DIC, ARDS induced by hepatic failure?

[Rajesh-Gupta]

    
      Re: DIC, ARDS induced by hepatic failure?
    


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Posted by HFHSM.D.-kb on March 11, 1998 at 13:05:02:

In Reply to: DIC, ARDS induced by hepatic failure? posted by Rajesh Gupta on February 21, 1998 at 18:11:34:

: Here is a case summary of someone who is very dear to me. I would appreciate
  any opinions, pointers, help, etc.
  Rajesh
  
                      CASE SUMMARY
                      ============
  This 36 year old male was absolutely alright till 19th Jan '98 when he got high
  grade fever associated with chillls and rigour for which he was treated and anti
  malarials and were given and he got better in 3 days. Patient again had fever
  on 23rd Jan. THis time he was treated with antibiotics (Ciprofloxacin)
  suspecting Enteric fever and patient got better. Patient again had fever on
  30th Jan. He was admitted in Kailash Hospital, Noida on 5th Feb with breathing
  difficulty. He was put on ventilator on 6th Feb, shifted to Apollo Hospital for
  further management.
  On Examination :
  ---------------
  Patient was conscious, opening eyes, raising all four limbs. Icterus++,
  Jaundice++, febrile, Cyanosis, scitis++, Pulse 134/m, BP 84/51 mm -- on
  Dopamine 4ml/hr and Dobutamine 4ml/hr. On PCIRV with Inspiration (Pressure
  control Ventilation).
  PR - 25 cmH2O
  TV - 0.50
  Rate 18/m Flo2 - 100% Peep - 4
  Maintaining good saturation - 97% on right lateral position.
  Chest - B/L air entery +
                occ. crepts +
  CVS - S1, S2n
  P/A - Spleenomigaty + ascitis +Hepatimegaly
  CNS - no neck rigidity, pupils - B/L Perria, Plantan - down
  All the investigations were done, showing renal failure and liver impairment
  and high blood sugar. He was put on broad spectrum antibiotics : Insulin, IV
  fluids, Ventilator and ionotropic support. Patient was continually running high
  fever, so fill dose of Inj Faleigo and afriaxone and Tarund given, but patient
  did not show any response. Patient got stress gastric ulcers so blood
  transfusion was given off and on. Bone marrow aspiration for AFB and malaria
  parasite was negative. Pertoneal and haemodialysis was doen several times for
  renal failure. Broncoscopy was done bronchial tree appearence was suggestive of
  fungal infections so antifungus was given. Culture report of bronchial lavage
  showed Pseudnass infection so Primaxin was started. Patient had geratised tonic
  clonic seizures lasting about 10 minutes subsided by Vaccuronium, so Primaxin
  was stopped. At present patient condition was critical. Patient is unconscious,
  not responding to deep painful stimulii. Maintaining blood pressure on
  isotropic support on CMV mode of ventilator. Daily haemodialysis for renal
  impairment. FFP for deranged blood parameters, plus other supportive treatment.
  Patient is also having signs of DIC with generalised bleeding from the WT,
  haematemesis, malina. Chest Xray picture is also suggestive of ARDS. At present
  patient is in multiple organ failure due to septicaemia. Presently on
  Aztirconam. ALl blood cultures negative. No M.P. seen. Total counts have
  remained between 6000-7000 ***. He has severe DIC.
  ===============================

  
  Hello,
  A friend of ours, ShriKant Srivastava, is in critical condition at Apollo
  Hospital, New Delhi, India. A case summary of his condition as given by the
  hopspital is enclosed above. We want to get input from people/doctors/others
  out there who have seen succesful treament for similar symptoms. If you have
  come across patients who have been treated for similar symptoms and are in a
  position to help by way of letting us know the line of treatment that was given
  then please get in touch with us. The main contact people are,
  Manu Lauria
  email   : ***@****
  Address : Cadence Design Systems (I) Pvt Ltd,
            SDF # B-8, NEPZ,
            Noida, 210305.
            India.
  Phone   : [phone] (Office)
            [phone] (Residence)
  Fax     : [phone]
  Sandeep Pagey
  email   : ***@****
  Address : Cadence Design Systems (I) Pvt Ltd,
            SDF # B-8, NEPZ,
            Noida, 210305.
            India.
  Phone   : [phone] (Office)
            [phone] (Residence)
  Fax     : [phone]
  Captain Srinivas
  email : ***@****
_____________________________
Dear Rajesh Gupta,
I appreciate the difficulties with your friend that you write about in your posting.  Obviously, from the limited description of this very difficult situation. I can make no diagnosis.  The presence of fever for several days prior to the development of multiorgan failure places sepsis high on the differential diagnosis.  Many infections, particularly viral can involve the liver including CMV, EBV, Herpses simplex, Hepatits A, B, and C and others.  In addition, many of the medications he received in the febrile period and thereafter are potentially hepatotoxic.
Treating the underlying infection, whatever that may be, would be the first line of therapy while organ function was being supported.  Liver transplanatation would be contraindicated in the setting of sepsis and would not appear to be appropriate from the description you have written.
The presence of splenomegaly and ascites does raise the additional possibility of preexisting liver damage which is now worse in the setting of infection.
I wish you and your friend the best in this difficult situation.  If you have any further specific questions please let us know.
This material is being presented for informational purposes only and should not be considered a formal evaluation.  If you have specific questions, you should contact your physician.
keywords: liver failure, DIC
HFHSM.D.-kb
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