Presented by: Dr. Ayman Bukhari
Under supervision of : Prof. Hassan Abdul-Jabbar
Dr. Faisal Kashgari
MR NO. 664144
 A 24 y.o single Chadian lady was brought to E.R on
28/01/2009 at 08:34 P.M with a complain of:
 P-V bleeding
 confusion
 generalized fatigue
for 3 days
The first assessment :
 Case was first referred to ICU department as the
patient was vitally unstable
 BP=62/41
 P=99
RR=24
T= 35.8
O2SAT=100%
ICU DOCTOR ASSESSMENT IN E.R
 Hx : moderate PV bleeding ..3 day’s duration
 LMP: 16 week ago
 No clots ,
 Dizziness for 1 day
 Palpitation
 No nausea ,,
 vomited once
cont.
ICU DOCTOR ASSESSMENT IN E.R
 O/E :
 BP = 50/40
 P=100
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RR= 24-30
conscious , oriented
S1+S2+0
RESP. : EAE , CLEAR
ABDOMEN : distended but lax
Suprapubic mass ?? bladder
cont.
ICU DOCTOR ASSESSMENT IN E.R
 No neck regidity
 No L.L oedema. . No DVT signs
 At 09:00 PM : 1 L N.S I.V bolus
 At 10:45 PM : BP= 70/55
P=100 O2SAT= 100%
 Pregnancy test was sent>>>> Positive
 Impression : shock for D.D : hypovolemic , ?? septic
cont.
ICU DOCTOR ASSESSMENT IN E.R
 Plan : keep MAP of 65 mmHg
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UOP >= 0.5 Ml/kg/hr
Give IVF challenges & monitor Pt. Response &
tolerance
O.B.GYN consultation
CXR, ABG, U&E, Coag. Profile, CBC, serum lactate
level
Recontact ICU after the results are shown
At 01:25 AM :
 Pt is not responding to IVF well
 ABG : severe metabolic acidosis
 PH= 7.1 HCO3= 3.8 PCO2=1.61
 Hb= 7.1
 WBC= 44
 PLT= 32
 Pt= 35.5
 Ptt=117
 INR- 3.4
PO2=17.99
 BG: B Positive
 Na=133
 K=3.5
 Cl=96
 BUN- 4.3
 CRTN= 242
 Ca= 2.04
 L.A= 17.2
Plan:
 Dopamine infusion was started
 Trace rest of results ,,
 Sickling test>>> Negative
 NAHCO3 50 Ml I.V
 D-D, Fibrinogen , Perepheral Bl. Film & hematology
referral
At 5:30 AM : Gyne. On-Call review
 22 YO single , medically ? Aneamia
 Amenorrhea
14-16 W
 LMP= Not sure
 P-V BL. Mild to moderate for 3 days
 Hx of fever , chills at home but not documented
Cont. Gyne. On-Call review
 Denied any Hx of pregnancy or attempting to abort
nor instrumentation
 Gave Hx of vaginal infection & took supposatories??
 Came to ER in shock, most likely Dx >> Septic shock
Cont. Gyne. On-Call review
 O/E :
 P/A: soft, distended, No tenderness, No Guarding
 Around 12 w GA uterus
 P/V: only inspection : minimal bleeding
 Impression: pt is in sepsis ,,,, to R/O septic abortion
 Plan: urgent U/S
At 05:30 AM :
 U/S result:
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small RPOC ( hyperechoic structure )
3.2 x 2.7 cm ,, No gestational sac ,, no fetal pole
moderate ascites
Repeated Labs :
Hb= 6.6 WBC= 38.7 HCT= 22.2
PLT= 25
Pt= 23.5 Ptt= 84.7
L.A = 13.1
Serology was sent >> negative
 At 05:45 am :
BP = 100/59
P=125
so the plan was to wean the Dopamine
 pt is conscious , oriented , no PV bleeding
 D/W consultant On-Call: to repeat U/S , QBHCG
& discuss with head of department about D&C
At 06:30 am :
 Pt is deteriorating with Dopamine
 BP= 70/55
 Plan : consultant is on the way for D & C
 The pt is admitted to MICU
 Arrangement for ER D&C ..
 Anaesthesia .. Will not start untill FFP & blood is
ready
At 07:40 am :
 FFP is ready + 2 U of PRBC in OR fridge
 Calling for the patient to be transferred to OR from
MICU
 At 08:50 am : pt was transferred to O.R
 Procedure: evacuation of RPOC for case of septic
abortion, septic shock
 Uterus= 14 W , hymen not intact
During O.R :
 Under U/S guidance:
moderate amount of tissue attached to the uterine wall
with offensive smell removed and sent to
histopathology>>
multiple fragments of tissue composed of blood clots
and decidua,,
final diagnosis : POC
During O.R :
 EBL= 1 L
 6 U FFP
 5 U PRBC
 2 Packs in Vagina
 Pt was shifted back to ICU
At 11:45 am ... Back to ICU
 Pt was received in MICU from OR as a case of :
 Septic shock
 DIC
 multiorgan dysfunction
due to septic abortion( post evacuation & curettage)
Upon arrival to MICU
 Intubated & ventellated
 Sedated on propafol infusion
 BP= 121/82
P=132
 On Norepenepherin 40 Mg/min
Upon arrival to MICU
 Chest was clear
 Sinus tachycardia
 Abdomen: mild distension
 2 packs in vagina .. Still bleeding
 Plan: CBC, PT , PTT Q6hrs
LFT , U&E, D-D, Fibrinogen, Peripheral Bl. Film &
blood culrue
Cont. Upon arrival to MICU
 Hb = 9.6
 WBC= 40
 PLT= 28
 PT= 20.5
 Fbrinogen= 193.8
 D-D = no reagent
 INR= 1.8
 L.A = 13.8
PTT= 62.5
Cont. Upon arrival to MICU
 6 U FFP ,, 6 U Cryoprecipitate
 Keep 10 U FFP stand by
 4U PRBC stand by
 Pt is on : Pip/Taz , Gentamycine , Ranitidine
On 30/01/2009
 Pt is intubated in ICU ,, FiO2 45%
 PEEP + 5
 BP= 80/70
 T= 38.5
 Intake=200cc/h
 UOP= 200 cc/h
 Hb= 8.3
 WBC=35.6
 PLT= 18
 PT= 17.9
PTT = 51.6
 L.A= 6.4
INR= 1.7
 Plan : cont. Ab
remove vaginal pack>> minimal clots & beeding
On 31/01/2009
 Pt is on assisted mechanical ventilation
 Minimal bleeding
 On Norepenipherine 14 mcg/h
 On Vasopressin 2.4 U/h
 UOP= 100cc/h
,,, positive balance 2019 Ml
 BP= 115/80
 Lax abdomen
 No incidence of CNS insult
Cont. IN MICU ON 31/01/09
 Inv : PH = 7.3
PCO2= 45.4 PO2= 83.1
HCO3=23.2
 Hb= 6.9
 WBC= 43.1
 INR=1.3
PTT= 50.8 PLT= 35
 Na= 141
K=3.1
CL-105
Mg= 0.9
 BUN= 6.7 CRTN= 128
Ca= 1.94
PO4=0.88
 AST= 1078
S. Lactate= 7.1
Plan :
 1 U PRBCs
 I.D referral
 NGT feeding
 ECHO
On 01/02/09
MICU
 Day 3
 Still sedated ,, on Propofol 1 Mg/Kg/h
 Pt is on vasopressin ,
 Norepenipherin stopped
 On NGT
 GCS : 8 /15
 ECHO >> EF = 40 % , severe T.R & Pulm. HPN
Investigations
 Hb =7.8
 WBC = 37
 PLT= 35
 PT= 13.4
 PTT= 42.8
 BUN= 7.8
 CRTN= 108
 INR= 1.3
On 02/02/09
MICU
 No much change..
 Blood culture : + Candidiasis , Diphthroid species
& Staph. Epideremedies
 Infection team : started Amphotericin B on top of
Gentamycine & Pip/Taz
On 03/02/09
MICU
 Pt is still intubated ..rate = 12 BPM , FiO2= 30%
 Bp= 95/56
 T= 36.8
 P=97
 Hb= 8.4
 WBC= 34.4
 PLT= 44
 INR=1
 PT= 11.7 (N)
PTT= 35.8 (N)
On 04/02/09
MICU
EXTUBATED
 Agitated ,, Psychiateric episodes
 Psychiatry consultation >> Lorazepam , Olanzapin
 Was clinically improving ,, minimal PV bleeding
 No much change on the day after
On 06/02/09 11:00 pm
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BP= 100/60
P= 112
T= 37.8
RR= 37
Hb = 9.1
WBC= 32.9
PLT= 73
PT=12.3
PTT=40.9
BUN=4.7 CRTN= 74
 D-D = 4084
INR= 1
L.A= 1.6 (N)
MICU
?? Pelvic Thrombophlebitis
 Heparin prohylactically was already started at same
day
 Switched to Heparin Infusion 1000 u / h
 Doppler U/S L.L
 C-T Pelvic Venography to R/O pelvic
thrombophelibitis
 Spiral C-T
Ordered
Next Morning 07/02/09
 Pt is conscious , oriented
 T=37
BP=110/70
RR=24
 Chest: clear , EAE
 Doppler >>> DVT both Distal Common Femoral Veins
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Hb= 9.5
WBC=21.1
PLT= 101
BUN= 4.8
CRTN= 60
PT= 11.5
PTT=51.8
INR=1
On 09/02/09
 P=94
 BP= 108/69
 RR= 23-30
 T= 37.6
O2 Sat=100%
 PV bleeding stopped
 Chest is clear
 Abdomen was soft & Lax
 Spiral C-T : confirmed the Dx of
PE
Bilateral segmental pulmonary emboli
 PLAN: to continue heparin infusion,
to keep INR within therapeutic range
After 2 weeks in MICU
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Pt was progressing well with heparin infusion
Was vitally stable
On 12/02/09 : Warfarrin 10Mg po started
On 13/02/09 :
BP= 106/49
P=89
T=36.5 O2Sat=100%
Hb=10.6
WBC=8.7
PLT=359
INR=2
PTT= 93
PT=22.6
On 14/02/09
MICU
 Pt has improved a lot
 BP= 100/64
 P=79
 T=36.5
 Hb=10.7
WBC= 9.5
 PT= 25.5
 INR= 2.3
 BUN & CRTN >> 4.6 & 68 ( N)
PLT= 464
On 15/02/2009
 Pt is vitally stable , in a good shape
 BP=101/70 P=83 RR= 20 T= 36.9
 Hb=10.7
WBC=9.5
 PLT=464
 On warfarin .. INR= 2.3
 PT=23.2
 PTT=52.9
 Blood Culture>>> No Organisms Identified
 Plan :
to discharge from Gyne site
to transfer to F.M.U
Pt is on : Gentamycine , Ranitidine
& Warfarrin 10 Mg
D/C Pip/Taz
D/C Olanzapine & Lorazepam
D/C Amphoterecin B
After 18 days MICU stay ..
 Plan to transfer the Pt to Female Medical Ward
in a stable condition
 Stayed under observation for 3 days in F.M.W
 Gentamycin was stopped in the 2nd day
On 18/02/2009 :
 BP=122/80
 P=71
 T= 37.2
 INR=2.8
 Pt=29.2
 Ptt= 53.4
 LFT & U/E >> N
RR=20
O2Sat= 99 %
Cont. On 18/02/2009 :
discharge day..
 After 3 days observation in F.M.W
 Pt looks very well
 Plan: Discharge on :
Warfarrin 10 Mg P.O O.D
 O.P.D 1/12 >> Medical & Hematology
 ECHO as an out patient
Thank You
Case 2
MR NO. 636979
 A 42 y.o Burmese lady
 G16 P14 + 1
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Un booked
GA= 36 w
K/C of chronic hypertension for 12 yrs on medications
Previous 2 C/S due to PET ..
First C/S >>outside &
the second one was an emergency C/S done in our
hospital on 28/01/2008>>severe PET , Left ParietoOccipital infarction >> 2 days ICU admission
On 19/01/2009
at 01:08 A.M
 patient presented to E.R with a chief complain of
CONVULSION one time at home and brought by
her relatives
 Vitals in triage at 01:15 A.M : BP=121/101
P=98
T=36 C
RR=22
O2 sat= 97%
 At 1:50 A.M : E.R Gyne doctor assessment:
G16 P14 + 1 , 36 w , prev. 2 C/S due to severe PET cof
convulsion one time .
Tonic-clonic .
Hx of H/A & blurred vision
No other complaints
Cont. E.R Gyne doctor assessment:
 manual BP= 147/109
 urine dip stick +3 protein
 P/A: soft , Lax & fundal hieght = date
 Doppler F.H = 147
 P/V: os = 1-2 cm
 Blood taken for PET profile,CBC,U&E ,LFT & cross
match
 Foley’s catheter
 Magnesium sulfate loading dose 4 g
 Paediatrics were informed
 Pt. was admitted to Labor room at 02:30 A.M
In L & D
at 02:35 A.M
 Pt is semi concious
 B/P= 147/105
 Urine protein +1
 Bed-side U/S >> lateral placenta , positive F.H
 Pt is on MgSO4 maintenance dose 2 g / hour
 CTG>>no uterine contractions ,no decelerations ,
base line 118 BPM, decreased variability
 Plan: to do C-T brain and after the result>> C/S
At 03:30 A.M :
 Pt was sent for C-T with the MgSO4 infusion
At 04:30 A.M : pt was recieved back from C-T
BP=136/100 P=96
T=36.8 RR=23
O2SAT = 98%
C-T result:
 Old infarction at the left fronto-parietal and parieto-
occipital lobes . No active infarcts nor intracranial
bleeding .
Lab results: AT 02:12 A.m
 PRBC X-Matching : A positive
 RBS:5.0
 PT= 10.6
 PTT= 27.5
 FIBRINOGEN=470.5
 D-D= 260.2
 INR= 0.9
 ALBUMIN=24
 ALP= 122
ALT=25 AST= 26 GGT= 12 TBIL= 3
Cont.
 WBC= 8.0 Hb. = 10.1 Hct= 30.6 Platelet = 255
 Na = 135
 K= 3.6
 Chloride = 101
 Urea = 2.7
 Creatinine = 70
 Calcium= 1.94
 Mg= 0.77 (N)
 At 05:15 A.M: anaesthesiologist reviewed the pt and
they refused to start unless if there was a SICU bed
available
 At 06:00 A.M: pt was pushed to O.R & emergency C/S
was done under S . A .. BP= 144/104
 A straight forward C/S with a baby girl delivered at
06 :55 am with good APGAR score wt>> 3.1 kg and
EBL= 600 cc
At 09:00 A.M :
 Post OP : Pt was having
heavy PV bleeding in
recovery area
 Examination : BP= 99/76
P=100
 P/A: Lax uterus
 Diagnosis of uterine atony was made
 Pt is on : zenacif , ferrus & caltirate
T=36
 Plan : prepare blood and to take the pt for O.R

 a subtotal hysterectomy was done
 EBL = 2.5 L >> received 4 U PRBCs , 6 U FFP & 6 U
cryoprecipitate
 Surgery finished at 11:15 A.M and pt was intubated
 BP=187/119 P=123 T=36.8 RR=28 O2SAT= 90%
 Pt was transferred to SICU
Lab results at 09:30 A.m
 INR= 2.8
 PT= 29.8 FIBRINOGEN= 80.9
 D-D = 18749 APTT= > 2 min.
 WBC= 8.1
Hb.= 5.1 HCT= 13.1 PLT= 122
 ALB = 7 ALP= 38 AST = 12 ALT= 16 GGT=7
Tbil=4
 Na= 139 K= 3.6 CL= 111 BUN= 1.8 CRTN= 41
IN SICU :
 Pt stayed for 4 days.
 To continue MgSO4 infusion 24 hr
 Propofol infusion .. Centeral line
 B/P = 170/100 upon admission to ICU
 Hydralazine 5 Mg I.V was given
SICU DAY 1: 19/01/2009
 Pt. Was intubated
 DROWSY
 BP = 133/92 – 158/98
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T = 36
S1+S2=0
Clear chest ,
abdomen :soft and lax , tender to touch
LAB works: Hb= 9.1 Wbc=8.2
Mg= 1.42
CXR>> N
Medications given :
 CEFUROXIME
 PANTAPRAZOL
 DEXAMETHAZONE
 HEPARIN
 AMLOR
 ATENOLOL
 I.S.S
 ASA
SICU DAY 2-4 : 20-22/01/2009:
 After overnight observation , unable to extubate due
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to probable laryngeal oedema ( difficult airway at time
of surgery & multiple attempts)
IV steroid was given
Day 3 patient was extubated
Fully concious. BP= 160/108
P=71 afebrile UOP= 3240 cc
Portovac= 410 cc bloody on day 2
Otherwise , uneventful ICU stay.
Lab works-day 2 IN SICU :
 WBC=11.4
Hb.= 9.4
HCT= 28
 PLT=169
 Na=136
 BUN= 1.5
 CALCIUM= 1.9
 Albumin= 18
K= 3.6
CRTN=63
Mg= 1.32
CL=101
Phosphate= 1.41
Lab works-day 3 IN SICU :
 WBC= 10.2
Hb.= 8.5
PLT= 166
 Hct= 26.8
 INR= 0.8
 Na= 138
 BUN= 2.7
 Mg= 1.01
 Phosphate= 1.73
 Albumin= 17
K= 4
CRTN= 69
Cl= 101
Calcium= 2.06
At discharge from SICU-Day 4
 Condition at discharge: stable
 Medications on discharge :
Cefuroxime 1.5 g Q8(19/01) x 5 days ,
Pantoprazole 40 mg iv od
Atenolol 50mg OD
Heparin 5000 U S.C BID
Amlodipine 10 mg OD
ASA 81 mg OD
 BP = 116/80
 P=74
 RR= 18
 O2Sat= 98%
 Urine : clear
Lab works
 Hb = 9.1
 Wbc=10.2
 PLT= 212
 PT=10.1
APTT=35.7
 Na=131
K =131
Mg=1.01 Crtn=69 Urea= 2.7
 Ca= 2.06 Ph=1.73 Albumin= 17
23/01/09 : in O.B ward :
 BP=118/81
P=66
RR=18 T =36 O2Sat=98%
 Clear chest, s1 + s2 + 0
 Portovac = 20cc in 24 h not removed serouse
 UOP= 2400cc/24 h
 No PV bleeding
On discharge :
 Pt was discharged on 25/01/2009 in a good condition
 Portovac was 5 cc>> removed
 BP=120/75 P = 82 afebrile
 WBC= 8.3
 PLT= 420
 ENT OPD 6/52
 GYN F/U 6/52
Hb= 10.3
INR= 0.9
Thank You