Adult ICU Morning Review Note

Intensive Care Unit

Date: 15/10/2023

Name of Patient: Robert Vance

Inpatient Admitting Consultant: Dr Sarah Jenkins

Inpatient Admitting Specialty: Colorectal Surgery

Other Specialty Involvement

Dr David Chen, Infectious Diseases Dr Priya Patel, Nephrology

Admitting Consultant: Dr Michael Ross

Ward Round attended by

ICU VMO: Dr Michael Ross ICU Registrar: Dr Liam O'Connor Admission Date: 12/10/2023 ICU resident: Dr Chloe Evans Nurse in Charge: RN Mark Taylor Bedside ICU nurse: RN Jessica Liu

Summary

• Robert Vance, 68yo M, PMHx HTN, T2DM, COPD, day 3 ICU, presented with acute abdomen secondary to perforated diverticulitis requiring emergency Hartmann's procedure on 12/10/2023. Currently intubated and ventilated, weaning noradrenaline for septic shock, on empiric IV piperacillin/tazobactam, clinically stabilising with decreasing vasopressor requirements and improving gas exchange.
• Option A, for full resuscitation and active management.

Past Medical History

• Hypertension
• Type 2 Diabetes Mellitus (non-insulin dependent)
• Chronic Obstructive Pulmonary Disease (GOLD Stage II)
• Gastro-oesophageal reflux disease
• Previous appendicectomy (1985)

Events over Last 24 Hours

• Weaned noradrenaline from 0.12 mcg/kg/min to 0.04 mcg/kg/min whilst maintaining MAP > 65 mmHg.
• Transitioned ventilation from SIMV to PSV; tolerating spontaneous breathing trials well.
• Febrile episode to 38.4 °C at 22:00; peripheral and central blood cultures sent.
• Stoma pink and patent, minimal serosanguinous output in bag.
• Commenced trophic nasogastric feeds at 20 mL/h, minimal gastric residual volumes.

Active Conditions and Issues List

1. Perforated diverticulitis

   • Post-operative day 3 following emergency laparotomy and Hartmann's procedure for Hinchey III purulent peritonitis.
   • Presented to ED 12/10/2023 with 2-day history of severe lower abdominal pain, fevers, and obstipation.
   • Background of untreated colonic diverticulosis noted on colonoscopy 2019.
   • Midline laparotomy wound clean and dry, pelvic Robinson drain in situ draining haemoserous fluid, end colostomy viable.
   • Dr Sarah Jenkins (Colorectal Surgery): Happy with surgical progress, keep NGT on free drainage if residuals > 250 mL, otherwise continue slow grading up of enteral feeds; remove pelvic drain tomorrow if output remains < 50 mL/24h.
   • Anastomotic or stump leak, intra-abdominal collection.

2. Septic shock

   • Secondary to faecal peritonitis; improving haemodynamic stability over past 24 hours.
   • Admitted from theatre hypotensive and lactataemic requiring high-dose vasopressors and fluid resuscitation.
   • Regular home medications: perindopril 5 mg PO daily and metformin 1,000 mg PO BID (both currently withheld).
   • Noradrenaline weaning, lactate cleared to 1.2 mmol/L, down-trending inflammatory markers.
   • Dr David Chen (Infectious Diseases): Intra-abdominal fluid growing E. coli and Bacteroides fragilis; continue IV piperacillin/tazobactam to complete 5-day course, cease vancomycin as no MRSA isolated.
   • Ongoing occult abdominal sepsis, catheter-related bloodstream infection.

3. Acute kidney injury

   • KDIGO Stage 2 AKI secondary to pre-renal hypovolaemia and sepsis, currently resolving without renal replacement therapy.
   • Oliguric on presentation to ICU with peak creatinine of 210 umol/L on 13/10/2023.
   • History of hypertension and T2DM; baseline creatinine 85 umol/L.
   • Urine output improved to > 0.5 mL/kg/h following fluid resuscitation and MAP optimisation; creatinine trending down.
   • Dr Priya Patel (Nephrology): Renal recovery evident, avoid nephrotoxins, no indication for CRRT, monitor electrolytes closely as polyuric phase may develop.
   • Acute tubular necrosis.

Examination Findings

Central Nervous System

Sedation and Paralysis: propofol 80 mg/h IV fentanyl 50 mcg/h IV

GCS: E 3 V T M 6

Pupils: 3 mm equal and reactive to light bilaterally

Muscle Power: Moving all four limbs symmetrically to command, power 4/5 throughout

Sedation and Paralysis: propofol 80 mg/h IV fentanyl 50 mcg/h IV

Respiratory System

Ventilation Parameters: PSV, PS 10 cmH2O, PEEP 5 cmH2O, FiO2 0.30, VT 480-520 mL, RR 16

Chest Findings: Clear air entry bilaterally, mild bibasal coarse crepitations clearing with suction.

ABG Results: pH 7.38, pCO2 41 mmHg, pO2 88 mmHg, HCO3 24 mmol/L, BE -1.0, Lactate 1.2 mmol/L

CXR: ETT 3.5 cm above carina, R IJV CVC tip at cavoatrial junction, mild bibasal atelectasis, no pneumothorax or pleural effusion.

Cardiovascular System

HR and Rhythm: 88 bpm, sinus rhythm

BP: 118/62 (MAP 81) mmHg

Peripheral Perfusion: Warm and well perfused, CRT < 2 seconds

Peripheral Oedema: Mild bilateral pitting pedal oedema to ankles

Gastro-intestinal System

Abdominal Palpation: Soft, mildly tender around midline laparotomy dressing, non-peritonitic.

Bowel sounds: Scant bowel sounds present.

Bowels open: Stoma active, passed 30 mL brown liquid stool today.

Feeding Requirements: Nutrison Protein Plus 20 mL/h via NGT, 4-hourly aspirates.

LFTS Bilirubin 18 umol/L (18 umol/L), ALP 115 U/L (115 U/L), GGT 68 U/L (68 U/L), ALT 42 U/L (42 U/L), AST 38 U/L (38 U/L), Albumin 26 g/L (26 g/L)

Drains: Pelvic Robinson drain in situ, 40 mL haemoserous fluid in last 24 hours.

Renal System

Urine output: 45-65 mL/h via IDC, clear yellow.

Augmentation: frusemide 20 mg IV STAT given at 06:00 for positive fluid balance.

Fluid Balance over last 24 hours: +450 mL (Intake 2,450 mL, Output 2,000 mL)

Cumulative Fluid Balance: +3,200 mL since ICU admission

Na, K, Ur, Cr, mg, phos, iCa Na 138 mmol/L (138 mmol/L), K 4.2 mmol/L (4.2 mmol/L), Ur 11.4 mmol/L (11.4 mmol/L), Cr 142 umol/L (142 umol/L), Mg 0.92 mmol/L (0.92 mmol/L), Phos 1.10 mmol/L (1.10 mmol/L), iCa 1.18 mmol/L (1.18 mmol/L)

Haematology

Hb, Plats, INR, APTT, Fibrinogen Hb 104 g/L (104 g/L), Plats 210 x10^9/L (210 x10^9/L), INR 1.1 (1.1), APTT 32 s (32 s), Fibrinogen 4.5 g/L (4.5 g/L)

D-dimer 1.2 mg/L

Sepsis

Temperature 37.2 °C currently, Tmax 38.4 °C at 22:00 yesterday.

Intermittent low-grade pyrexia overnight, normothermic since 02:00.

WCC, CRP, Pro Calcitonin WCC 13.8 x10^9/L (13.8 x10^9/L), CRP 145 mg/L (145 mg/L), Pro Calcitonin 1.8 ng/mL (1.8 ng/mL)

Current Antibiotics

piperacillin/tazobactam (Tazocin®) 4.5 g IV QID (Day 3 of 5)

Microbiology

12/10/2023 Blood cultures: No growth after 72 hours. 12/10/2023 Intra-abdominal swab MCS: Heavy growth Escherichia coli (sensitive to piperacillin/tazobactam, ceftriaxone) and Bacteroides fragilis (sensitive to metronidazole, piperacillin/tazobactam). 13/10/2023 Urine MCS: < 10^6 WBC, no significant growth. 14/10/2023 Sputum MCS: Mixed upper respiratory tract flora. 14/10/2023 Blood cultures: Pending.

DVT/Ulcer Prophylaxis

enoxaparin (Clexane®) 40 mg SC daily and sequential compression devices in situ

pantoprazole (Somac®) 40 mg IV daily for stress ulcer prophylaxis whilst intubated

Family Update

Margaret Vance (Wife) David Vance (Son)

Updated by Dr Liam O'Connor (ICU Registrar) and RN Jessica Liu on 15/10/2023 at 10:30. Discussed surgical recovery, weaning of blood pressure support, and plan for trial of extubation today. Wife stated she is "relieved he is turning the corner" and will visit at 14:00.

Goals of care

Option A: For full active treatment including CPR, intubation, and vasopressor support.

Impression

Robert Vance, 68yo Male, resolving septic shock and AKI post emergency Hartmann's procedure for perforated diverticulitis on a background of HTN, T2DM, and COPD. Planned for sedation wean and extubation today, ongoing IV antibiotic therapy, and grading up of enteral nutrition over the next few days.

Plan

• Cease propofol infusion, titrate fentanyl to RASS 0 to -1, and assess for extubation this morning.
• Extubate to high-flow nasal prongs 40 L/min FiO2 0.30 if cuff leak present and spontaneous breathing trial successful.
• Wean noradrenaline off as tolerated to maintain MAP > 65 mmHg.
• Dr David Chen (Infectious Diseases): Cease vancomycin, continue piperacillin/tazobactam 4.5 g IV QID to complete 5 days total.
• Dr Sarah Jenkins (Colorectal Surgery): Grade up nasogastric feeds by 20 mL/h every 4 hours to target 65 mL/h if aspirates < 250 mL; stoma therapy review today; remove pelvic drain tomorrow if output < 50 mL.
• Dr Priya Patel (Nephrology): Monitor daily UEC, avoid nephrotoxic agents, aim neutral fluid balance today.
• Continue enoxaparin 40 mg SC daily and pantoprazole 40 mg IV daily.
• Chest physiotherapy post-extubation.

Parameters

O2 Sats: > 92%

MAP: > 65 mmHg

Urine output: > 35 mL/h

Electrolyte Management: Keep K > 4.0 mmol/L and Mg > 0.85 mmol/L

Fluids/feeding requirements: Grade up Nutrison Protein Plus to target 65 mL/h; no routine maintenance IV fluids.

Notify Registrar if: HR > 110 bpm, MAP < 65 mmHg, Resp Rate > 28, SpO2 < 92%, UO < 35 mL/h for 2 consecutive hours, or T > 38.3 °C.

This Clinical note has been written or checked for accuracy by

Claire Matthews, Nurse Practitioner, MNP, GradDipCritCare, RN