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Synthesis & IntegrationUnknown Case
Synthesis & IntegrationUnknown Case
Infection & ImmunityElevated Temperature
November 15th, 2010
Amanda Kocoloski, OMS IV
Patient ProfilePatient Profile
Orvill R. Baker is a 58-year-old white male who exhibits a sudden elevation of body temperature during surgery
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SubjectiveSubjective CC/HxCC: Mr. Baker was undergoing radical
prostatectomy under general anesthesia for prostate cancer. He suddenly began to spike a fever, and developed muscle rigidity on the OR table just after initial abdominal incision was made. A sterile dressing was applied to his incision and he was brought to the recovery room. Chart review discloses that his prostate cancer was diagnosed by his primary care physician who noted a firm irregular nodule on his prostate during a routine physical exam. When biopsy confirmed the diagnosis, he was scheduled for surgery.
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DefinitionsDefinitions
Fever Regulated rise to a new “set point” of body temperature
Hyperthermia Body metabolic heat production or environmental
heat load exceeds normal heat loss capacity or when there is impaired heat loss
Why do we differentiate? Hyperthermia can be rapidly fatal and characteristically does not respond to antipyretics
Temperature Regulation
Temperature Regulation
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PO/AH
Differentials?Differentials?
Severe infection Thermoregulatory dysfunction Malignant hyperthermia Neuroleptic malignant syndrome
Serotonin syndrome Thyrotoxicosis Prolonged seizures Illegal drugs
Amphetamines, cocaine, PCP, LSD
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SubjectiveSubjective
Past Medical History: Prostate hypertrophy and doubling of PSA in one year to 8.0.
Injuries: Denies any past injuries. Immunizations: No immunizations beyond
childhood. Medications: Presently takes no medication on a
regular basis, including no OTC drugs. Allergies: Denies any significant drug or
environmental allergies. Surgical History: Has had no prior surgery. Hospitalizations: Never been hospitalized.
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Health Influencing Behaviors
Health Influencing Behaviors
Diet: The patient eats a “balanced diet” but follows no special dietary restrictions.
Exercise: Follows no particular exercise plan.
Sleep patterns: Sleeps approximately six hours nightly.
Caffeine use: Denies. Alcohol use: Denies. Nicotine use: Denies. Other substances: Denies.
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SubjectiveSubjective
Family Medical History: 3 siblings and 2 sons, all alive and well. Mother died unexpectedly during routine hysterectomy 30 years ago. Father living, age 82, with metastatic cancer of prostate.
Sexual History: No sexual activity for past 5 years due to erectile dysfunction.
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Social HistorySocial History
Family: Very supportive 58 year-old spouse whose only medical problem is DM Type II; 2 grown sons, healthy and living away from home.
Faith or spiritual beliefs: Attends a community church regularly.
Hobbies: Likes to travel and work around the house.
Occupation: Took early retirement from high school teaching last year.
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Review of SystemsReview of Systems
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System(s)
Findings
HEENT No headaches, blurry vision, difficulty swallowing
Face Symmetrical, no unusual facies
CV No chest pain or palpitations
Lungs No shortness of breath or cough
GI No diarrhea, constipation or abdominal pain
GU Complains of hesitancy, frequency, and difficulty starting stream
MSK No joint or muscle pain
Neuro No difficulties with movement, numbness or paresthesias
Endo No easy bruising, heat or cold intolerance
ObjectiveObjective
Vital Signs: T: 40.5 ˚C (105˚F) P: 150 bpm R: 14 resp/min (mechanical ventilation) BP:100/60 mmHg
General Appearance: Unconscious under general halothane anesthesia and succinylcholine muscle relaxation; mechanical ventilation via volume-cycled ventilator
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Where Was the Temperature Taken?
Where Was the Temperature Taken?
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Modified from Iaizzo PA, Kehler CH, Zink RS, et al: Thermal response in acute porcine malignant hyperthermia. Anesth Analg 82:803-809, 1996.)
Objective: Physical Exam
Objective: Physical Exam
Head, Eyes, Ears, Nose: Normocephalic; PERRL; EACs patent, TMs clear; nasal mucosa pink.
Throat: Mucosa dry; no pharyngeal inflammation or exudates. Remainder of exam hindered by presence of orotracheal tube.
Face: Symmetrical; no maxillary or frontal sinus tenderness.
Neck: Rigid and spastic; no palpable masses; no lymphadenopathy; thyroid is not palpable; trachea is midline and movable; no JVD; no carotid bruits.
Heart: Rapid, bounding rhythm; apical impulse palpated in left intercostal spaces four and five, lateral to midclavicular line; + S1 and S2; no S3 or S4; no murmurs, gallops or rubs.
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Objective: Physical Exam
Objective: Physical Exam
Lungs: (The patient is intubated and being ventilated with a volume-cycled respirator) clear to auscultation and percussion; full breath sounds bilaterally.
Breast: No masses, discharge or tenderness noted.
Abdomen: Slightly distended, firm; no masses or organomegaly; no fluid wave; no hepatojugular reflux; no inguinal lymphadenopathy; bowel sounds present in four quadrants; no bruits auscultated.
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Objective: Physical Exam
Objective: Physical Exam
Rectal: Deferred Structural: Deferred Extremities: Generalized muscular rigidity
and spasm; no cyanosis or clubbing; no edema or varicosities.
Skin: Hot, dry. Genital: Circumcised male; no scrotal
masses or penile discharge. Neurological: Generalized muscular
rigidity and spasm; unresponsive to any stimuli (patient under general anesthesia); mechanical ventilation.
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Diagnostic Studies?
Diagnostic Studies?
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Diagnostics- Urinalysis
Diagnostics- Urinalysis
Results
Normal
color brown amber-yellow
myoglobin positive
negative
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Diagnostics- ElectrolytesDiagnostics- Electrolytes
Result Normal
Sodium 140 mEq/L 135-147 mEq/L
Potassium 5.8 mEq/L 3.5-5.0 mEq/L
Chloride 100 mEq/L 95-105 mEq/L
Bicarbonate 18 mEq/L 24-40 mEq/L
BUN 26 mg/dL 8-25 mg/dL
Creatine kinase (CK, CPK)
5400 IU/mL 0-160 IU/mL
Creatinine 2.4 mg/dL 0.6-1.2 mg/dL
Phosphate 6.0 mg/dL 2.5-5 mg/dL
Uric Acid 8 mg/dL 2-7 mg/dL
Diagnostics- ElectrolytesDiagnostics- Electrolytes
Result Normal
Sodium 140 mEq/L 135-147 mEq/L
Potassium 5.8 mEq/L 3.5-5.0 mEq/L
Chloride 100 mEq/L 95-105 mEq/L
Bicarbonate 18 mEq/L 24-40 mEq/L
BUN 26 mg/dL 8-25 mg/dL
Creatine kinase (CK, CPK)
5400 IU/mL 0-160 IU/mL
Creatinine 2.4 mg/dL 0.6-1.2 mg/dL
Phosphate 6.0 mg/dL 2.5-5 mg/dL
Uric Acid 8 mg/dL 2-7 mg/dL
Diagnostics- Arterial Blood
Gases (ABGs)
Diagnostics- Arterial Blood
Gases (ABGs)
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Results Normal
PaO2 86 mmHg (80-100mmHg)
PaCO2 40 mmHg (35-45mmHg)
pH 7.22 (7.38-7.44)
HCO3 16 (21-30 mEq/L)
Diagnostics- Arterial Blood
Gases (ABGs)
Diagnostics- Arterial Blood
Gases (ABGs) Results Normal
PaO2 86 mmHg (80-100mmHg)
PaCO2 40 mmHg (35-45mmHg)
pH 7.22 (7.38-7.44)
HCO3 16 (21-30 mEq/L)
RhabdomyolysisRhabdomyolysis
Muscle necrosis results in systemic manifestations
Related to muscle injury or excessive muscle contraction
A syndrome of multiple etiologies Features include:
Myoglobinuria Renal insufficiency Markedly elevated creatine kinase (CK) levels
Frequently, multiorgan failure as a consequence of other complications of the trauma
Hyperkalemia in 10-40% of cases, due to release of K+ from injured skeletal muscle
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Cause of Elevated Temperature?
Cause of Elevated Temperature?
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AssessmentAssessment
Primary Diagnosis: Malignant hyperthermia Secondary Diagnoses:
RhabdomyolysisMyoglobinuriaHyperkalemiaTachycardiaPossible acute renal failure
Modifiable Risk Factors (MRF): None Non- Modifiable Risk Factors (NMRF): None
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Malignant hyperthermia
Malignant hyperthermia
Genetic mutation of ryanodine receptor type 1; autosomal
Disorder causes increased intracellular calcium; prevents Ca2+ reuptake after contraction and prevents relaxation
Usually asymptomatic until anesthesia
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Signs and SymptomsSigns and Symptoms Rigidity after induction of anesthesia
Sinus tachycardia or arrhythmias
Decrease in 02 saturation
Increase in PCO2
with ventilation Increase in temperature above 38.8 ˚C (101.8 ˚F)
Elevated temperature can be a late finding
Extreme acidosis Damage of skeletal muscle Rhabdomyolysis Myoglobinuria Hyperkalemia Acute renal failure
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CLINICAL FEATURESNEUROLEPTIC
MALIGNANT SYNDROMESEROTONIN SYNDROME
MALIGNANT HYPERTHERMIA
Triggering agent Neuroleptic Proserotonergic agent Succinylcholine or inhaled anesthetic
Onset Slow (hours to days) Fast (minutes to hours) Very fast to fast (minutes to hours)
Duration Long (days to weeks) Short (1–2 days) Short (1–3 days)
Agitation Sometimes Yes No
Confusion Yes Sometimes Unusual
Hyperactivity No Yes No
Bradykinesia/stupor Yes No Unusual
Myoclonus No Yes No
Shivering No Yes/sometimes No
Tremor Sometimes Yes No
Pupils Mid-sized Large Not specific
Rigidity Severe Sometimes Severe
Rigidity type Extrapyramidal (leadpipe) Pyramidal (clasp-knife) Generalized
Hyperpyrexia Yes Yes Severe
Tachypnea Yes Yes Yes
Tachycardia Yes Yes Yes (severe)
Leukocytosis Yes Uncommon Not typical
Elevated creatine phosphokinase
Severe Mild Severe
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PlanPlan
Treatment:Stop surgery and anesthesia ASAP Dantrolene
Inhibits the release of calcium from the sarcoplasmic reticulum, reducing actin-myosin contractile activity
Manage metabolic acidosisInitiate core and surface cooling
Avoid all future anesthesia using halothane and muscle relaxants
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PlanPlan
Diagnostic follow-up:Monitor for myoglobinuriaMonitor for renal failure (kidney
function studies)Monitor for cardiac dysrhythmias
Patient Education:Avoid all future anesthesia using
halothane and muscle relaxants
Cooling MeasuresCooling Measures
Alcohol sponges
Cold sponges Ice bags Ice-water enemas (burr)
Ice baths
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http://emedicine.medscape.com/article/149546-treatment
Quiz!Quiz!
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The elevated temperature in this
patient is most likely caused by
The elevated temperature in this
patient is most likely caused by
1 2 3 4
25% 25%25%25%
1.increased hypothalamic set point
2.endogenous pyrogens
3.excessive heat production
4.fever
What is the likely cause of the abnormal urinalysis and
serum potassium in this patient?
What is the likely cause of the abnormal urinalysis and
serum potassium in this patient?
1 2 3 4
25% 25%25%25% 1.Acidosis2.Excessive muscle
contraction and loss of sarcolemma integrity
3.Acute renal failure
4.Severely elevated temperature
The muscle rigidity in this patient is caused
by
The muscle rigidity in this patient is caused
by
1 2 3 4
25% 25%25%25%1. excessive motor
unit activation 2. excessive release
of calcium from the sarcoplasmic reticulum
3. halothane induction of calcium influx into muscle cells
4. hyperkalemia
What is the most likely reason why homeostatic mechanisms were unable to defend the thermal challenge presented
in the malignant hyperthermia case?
What is the most likely reason why homeostatic mechanisms were unable to defend the thermal challenge presented
in the malignant hyperthermia case?
1 2 3 4
25% 25%25%25%1. Body heat storage occurred
too rapidly2. General anesthetics
impaired the normal shivering response
3. General anesthetics impaired normal behavioral thermoregulatory responses
4. Surgery-induced dehydration changed the gain in the feedback control system
The elevated temperature in this patient can be
effectively controlled by
The elevated temperature in this patient can be
effectively controlled by
1 2 3 4
25% 25%25%25%1. dantrolene sodium
(inhibits Ca2+
release)2. high-dose aspirin
(inhibits PGE synthesis)
3. normalizing serum potassium
4. succinylcholine (neuromuscular blocking agent)