Hypothermia II

This patient (described in the previous post) with a core temperature of 24.8 degrees was intubated for airway protection and rewarmed. During the process, he began to have cardiovascular collapse, possibly from the vasodilation during rewarming. He was admitted to the intensive care unit. This was truly an ICU patient; he had something wrong with every organ system. From a neurologic standpoint, he was altered and then sedated. When he was extubated, he was only oriented to person and his speech was incoherent. From a cardiovascular standpoint, he required vasopressors in the ICU to maintain his blood pressure. From a pulmonary standpoint, he was not only intubated, but subsequent scans found incidental pulmonary emboli and moderate bilateral pleural effusions. From a gastrointestinal standpoint, he had severe necrotizing pancreatitis. In my reading, I learned that cold is one of the lesser-known causes of pancreatitis (along with the dreaded scorpion sting). Repeat CT scans showed necrosis of >30% of the pancreatic body and tail; necrotizing pancreatitis is a dangerous variant, but it is not surgical unless the patient is infected. We covered him with ertapenem. He also later developed a transaminitis which we attributed to TPN cholestasis. From an FEN/renal (fluid, electrolyte, nutrition) standpoint, he developed renal failure in the ICU, probably from acute tubular necrosis and contrast nephropathy. He required CVVH renal replacement therapy. From a hematologic standpoint, he had a thrombocytopenia of unknown etiology in the ICU which resolved on its own as well as a severe anemia (Hgb 7.8) that was likely multifactorial (a borderline macrocytic nature and history of alcohol use suggested B12 and folate deficiency, the iron studies suggested a component of chronic disease, and a finding of body lice could also contribute). From an infectious disease standpoint, he had a rising leukocytosis of unknown origin. After his ICU issues resolved, he was transferred to us and given to me. It was a lot of hard work, but very interesting.