Kruthika Reddy

1009: A BIG BLEED FROM A SMALL PILL

Critical Care Medicine • Volume 46 • Number 1 (Supplement) www.ccmjournal.org Learning Objectives: Diffuse pulmonary hemorrhage (DAH) results from damage to the small pulmonary vessels which can disrupt gas exchange, the consequences can be fatal if not treated. Dabigatran, a newer oral anticoagulant, works as a direct thrombin inhibitor and is indicated for use in non-valvular atrial fibrillation, deep venous thrombosis and pulmonary embolus. Methods: A 66 year old Caucasian male with a medical history of hypertension, diabetes mellitus type 2, atrial fibrillation on dabigatran, and abdominal aortic aneurysm presented to the ED with complaints of hemoptysis. Patient reported fever, cough, and dyspnea on exertion for 2 weeks which worsened the night prior to presentation. Initial labs showed leukocytosis 13.6, lactate 2.9, APTT 50.1 and hemoglobin 13.4. CT scan of the chest showed bilateral perihilar consolidation and ground glass opacity associated with interlobular septal thickening consistent with DAH. Given continued hemoptysis and labored breathing, the patient was intubated. Idarucizumab was administered to reverse the anticoagulation effects of dabigatran. Less than 48 hours following intubation, repeat CT scan showed clearing of the hemorrhage and he was successfully extubated. Respiratory cultures grew Streptococcus Pneumoniae, Escherichia Coli and Klebsiella Pneumoniae, and he treated with ceftriaxone. Vasculitis work up including ANA, c-ANCA, p-ANCA, C3, C4, total complement and Myeloperoxidase antibody, was negative. Additionally anti-gm antibody, mycoplasma pneumonia IgM and mixing studies were also negative. No other cause of the pulmonary hemorrhage could be identified, and it was attributed to the use of dabigatran. Results: Our research did not identify any reported case of the use of praxbind to reverse DAH secondary to dabigatran in the setting of pneumonia. Another case of DAH secondary to dabigatran was reported in Japan in 2012 before the advent of idarucizumab. DAH is fatal if not treated in a timely manner. This case raises the importance of identifying risk factors such as an underlying pneumonia, which can increase the risk of hemorrhage while on an oral anticoagulant. The use of a reversal agent in a timely manner can drastically alter clinical course.

426: ARE PATIENTS IN THE ICU UNDERFED? ENTERAL NUTRITION GOAL ATTAINMENT IN ICU PATIENTS

Critical Care Medicine • Volume 46 • Number 1 (Supplement) www.ccmjournal.org Learning Objectives: Actual delivery of 60% to 70% of enteral feeding goals within the first week of ICU admission is associated with a shortened length of stay, duration on mechanical ventilation and fewer infectious complications. However, only about half of critically ill enterally fed patients receive their energy requirements. Our objective was to study how effectively daily caloric goals are achieved with enteral nutrition (EN) in the ICU and what the barriers may be to attaining caloric goals. Methods: A retrospective chart review of all patients admitted to a medical/surgical ICU at a community hospital over a 3 month period who were started on EN was performed. The amount of calories delivered on a daily basis and the average number of calories delivered on days 3, 7, and throughout ICU stay was calculated. Data was compared to registered dieticians (RD) recommendations & statistical analysis was performed to measure the deficit. Potential barriers to effective delivery of EN were identified. Results: The average number of calories delivered when compared to RD’s recommendations was deficient by 658 Kcals/day (36.5% deficient; p < 0.001) on day 3, 515 Kcals/day (30% deficient; p = 0.006) on day 7 and 488 Kcals/day (27% deficient; p < 0.001) throughout ICU stay. Study population consisted of predominantly elderly (mean age=69 years), male (55%), AfricanAmerican (55%) patients. 29% patients had delay in initiation of EN with 73% of them having no identifiable reason for delay in initiation. 84% patients had a lower rate of initiation and 26% patients had an inappropriate goal rate. 71% had interruptions in EN with 33% of them having no identifiable reason for interruption. Conclusions: Our study quantitatively demonstrated how often we achieve intended caloric goals, as well as some barriers to doing so. We plan to use this knowledge to educate our ICU multidisciplinary team on these findings to develop refined pathways in which to overcome real or perceived barriers to optimal nutrition in the ICU.

1739: WARFARIN-INDUCED SEPTIC SHOCK? A RARE CASE OF DELAYED-ONSET WARFARIN-INDUCED SKIN NECROSIS.

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) in the differential diagnosis of conjugated hyperbilirubinemia in a young infant. This can lead to delay in diagnosis and treatment of a potentially fatal disease. Our case highlights this possibility and reminds clinicians to consider malignancy while evaluating similar patients to facilitate early recognition and prompt referral to the Pediatric Oncologist to initiate appropriate therapy.

Unusual case of pheochromocytoma presenting with diabetic ketoacidosis

Pheochromocytoma is a rare catecholamine-secreting tumour that arises from chromaffin cells in the adrenal medulla or extra-adrenal sympathetic ganglia. It classically presents with paroxysmal headaches, hypertension, palpitations and sweating related to catecholamine excess. Diabetes is reported to be present in approximately one-third of patients with pheochromocytoma; however, diabetic ketoacidosis is an extremely rare complication. We present a case of an African-American male aged 30 years who initially presented with diabetic ketoacidosis and hypertensive urgency whose blood pressure and glycaemic control improved remarkably following tumour excision. We will discuss this unusual presentation of pheochromocytoma along with a management approach for such adrenal incidentalomas.

Spatial Modeling of Evapotranspiration for Efficient Water Management at Regional Scale

The meteorological data on maximum and minimum temperature, maximum and minimum humidity, wind speed and sunshine hours were collected from IMD-AWS as open source data for 373 stations for 50th and 20th meteorological week of 2011 and 2012, respectively. The data of 353 stations were used to develop water balance model and 20 stations were used for validation and testing of the model. Data were used to compute potential evapotranspiration using Penman-Monteith method. These locations with their respective latitude, longitude and elevation were brought under GIS environment for spatial database management. Separate layer of water deficit/surplus database was generated using derived evapotranspiration and rainfall data. The derived water deficit/surplus data was further interpolated into 2 km x 2 km grid using RBF (radial basis function) interpolation algorithm to produce spatial water balance model for the given week. The developed methodology was tested for 20 different locations. It was found that the model overestimated lower values and underestimated higher values. Overall, for all 20 locations, the model estimated 7.6% higher PET with average of 18.55 mm for the week under consideration (50th and 20th meteorological week of year 2011 and 2012, respectively). The range of the model prediction was found to be 26.86 mm as compared to observed value of 34.80 mm. The standard error was computed as 1.91 mm for estimates while it was 2.19 mm for observed.