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					Case conference
Patient Profile
• เด็กชายอายุ 5 ปี
• ภูมิลาเนา อ.เขมราฐ จ. อุบลราชธานี
Chief complaint
• 5 วันก่อนมารพ.        ู
                   ไข้ สงตลอดวัน ไม่มีURI symptoms,
                                             ุ
                   ปั สสาวะอุจจาระปกติ ไม่มีจดเลือดออก
                   ไม่มีเลือดกาเดาไหล ไปรพช. admit
                    CBC

    31/5/55          2/6/55          3/6/55
Hct    33        Hct 34%         Hct 35
WBC 8,000        WBC 2,600       WBC 2,000
N      83%       N     44%       N     56%
L      14%       L     52%       L     40%
Plt    180,000   Plt   126,000   Plt   69,000
                   CBC

      4/6/55                 4/6/55
Hct       33%            Hct     27%
WBC       1,700          WBC     1,600
N         41%            N       38%
L         48%            L       54%
Plt       11,000         Plt     7,000
  At รพ.สปส.
Date   BT   PR BP        RR Hct       DTX IV       Rate total
4/6/55 39.2 124 90/50    26    39%    120   5%DNSS 100   400

                              4 hrs
       38   100 110/30         40     150   5%DNSS 140   560


                              4 hrs
       39   110 90/60          38     200   5%DNSS 100   800
Date   BT   PR BP        RR Hct     DTX IV      Rate total
5/6/55 39   120 100/60 30    38         5%DNSS 60     180
                                        Lasix
                                        10mg

                            3 hrs
       36.5 136 100/80       40         5%DNSS 60     60
                                        PRC 200

                            1 hrs
       36.5 140 113/81 56               Dextran 140   140


                            1hrs
 4/6/55

    CBC       Bloodchemistry          LFT
Hct   37%     BUN    6         TB       0.33
WBC   2,150   Cr     0.4       DB       0.18
N     42      Na     135       SGOT     822
L     50      K      4.0       SGPT     243
ATL   2       Cl     104       ALP      150
Plt   4,000   CO2    19
Date     BT   PR BP        RR Hct     DTX IV        Rate total
5/6/55        136 148/66 36    37     129   FFP     140   140
                                            Lasix
                                            10mg

                              1 hrs
         40.4 172 131/94 58                 Voluven 60    60


                           30mins
         40.2 165 135/90       39     124



                              1 hrs
 5/6/55
Bloodchemistry
                        LFT
BUN    6
                 TB       0.55     coagulogram
Cr     0.4
                 DB       0.11   PT      15.6
Na     134
                 SGOT     942    PTT     85.1
K      4.2
                 SGPT     255
Cl     107
                 ALP      110
CO2    14
Date    BT    PR BP          RR Hct      DTX IV         Rate total
5/6/55 ปวดท้ องมาก, Pulse full                 Plt. Conc 200   200


                                 1 hrs
              150 118/89          36%          Voluven 40      160
                                               Lasix
                                               10mg


                                 4 hrs
        39.5 120 139/93 54        36     124   Voluven 20      80
Date   BT   PR BP        RR Hct   DTX IV          Rate total
6/6/55 39   138 129/93 38   36    121   Voluven KVO
                                        Lasix
                                        20mg

                       1 hrs
                Agitation confuse
            144 120/96                  Voluven KVO
            เบา                         PRC     30     100

                 2 hrs  On ETT
       37.8 162 126/34 50   40    18    glucose
 6/6/55 (9.00น.)

    CBC       Bloodchemistry          LFT
Hct   36%     Na     141       TB       0.33
WBC   6,000   K      4.2       DB       0.18
N     38      Cl     103       SGOT     2,157
L     47      CO2    21        SGPT     562
Mo    12                       ALP      131
Plt   6,000                    Alb      2.6
6/6/55 (12.00น.)

         LFT                LFT
TB         0.33    TB         1.51
DB         0.18    DB         1.03
SGOT       2,157   SGOT       3,206
SGPT       562     SGPT       818
ALP        131     ALP        153
Alb        2.6

       9.00 น.            12.00 น.
6/6/55 (12.00 น.)
•   On ETT + ventilator
•   G/M Fresh whole blood 2,000 ml for total exchange
•   Novo-7 : 1,500 mcg iv q 8 hrs
•   On Double lumen
•   Lactulose
•   Neomycin (80 MKD)
•   Ceftazidime 3gm iv drip in 24 hrs
•   10% aminoleban iv 25 ml/hr
•   10% DNSS 30 ml/hr
6/6/55 (12.30น.)
• BP 69/50 mmHg, PR 180/min, cold clammy skin, pale (Hct
                        37%)
       • Dopamine + Dobutamine 10 mcg/kg/min



                 • PRC 300 ml IV push
                           30
                           min

                   • Coffee ground
                • PR ? BP? HR 140/min
6/6/55 (14.00น.)



• Total exchange x 3 hrs
6/6/55 (post exchange)

       LFT                LFT
TB       1.51      TB       0.33
DB       1.03      DB       0.18
SGOT     3,206     SGOT     2,581
SGPT     818       SGPT     817
ALP      153       ALP      131
                   Alb      2.6
6/6/55 ( 17.40น.)
•   Hct 34% PR 134/min, BP 114/72 mmHg
•   Platelet concentration 8 U iv in 1 hr
•   Total IV = 70% M, GIR 2.34
•   Urine output 2-3 ml/kg/hr
6/6/55 ( 22น.)
• BP 121/82 mmHg, PR 147/min
• PRC 300 ml iv in 4 hrs
• Hct หลัง PRC 30% ( bleed from central line)
• Melena
7/6/55 (0 น.)
•   Fresh blood per NG
•   FFP 100 ml iv in 2 hrs
•   Hct 30%
•   Urine output 0.25 ml/kg/hr

• 4.00 น.
    – Hct 27% BP 107/65mmHg, PR 140/min
    – PRC 200 ml iv in 2 hrs
    – Urine output 0 ml
7/6/55( 7.00 น)

• PT 27 sec             • FFP 200 ml iv in 1 hr
• PTT 58.3 sec          • Platelet concentration 4
                          U iv in 1 hr
• AST 34,980            • Cryoprecipitate 200 ml
• ALT 5,689               iv in 1 hr
                        • Bleeding at central line
• Calcium 8             • G/M Fresh whole blood
                          2,000 ml for total
                          exchange
• Hct 27%, Plt 55,000
 7/6/55( 8-9.00 น)
 • Fresh blood per NG         • PRC 300 ml IV push
 • PR 170/min                 • Consult nephro
 • Total anuria               • Total iv = insensible loss
                                          + urine output



7/6/55( 11-14.00 น)
          Total exchange
Lung : expiratory wheezing lasix 40 mg iv  void ติดสาย
7/6/55

       LFT               LFT
TB       2.47     TB       2.69
DB       1.67     DB       1.68
SGOT     34,980   SGOT     33,670
SGPT     5,689    SGPT     2,582
ALP      112      ALP      111
Alb      2.7      Alb      3.6
7/6/55 15.00น.
• PR 142                   • Cut down
• Void 0.18 ml/kg/hr          – CVP 24 cm
• CxR                      • Single donor platelet 1u
  – Pulmonary congestion
7/6/55 18.00น.
• Acute peritoneal dialysis
  – 2.5% PDF
  – 10ml/kg/cycle
8/6/55 (7.00น.)
•   E2VTM4              • IV = insensible loss + Uo
•   BP 111/77 mmHg      • Total GIR 1.8
•   PR 130/min          • Continue peritoneal
•   CVP 14 cm             dialysis
•   Total UF 1,280 ml
9/6/55 (7.00น.)
•   E2VTM3               • Continue peritoneal
•   DTR 3+                 dialysis (1..5% PDF)
•   No flapping tremor
•   BP 102/48 mmHg
•   PR 133/min
•   I/O = 1454/15
•   Bleeding 800 ml
•   Hct 24-25%
9/6/55

       LFT              LFT
TB       5.34    TB       5.36
DB       4.00    DB       4.07
SGOT     6,011   SGOT     3,625
SGPT     1,282   SGPT     832
ALP      162     ALP      120
Alb      -       Alb      2.6
9/6/55 (16.00-7.00น.)
• Bleeding at central line   •   PRC 2 U
  insertion                  •   FFP 200 ml iv q 8 hr
• Hematochezia               •   Cryoprecipitate 2 u
• CVP 4                      •   Transamine 250 mg iv q
                                 6 hrs
10/6/55
•   BP 98/38 mmHg     • IV = insensible loss +Uo
•   PR 154/min        • Continue peritoneal
•   Hct 25%             dialysis
•   Total UF 214 ml   • 10% calcium gluconate
•   I/O 1,589/O ml      10ml iv q 8 hr


• Plt 79,000
• AST 3,296
• ALT 816
11/6/55
•   Persist hypoglycemia   • Hold peritoneal dialysis
•   Metabolic acidosis     • 7.5% NaHCO3
•   BP 79/34 mmHg          • Adrenaline
•   PR 156/min               1 mcg/kg/min
•   CVP 1

                           •        DEATH

				
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posted:8/14/2012
language:Thai
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