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Casi Clinici – Varese - 2014 Caso Clinico: F 55 aa Ictus ischemico in endocardite batterica Cardiologo – Ecocuore TT Dilatazione VS e AS con FEVS > 50%, non alterazioni cinetica
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AGGIORNAMENTI SUL PAZIENTECON SEPSI SEVERA
- Casi Clinici –
Dr. Massimo BianchiU.O. Pronto Soccorso e Accettazione
A.O. Ospedale di Circolo e Fondazione Macchi - VareseDirettore: Dr. Francesco Perlasca
Infection, documented or suspected, and some of the following:General variables
•Fever (> 38.3°C)•Hypothermia (core temperature < 36°C)•Heart rate > 90/min–1 or more than two sd above the normal value for age•Tachypnea•Altered mental status•Significant edema or positive fluid balance (> 20 mL/kg over 24 hr)•Hyperglycemia (plasma glucose > 140 mg/dL or 7.7 mmol/L) in the absence of diabetes
Inflammatory variables•Leukocytosis (WBC count > 12,000 L–1)•Leukopenia (WBC count < 4000 L–1)•Normal WBC count with greater than 10% immature forms•Plasma C-reactive protein more than two sd above the normal value•Plasma procalcitonin more than two sd above the normal value
Hemodynamic variables•Arterial hypotension (SBP < 90 mm Hg, MAP < 70 mm Hg, or an SBP decrease > 40 mm Hg inadults or less than two sd below normal for age)
Organ dysfunction variables•Arterial hypoxemia (Pao2/Fio2 < 300)•Acute oliguria (urine output < 0.5 mL/kg/hr for at least 2 hrs despite adequate fluid resuscitation)•Creatinine increase > 0.5 mg/dL or 44.2 mol/L•Coagulation abnormalities (INR > 1.5 or aPTT > 60 s)•Ileus (absent bowel sounds)•Thrombocytopenia (platelet count < 100,000 L–1)•Hyperbilirubinemia (plasma total bilirubin > 4 mg/dL or 70 mol/L)
Tissue perfusion variables•Hyperlactatemia (> 1 mmol/L)•Decreased capillary refill or mottling
Cosciente, risvegliabile, orientata. Sospetta sepsi nddScambi e meccanica respiratoria sufficientiPA 100/60, FC 90 ar, Sat o2 100% in O2, diuresi validaCVC 3 vie, PAIProsegue la terapia in corsoDa rivalutare
Pz in trattamento empirico con sulbactam/ampicillina +gentamicina per MOF in portatrice di protesi mitralicameccanicaVigile, collaborante, sofferente, non rigorGià effettuate emocolture prima di AB. Si consiglia Eco-cuore (già richiesto)Prosegue Unasyn e Gentamicina (incrementata a 3.5mg/kg die
Dilatazione VS e AS con FEVS > 50%, non alterazioni cineticaregionaleLieve dilatazione VD con cinetica lievemente ridottaValvola aortica senza vegetazioniProtesi mitralica normofunzionante, non macroscopici segnidi endocarditeSospetto leak periprotesico commissura mitro-aortica
Rilievi compatibili con accidente cerebrovascolare acutonel territorio dell’a. cerebrale media dx, a verosimilegenesi cardio-embolica.Controindicata la fibrinolisi per piastrinopeniaControllo TC a 12-24 hClexane 8000Mannitolo 100 x 5Richiedere ECO-CD TSAValutaz. Cardiologica / CCH
Rivalutaz CCH: non ancora eseguito ECO-TE, che siritiene opportuno eseguire appena possibile (allertatocardiologo di guardia). Comunicazione con i familiari
Diagnosi strumentaleTC cerebri (06-01): non lesioni emorragiche né ischemicheTC cerebri (07-01): sfumata ipodensità frontale sinTC cerebri (08-01): lesione ischemica nuclei della base dx con modesto
effetto massa sul ventricolo controlat.TC addome (10-01): 2 infarti splenici, focolaio flogistico rene sinEcocardioTE (8 e 13-01): vegetazioni filamentose fluttuanti sul vers
atriale della prot meccanica mitralica, lieve Iao,lieve Itr
Lento recup postopDisartria ed emiplegia sinistra persistentiTer AB: vancomicina dal 06-01 fino al 04-03EcocardioTT: bioprot M normofunz, lieve Sao, Iao moderata, ITr lieve02-02 Trasferita in 19^ giornata postop
c/o Centro di Riabilitazione Neuromotoria (Cunardo Le Terrazze),progressivo miglioramento posturale (>arto inf sin)
Infection, documented or suspected, and some of the following:General variables
•Fever (> 38.3°C)•Hypothermia (core temperature < 36°C)•Heart rate > 90/min–1 or more than two sd above the normal value for age•Tachypnea•Altered mental status•Significant edema or positive fluid balance (> 20 mL/kg over 24 hr)•Hyperglycemia (plasma glucose > 140 mg/dL or 7.7 mmol/L) in the absence of diabetes
Inflammatory variables•Leukocytosis (WBC count > 12,000 L–1)•Leukopenia (WBC count < 4000 L–1)•Normal WBC count with greater than 10% immature forms•Plasma C-reactive protein more than two sd above the normal value•Plasma procalcitonin more than two sd above the normal value
Hemodynamic variables•Arterial hypotension (SBP < 90 mm Hg, MAP < 70 mm Hg, or an SBP decrease > 40 mm Hg inadults or less than two sd below normal for age)
Organ dysfunction variables•Arterial hypoxemia (Pao2/Fio2 < 300)•Acute oliguria (urine output < 0.5 mL/kg/hr for at least 2 hrs despite adequate fluid resuscitation)•Creatinine increase > 0.5 mg/dL or 44.2 mol/L•Coagulation abnormalities (INR > 1.5 or aPTT > 60 s)•Ileus (absent bowel sounds)•Thrombocytopenia (platelet count < 100,000 L–1)•Hyperbilirubinemia (plasma total bilirubin > 4 mg/dL or 70 mol/L)
Tissue perfusion variables•Hyperlactatemia (> 1 mmol/L)•Decreased capillary refill or mottling