Question 17

Created on Sat, 05/16/2015 - 06:55
Last updated on Thu, 10/01/2015 - 00:31
Pass rate: 38%
Highest mark: 7.4

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You are asked to admit a 48-year-old woman for the management of respiratory failure, who received an allogeneic bone marrow transplant 2 weeks ago for acute myeloid leukaemia. A Chest X-Ray demonstrates a diffuse pulmonary infiltrate.

Initial observations

  • GCS 14
  • Temp 38.4 ºC
  • PR 140 /min, BP 90/40mm Hg
  • RR 35, SaO²
  • 88% on 10 lpm O²

.
The full blood count report from yesterday is at the bedside.

  • Hb 68 g/L
  • WCC 0.2 No differential
  • Plt 39

Comment - Occasional tear drops, Occasional elliptocytes, Occasional lymphocyte and
neutrophil seen.


a) List your differential diagnosis for the respiratory failure

b) List your immediate management priorities (i.e. within the first two hours) of the patient on admission to ICU

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College Answer

a) List your differential diagnosis for the respiratory failure

Infective – Severe sepsis in a patient with pancytopenia and agranulocytosis
Nosocomial pneumonia
– Bacterial –Gm negative –e.coli, Pseudomonas, Klebsiella,
– Gm positive –Strep, Staph epi
– Fungal -Aspergillus, Candida, Cryptococcus
– Atypical – Legionella, mycoplasma
– Viral –CMV, HSV, RSV, Influenza, H1N1, VZV
– PCP, toxoplasmosis
– TB (depending on background)
Sepsis due to other site and ARDS

Non- infective
- Idiopathic pneumonia syndrome
- Cardiac failure (cardiotoxicity due to induction chemo)
- Diffuse alveolar haemorrhage
- GVH – too early unless this is second graft
- Non cardiogenic capillary leak syndrome
- Chemo induced ALI / pneumonitis (methotrexate)
- TRALI
- Fluid overload

b) List your immediate management priorities (i.e. within the first two hours) of the patient on admission to ICU

Hypoxic respiratory failure
Non-invasive respiratory support commencing with CPAP progressing to BiPAP / invasive ventilation
as indicated

Circulatory support
Judicious fluid resuscitation +/- inotropes to restore circulation
Central access with platelet cover

Severe sepsis
Early commencement of broad-spectrum antibiotic cover or, if already on antibiotics, review existing
microbiology results, antibiotic duration and broaden or target antibiotic cover and add antifungal
therapy
Review and consider removal of existing indwelling vascular devices

Pancytopenia with agranulocytosis
Reverse barrier nursing in single room
Transfusion of blood products

Investigations
CXR, ABG, Biochemistry, FBC, coagulation profile, blood cultures, sputum, urine MC&S, viral
serology, echo

Discussions re prognosis
Liaison with treating haematologist to ascertain likely outcome from primary disease and BMT and
also discuss with patient and family high risk of deterioration and mortality

Discussion

This question refers to the management of neutropenic sepsis in the ICU. It asks: what organisms are likely to be causing pneumonia or ARDS in a neutropenic patient? And what are you going to do about it?

 This is a pre-engraftment patient with neutropenic sepsis. One can already generate a list of differentials for which pathogens are likely to be active here. Hint: its pretty much all of them. One could not go too wrong simply regurgitating a list of pathogens.

The non-infectious causes of widespread pulmonary infiltrate and shock are also a standard panel.

The management within the first two hours is a reference to the Surviving Sepsis campaign recommendations.

The management of hypoxic respiratory failure here begs a mention of NIV, and its mortality-reducing utility in this setting.

The establishment of central venous access should occur with platelet cover; then, one may pursue goal-directed resuscitation with vasopressors and fluids.

The removal of old lines is a part of source control and should also be mentioned

The commencement of early antibiotics should be mentioned, with the emphasis on "early"; one ought to also mention the collection of multiple blood culture specimens.

A responsible candidate will also rattle off a list of investigations, mention the need for blood products, and comment on the usefulness of a haematologist in the management of a haematology patient.

Ultimately, the prognosis for these people is very poor, and the answer should finish with a call to contact the family and discuss the potential need to set treatment limitation.

References

Here is a list of references from my notes on sepsis in the immunocompromised host, and specifically in the bone marrow transplant recipient:

Leather HL, Wingard JR. Infections following hematopoietic stem cell transplantation. Infect Dis Clin North Am. Jun 2001;15(2):483-520.

Thiéry G, Azoulay E, Darmon M, Ciroldi M, De Miranda S, Lévy V, Fieux F, Moreau D, Le Gall JR, Schlemmer B. Outcome of cancer patients considered for intensive care unit admission: a hospital-wide prospective study. J Clin Oncol. 2005 Jul 1;23(19):4406-13.

Hilbert, Gilles, et al. "Noninvasive ventilation in immunosuppressed patients with pulmonary infiltrates, fever, and acute respiratory failure." New England Journal of Medicine 344.7 (2001): 481-487.

Antonelli M, Conti G, Rocco M, et al. A comparison of noninvasive positive-pressure ventilation and conventional mechanical ventilation in patients with acute respiratory failure. N Engl J Med 1998;339:429-435

Afessa, Bekele, and Elie Azoulay. "Critical care of the hematopoietic stem cell transplant recipient." Critical care clinics 26.1 (2010): 133.

Soubani AO, Kseibi E, Bander JJ, et al. Outcome and prognostic factors of hematopoietic stem cell transplantation recipients admitted to a medical ICU. Chest 2004;126(5):1604–11.

Scales, Damon C., et al. "Intensive care outcomes in bone marrow transplant recipients: a population-based cohort analysis." Crit Care 12.3 (2008): R77.