Thread by @IM_Crit_

ICU stories (a boring one…): If you work in a general ICU of a community hospital in United States, one of the common admissions you will get is the unfortunate resident of a nursing home or rehabilitation center that lives there for several decades & at some point becomes

febrile/“altered” & is sent to the ED for “evaluation”. The course is so predictable that we usually consider these admissions “boring”. This is the case of a middle-aged pt w cerebral palsy/mental retardation/seizures (on valproic)/PEG-chronic Foley in place who was sent to

the ED for fever+hypotension+tachycadia. Labs: WBC 15k, lactate 4.0. UA -as usually- suggestive of UTI (WBC>50, +bacteria, +nitrite, +esterase). CXR “clear” & pt w sat 99% on room air. Received ivf, Abx (pip/tazo + vanco) but due to persistent ⬇️BP, norepinephrine gtt was ordered

You check the pt's chart while calling back to "accept" the admission and you see this:

👆This is a common scenario where pts remain hypotensive for h in the ED/ICU waiting for fluids to "work" or even for pressors to "kick in". Especially after pressors are started, the nurses need to be trained to start "high" instead of following this extremely annoying protocol

While talkng to the ED attending, you had the luxury of time to check microbiology data from previous admissions. In the most recent one, the urine culture grew:

👆This is another common scenario where pts receive pip/tazo + vanco regardless of their history. The ED is a hectic place but it is inexcusable for the ICU to leave old records unchecked & not modify the antibiotics accordingly. The pt was ready to be transferred to the ICU

Would you ask anything else from the ED before transfer? What about a CT?

CT was ordered while patient was still in the ED. CT chest showed bilateral pulmonary emboli. This is from the L lung:

CT A/P showed:

What would you do?

The balloon of the Foley catheter was inflated in the penile urethra. Let's see:

Patient arrived in the ICU. Foley was advanced. Pip/tazo was changed to meropenem & heparin drip was added for PE. A lower extremities venous US was performed (I skip the heart POCUS). This is what you saw when you placed the linear probe in the L groin:

What do you think this 👆 is?

Oops, I hear you, I did not include compression. Here it is:

It was actually one of the DVT mimics. If you fan up and down, you see that it is a round structure (?lymph node) not a tubular one (like a vein should be). In addition, a CFV should be next to the CFA. Let's check again:

Patient was doing very well, fever had resolved, pressors had been stopped and while looking good, suffered a grand mal seizure and had to be intubated for airway protection. What happened? This 👇 happened:

Valproic acid levels ⬇️ significantly triggering a grand mal seizure. This is a well known interaction of carbapenems with valproic acid (VPA). Carbapenems inhibit the activity of the acylpeptide hydrolase enzyme that converts VPA-glucuronide to VPA, resulting in

greater elimination, a shortened half-life, and sub-therapeutic plasma concentrations of VPA (and occasionally breakthrough seizures...). journals.sagepub.com/doi/abs/10.117…

Actually our patient never had a seizure since the interaction was quickly recognized, the meropenem was changed to a different antibiotic and levetiracetam was used for a day

Take-home messages:
1. We should be careful when we manage "boring" cases
2. Pts, especially the ones that come to the ICU, can have more than 2 life-threatening diagnoses at the same time
3. Old microbiological date should be thoroughly reviewed in order

to choose the most appropriate antibiotics
4. We should be aware of DVT mimics
5. We should be aware of drug interactions that can make our treatment less effective or even harmful

Thanks for reading this boring case!

#POCUS #ECHOFIRST #POCUSpeeps #FOAMed #FOAMus #FOAMcc #IMPOCUS #MedTwitter #MedEd #EMBound @ACEP_EUS @MetroHealth_EM @MH_EMultrasound @ThinkingCC @RJonesSonoEM @katiewiskar @kyliebaker888 @TomJelic @msiuba @siddharth_dugar @thepocusatlas @NephroP @HeyDrNik

@ICUltrasonica @khaycock2 @NickjohnsonMD @TaotePOCUS @echotalk @cianmcdermott @PorrosE @chileanestesia @vaszochios @nickmmark @cjosephy @KalagaraHari @UAlberta_Sono @EMUGs_ @UAlberta_ICU @UAB_Sono @critconcepts @MediCasos @MegriMohammed

@emily_fri @icmteaching @curromir @iceman_ex @Wilkinsonjonny @Thind888 #MedStudentTwitter