Resolva o Caso Falho Nº 2
Autor: LACMI | Publicado: 2010-10-06T06:23:00-03:00

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Paciente M.L.M, 47 anos, sexo feminino, HAS, DM, IRC em hemodiálise, iniciou há 4 dias um quadro de mialgia em MMII e região escapular bilateralmente. Há 2 dias apresentou também diminuição da força muscular, procurou então atendimento médico sendo solicitada internação hospitalar no dia 25/09/2010.Durante internação apresentou dispnéia em repouso e vômitos. Nega precordialgia. Relata febre não aferida.No dia 27/09/2010, durante sessão de HD evoluiu com rebaixamento do nível de consciência, hipotensão e sudorese, sendo internada no CTI.
Medicações em uso :&nbsp; Carvedilol 6,25mg 12/12h&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Apressolina 25mg 8/8h&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Furosemida 80mg 8/8h&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Losartan 100mg 12/12h&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Monocordil 40mg 8/8h&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Sulfato ferroso 40mg 12/12h&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Rivotril 2mg 12/12h&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Atensina 0,1mg 12/12h&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; AAS 100mg/dia&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Clopidogrel 75mg/dia&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Insulina NPH 10UI pela manhã, 10UI almoço e 12UI ao jantar 
Exame físico à Admissão no CTI:Pct sonolenta, despertável ao chamado verbal, sudoreica, hipocorada (3+/4+), hipohidratada (+/4+), acianótica e anictérica. Afebril. Ventilando em ar ambiente, algo dispnéica. Hipotensa sem uso se aminas. 
SV: PA=80x50 mmHg&nbsp;&nbsp;&nbsp;&nbsp; FC= 72 mmHg&nbsp;&nbsp;&nbsp; FR= 25 irpm
ACV: RCR, 2T, BNF, sem sopros.AR: MV diminuído em HTD, sem RA.ABD: Sem alterações.MMII: Dor a mobilização ativa e passiva em MIE. Sem edemas, panturrilhas livres.
Ex. Laboratoriais à admissão no CTI:&nbsp;&nbsp; 
Hto: 20&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Leuco: 5.000Hb: 6.9&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Bastões: 10%Ur:179&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; K: 5.2Cr: 6.8&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; PCR: 33
Conduta:&nbsp; - Laboratório + Culturas + Swab&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; - Rx de Tórax e Rx Coxo-Femural E&nbsp;&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;- Eco-doppler venoso de MIE&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; - Ecocardiograma&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; - Parecer para Neurologia&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; - Vigilância Hemodinâmica
Dia 28/09/2010: Quadro mantido.
Rx de Tórax: Mostrava apenas um padrão congestivo.
Conduta: &nbsp;&nbsp;- Substituir Cateter p/ HD de JIE para FD com triplo lúmem, enviada ponta de cateter para cultura.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Não iniciaram ATB)

Parecer da Neurologia: Exame neurológico sem alterações significativas que justifiquem o quadro a não ser fraqueza nos 4 membros.ID: Quadro Reumatológico (?), Dist. Hidroeletrolítico com hipocalcemia (?).Conduta: Avaliar causas acima. (Solicitado dosagem de Ca, PO2, Mg, CPK, Mioglobina, LDH, VHS, PCR)
Ex. Laboratoriais: Hto:22.2&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Ur: 160&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Leuco:8.900&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Hb: 7.4&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Cr:4.7&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Bastões: 10%&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 

Dia 29/09/2010:&nbsp;&nbsp; Realizou sessão de Hemodiálise pela manhã, sem intercorrências.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Recebeu 1 concentrado de Hemácias.
Ex. Laboratoriais: Hto: 22.7&nbsp;&nbsp;&nbsp;&nbsp; Ur: 200&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Leuco: 14.700&nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Hb: 7.5&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Cr:4.7&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Bastões: 11%&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Restante sem alterações.
Hemoculturas e Urinocultura em andamento e ainda negativas.EAS com piúria (15 Leucócitos /campo) e flora bacteriana aumentada.

Às 17h evoluiu com piora do estado geral, taquicardia sinusal,&nbsp; insuficiência resp aguda, saturando a 87% em MACRO, (praticamente em parada respiratória, com cianose de extremidades). Evoluiu p TOT + VM, sedada com Dormonid e Fentanil. Precisou iniciar Nora (10ml/h) devido a hipotensão grave não responsiva a volume.
Na manhã do dia seguinte a paciente apresentou PCR que não conseguiu ser revertida. &nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;Desconfia de qual é o erro? Poste sua resposta aqui em baixo então!