrome
It is characterized by:
i. Portal hypertension (with or without cirrhosis)
ii. Hypoxaemia (A-a gradient > 15 mmHg on room air)
iii. Evidence of pulmonary vascular dilatation

Diagnosis: Contrast enhanced echocardiography demonstrates delayed  visualization of microbubbles (more than 3 cardiac cycles) into the left heart of injected agitated saline bubbles intravenously. This suggests intrapulmonary shunt, whereas immediate visualization would suggest intracardiac shunting.

Treatment: Oxygen therapy, exclusion of other causes of hypoxaemia (shunt) and liver transplant

B. Portopulmonary hypertension

It is characterized by:
i. Portal hypertension
ii. PCWP < 15 mmHg
iii. Pulmonary hypertension (mPAP > 25 mmHg at rest)
iv. Pulmonary vascular resistance > 120 dynes per m-5 (3 Woods units)

Diagnosis: Right heart catheterization with measurement of PAP is the 'gold standard for diagnosis.

Treatment is a liver transplant (LT). In appropriately selected subjects, LT can effectively treat all the complacations of endstage CLD. LT can be determined by calculation of the model for end-stage liver disease (MELD) score. It is contraindicated in severe pulmonary hypertension (mPAP > 50 mmHg) but can be considered in those who respond to treatment with oral or IV vasodilator therapy.

Reference: Manual of Intensive Care by Irwin and Rippe.

Questions: Forty year old man with history of hepatitis C presents with dyspnoea. On examination he is jaundiced, with spider naevi and ascites. Chest X-Ray and spirometry are normal. Pulse oximetry is performed: Standing 88% and Supine 97%. (From data interpretation in critical care medicine)

1. What is the likely diagnosis?
     Answer: Hepatopulmonary syndrome in end-stage Hep C cirrhosis.

2. What is the postulated pathophysiological mechanisms?
     Answer: Intrapulmonary vasodilation with right to left shunting. The process affects mainly the bases. Changes in posture that increase basal pulmonary blood flow (upright position) worsen gas exchange.

Orthodeoxia is hypoxaemia accentuated in the upright position.
Platypnoea is increased dyspnoea in upright position, improved by assuming the recumbent position. Causes are: a. Intracardiac shunts (intra-atrial shunt) with or without lung disease and b. Pulmonary vascular shunts (pulmonary artery-pulmonary vein communications) either anatomical or parenchymal.

3. What further investigation is indicated?
     Answer: see above

4. Is liver transplantation likely to help?
    Answer: Yes, over 80% of patients with hepatopulmonary syndrome have resolution or marked improvement in intrapulmonary vasodilatation with LT. This contrasts with portopulmonary hypertension which is considered a contraindication (see comment above).




 

stroke- imaging

A 55 year old man presented to the department of emergency medicine after developing right sided weakness and inability to speak. He has a history of hypertension on ACEI.

Q1: List CT head abnormalities seen in an acute ischemic stroke.
A:
1. Hyperdensity within an intracranial vessel owing to intraluminal thrombus.
2. Parenchymal hypoattenuation owing to cytotoxic oedema. Hypoattenuation on CT is highly specific for irreversible ischemic brain damage.
 3. Obscuration of gray white matter contrast and effacement of sulci owing to edema
 4. Insular ribbon sign. Hypodensity and swelling of insular cortex. Located between the Sylvian fissure and the basal ganglia, it is supplied by small perforating branches of the MCA.
5. Obscuration of the lentiform nucleus. Also called blurred basal ganglia - early and frequent sign in MCA infarction.

Q2: List the abnormalities you might expect to see in an MRI done in a patient with an acute ischaemic stroke.
Answer:

1. Subtle low signal (hypointense) on T1 - often difficult to see at this stage
2. High signal (hyperintense) on T2 - comparable to hypodensity on CT
3. High intensity on DWI - the most sensitive sequence for stroke imaging. DWI sensitive to restriction of Brownian motion of extracellular water due to imbalance caused by cytotoxic edema.

Reduction in the ADC. DWI is sensitive to the microscopic random motion of the water molecule protons, a value known as the apparent diffusion coefficient (ADC), which is measured and captured by this type of imaging. ADC maps allow us to assess the extent of ischaemic disease. Measuring the ADC allows us to get an idea about the depth of ischemia in the penumbra itself and to obtain data regarding tissue viability.

MRI is commonly used method for assessment of the ischemic core and penumbra. The diffusion weight MRI (DWI) lesion is generally assumed to reflect the ischemic infarct, whereas the PWI perfusion weighted MRI (PWI) which uses gadolinium contrast lesion includes both infarct and penumbra hence the potential for perfusion mismatch.

DATA interpretation on coagulation

A 44 year old man presents with dyspnoea and is diagnosed as having multiple pulmonary emboli on CTPA. He is commenced on heparin 1000 units/hr after a 5000 unit bolus. During the night his heparin has increased to 1500 units/hr. The blood results are from the next morning:

PT 12, APTT 38.3
Fibrinogen 3.8g/L
D-dimer (latex immunoassay) > 20.0 mgh/ml (normal < 0.5)

1. Give two reasons for the low APTT despite heparin
2. List causes for an increased predisposition to venous thromboembolic disease?

Answer 1
Inadequate heparinisation, AT-III deficiency, increased heparin clearance, increased heparin binding proteins

Note: Heparin resistance is a term used to describe patients who require unusually high doses of heparin (>35,000u/day), and can be attributable to antithrombin deficiency, increased heparin clearance, elevation in heparin-binding proteins, elevation in factor VIII, and elevation of fibrinogen.
Heparin protocols are more effective in achieving goal in anticoagulation than ad hoc approach.

Heparin is a natural gycosaminoglycan that is extracted from procine intestinal mucosa. Intravenous administration results in immediate onset of action with t1/2 of 60secs-90 minutes. Liver and renal disease results in prolonged t1/2. When heparin combine with antithrombin III (heparin cofactor), thrombosis is blocked through inactivation of activated factor II, IX, X, XI and XII. Heparin also binds to platelets, both inhibiting and promoting their function.
Coagulation test findings: increased APTT, mildly increased PT, increased TCT, normal protamine corrected APTT test, normal reptilase time
TCT: thrombin clotting time -   test of the traditional final common pathway of the coagulation cascade which converts fibrinogen to fibrin.
Reptilase time - assist with the differentiation of causes of an increased TCT. Reptilase is a thrombin -like molecule that converts fibrinogen to fibrin but is not inhibited by antithrombin III.
Protamine corrected APTT: the APTT after protamin is added to the patient's blood.


Answer 2
1. anti-thrombin III deficiency
2. protein C and S deficiency
3. Factor V Leiden gene mutation
4. Lupus anticoagulation and anti-cardiolipin
5. malignancy
6. hyperhomocysteinemia

QUESTION 2

A 54 year old man post CABG is bleeding briskly into the chest drains
INR 1.4, PT 16, APTT 55, TT 17, fibrinogen 1.2 and Platelet 65

1. How would you correct this man's coagulation?
Answer: The TT is normal, so coagulopathy is not due to heparin. Consumptive or dilutional coagulopathy and needs platelets, FFP, and cryoprecipitate.

QUESTION 3

A 24 year old woman has the following haematology and coagulation profile post admission to ICU after post partum haemorrhage.
WCC 5.6, Hb 6g/dL, Platelts 30, PT 30.6, APTT > 150, fibrinogen 0.8, D-Dimer > 10 (normal < 0.4)
1. What is the likely cause of these abnormalities?
Answer: DIC
2. In this context list 3 likely causes of this coagulation profile
-preeclampsia, AF embolism, sepsis
-intrauterine fetal death
-massive or mismatched transfusion
3. What does an elevated D-dimer indicate?
Answer: Tests fibrinolysis (breakdown of the X linked fibrin)

QUESTION 4

A 54 year old woman presented to the ED after having been unwell for 4 days. Her FBC report is:
Hb 12.8 g/dL, WBC 56.5, Platelet 347, Hct 41.4%
Neutrophil 96.3%
Lymphocyte 2.8%
Mono 0.7%, Eosin 0.1%, Baso 0.1%
Moderate rouleaux. Marked neutrophilia. Dohle bodies present, toxic granulation present.
1. What likely hematological process is revealed by the abnormal white cell count?
Answer: Acute leukemoid reaction.
-> 50,000 cells, normal baso and eosinophil counts, Dohle bodies, toxic granulation