A 58-year-old man with a history of decompensated alcoholic cirrhosis is evaluated in the … — USMLE Step 3

A $58$ -year-old man with a history of decompensated alcoholic cirrhosis is evaluated in the emergency department for a $2$ -day history of worsening abdominal distension, diffuse abdominal pain, and lethargy. His temperature is $38.4^\circ \text{C}$ ( $101.1^\circ \text{F}$ ), blood pressure is $92/58 \text{ mmHg}$ , and heart rate is $106/\text{min}$ . Physical examination reveals scleral icterus, severe ascites with a positive fluid wave, and diffuse mild abdominal tenderness. Laboratory studies reveal:

Laboratory Test	Result
Serum sodium	$132 \text{ mEq/L}$
Serum creatinine	$2.4 \text{ mg/dL}$ (baseline $1.0 \text{ mg/dL}$ )
Total bilirubin	$4.6 \text{ mg/dL}$

A diagnostic paracentesis is performed, and ascitic fluid analysis shows a total leukocyte count of $1,200/\text{mm}^3$ with $70\%$ neutrophils. Which of the following pharmacologic interventions are indicated as part of this patient's immediate management? (Select all that apply)

Intravenous cefotaximeCevap
Intravenous albuminCevap
C
Intravenous gentamicin
D
Intravenous furosemide
E
Oral propranolol

Cevap

The correct interventions are intravenous cefotaxime and intravenous albumin.

Intravenous cefotaxime provides appropriate empiric coverage for the enteric organisms that typically cause spontaneous bacterial peritonitis (SBP). Intravenous albumin acts as a volume expander and is proven to decrease the incidence of hepatorenal syndrome and improve survival in SBP patients who meet high-risk criteria (creatinine

> 1.0 \text{ mg/dL}

, BUN

> 30 \text{ mg/dL}

, or bilirubin

> 4.0 \text{ mg/dL}

). This patient meets both the creatinine and bilirubin criteria.

Adım Adım Çözüm

Calculate the absolute neutrophil count (ANC) in the ascitic fluid to confirm the diagnosis.

ANC =

1,200 \times 0.70 = 840/\text{mm}^3

An ascitic fluid ANC

\geq 250/\text{mm}^3

is diagnostic of spontaneous bacterial peritonitis (SBP).

Select appropriate empiric antimicrobial therapy for SBP.

Intravenous cefotaxime (or ceftriaxone) should be initiated.

Third-generation cephalosporins provide excellent coverage against the most common enteric Gram-negative and Gram-positive organisms responsible for SBP.

Assess the patient's renal function and risk for hepatorenal syndrome.

The patient has acute kidney injury (creatinine

2.4 \text{ mg/dL}

) and significantly elevated bilirubin (

4.6 \text{ mg/dL}

Patients with SBP are at high risk for developing hepatorenal syndrome, especially when certain laboratory thresholds are met.

Determine the indication for adjunctive therapy based on laboratory findings.

Intravenous albumin must be administered alongside antibiotics.

IV albumin reduces mortality and the incidence of renal impairment in SBP patients who meet specific criteria: serum creatinine

> 1.0 \text{ mg/dL}

, BUN

> 30 \text{ mg/dL}

, or total bilirubin

> 4.0 \text{ mg/dL}

Identify medications that are contraindicated in this acute setting.

Aminoglycosides, diuretics, and non-selective beta-blockers should be avoided or held.

These agents can precipitate or worsen acute kidney injury and hemodynamic instability in a patient with decompensated cirrhosis and sepsis.

Anahtar Kavram

Pharmacologic management of Spontaneous Bacterial Peritonitis (SBP) and prevention of Hepatorenal Syndrome

Soru

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Konular

Bu konudan daha fazla soru