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KYLE CRISCOIPPE-I I I INPATIENT ROTATION
PRECEPTOR: DR. WOODS
Case Presentation
Sepsis
SIRS (Systemic Inflammatory Response Syndrome) Temperature
38°C or 36°C HR 90 beats/min Respirations 20/min WBC 12,000/mL or 4,000/mL or >10% immature neutrophils
Sepsis ≥2 SIRS criteria + active infection
Severe sepsis Sepsis + organ dysfunction (cardiovascular, CNS, hemostasis,
hepatic, renal, respiratory, or unexplained metabolic acidosis) Septic shock
Sepsis + refractory hypotension
Bone RC, et al. Chest 1992;101:1644Opal SM, et al. Crit Care Med 2000;28:S81
Sepsis
Most common pathogens In order of decreasing occurrence
Gram (+) Staphylococcus aureus, Staphylococcus epidermidis,
Streptococcus pneumoniae Gram (-)
E. coli, Pseudomonas, Enterobacter, Serratia, Proteus, Citrobacter
Mixed Fungi
Candida
Signs/Symptoms
HyperventilationHypothermiaTachycardiaTachypneaLesionsErythemaAltered mental statusPyrexiaLeukocytosisBlood cultures (+)
Complications
Acute Respiratory Distress Syndrome (ARDS)
Disseminated Intravascular Coagulation (DIC)
Adrenal insufficiency
Treatment
Resuscitation Antibiotics
Broad spectrumIdentify sourceCorrecting hypotension
Vasopressors Norepinephrine Vasopressin Dopamine Dobutamine Epinepherine Phenylepherine
Corticosteroids Hydrocortisone Prednisone Methylprednisolone Dexamethasone Fludrocortisone
Supportive Care
Mechanical ventilationFluids/nutritionGlycemic controlElectrolyte correctionsPain managementSedationStress ulcer prophylaxisVTE prophylaxis
Subjective
Overview
KA – 37 y/o Caucasian maleCC/HPI
KA arrived at the ED on 10/21 with fever, dyspnea, and tachycardia. Possible preliminary diagnoses included respiratory failure and sepsis so patient was started on broad spectrum antibiotics. KA is mentally handicapped secondary to cerebral palsy and resides at the Brian Center. On 10/25, KA experienced intermittent brownish, orange emesis. Originally this was suspected to be related to a malfunction of his G-tube, however after replacing the G-tube and then problem continued KA was transitioned to a J-tube on 10/31 and the feed rate was slowed. Still, emesis continued, until the J-tube was replaced on 11/2 and the problem ceased.
SH – lives at Brian CenterFH – sister is his medical decision makerNKAOther pertinent information
Multiple admissions for aspiration pneumonia Recurrent UTIs requiring hospitalization Bilateral hip pinning to repair hip fracture On Oct 3rd, patient received treatment for sepsis
Home Medications
PMH Cerebral palsy
Seizures
Spasticity GERD Miscellaneous
Medications bethanechol 25 mg PO Q6H bromocriptine 2.5 mg PO BID clorazepate 3.75 mg PO TID PRN Levetiracetam 500 mg PO BID lamotrigine 100 mg PO QHS baclofen 20 mg PO TID lansoprazole 30 mg PO QD bisacodyl 10 mg PR QD calcium carbonate 1250 mg PO BID docusate 100 mg PO BID lorazepam 2 mg PO TID PRN (HR>120
BPM and diaphoresis) ondansetron 4 mg PO Q6-8H PRN N/V
Objective
Vitals
Ht = 142.24 cm (56 inch) Wt = 47 kg (103.4 lbs) Pain – at most 4, but difficult to assess throughout given
mental disability
21-Oct 22-Oct 23-Oct 24-Oct 25-Oct 26-Oct 27-Oct 28-Oct 29-Oct 30-Oct 31-Oct 1-Nov 2-Nov 3-Nov 4-Nov
Temp 99.5 99.3 100.4 99.1 98.5 98.4 98.8 97.8 99.0 99.2 97.6 98.0 98.5 98.2 98.5
BP 93/55102/65111/83115/79120/73 95/53103/56120/65108/54104/62 84/54102/59 95/60 93/59102/68
HR 93 107 121 117 110 105 120 106 87 100 65 61 80 66 73
RR 14 17 21 24 29 21 23 19 21 26 15 13 18 20 20
O2 Sat 100 100 99 98 98 94 94 96 94 95 93 96 93 96 95
Physical Exam
WNL except Resp: rhonchi (+) Cardio: irregular heart rhythm GU: condom catheter and PEG tube in place Skin: abrasions on left knee and right toes Neuro: spasticity in LUE, RUE, LLE, and RLE,
paralyzed Psych: mentally handicapped, does not respond or
interact Extremities: contracted, wearing bilateral unna boots,
L peripheral IV
Urine Analysis
amber, hazy appearance (-) for glucose and bacteriaspecific gravity = 1.028RBC>100pH = 8.5urobilinogen = 4.0leukocyte esterase = smallWBC = 18mucus = many
CBC21-Oct 22-Oct 23-Oct 24-Oct 25-Oct 26-Oct 27-Oct 28-Oct 29-Oct 30-Oct 31-Oct 1-Nov 2-Nov 3-Nov 4-Nov
WBC 11.2 8.1 7.1 9.0 4.6 6.3 6.4 7.0 5.9 6.0 4.7 3.8 4.1 3.2 3.8
neut 81 72 73 66 69 70 61 51 48 53 52
lymph 7 18 16 20 18 19 30 34 38 33 35
mono 11 7 10 13 11 10 8 12 10 10 6
eosino 0 3 1 1 1 1 1 3 4 4 6
baso 1 0 0 0 1 0 0 0 0 0 0
Hgb 13.2 8.2 8.0 9.4 9.2 11.2 9.9 8.4 8.4 9.2 8.5 8.3 9.8 10.1 9.6
Hct 41 26 25 29 28 35 31 26 26 28 27 26 31 31 30
Platlets 327 183 157 182 187 242 226 253 253 300 273 270 247 314 364
MCV
RBC 4.58 2.85 2.81 3.26 3.17 3.93 3.48 2.93 2.96 3.20 2.94 2.88 3.44 3.53 3.41
RDW 16.9 16.7 17.0 17.0 17.3 17.5 17.2 17.2 17.0 17.3 17.6 17.1 16.4 17.1 16.7
CMP
21-Oct
22-Oct
23-Oct
24-Oct
25-Oct
26-Oct
27-Oct
28-Oct
29-Oct
30-Oct
31-Oct
1-Nov
2-Nov
3-Nov
4-Nov
Na 152 151 138 135 138 136 143 141 144 139 139 141 137 139 139
K 5.1 2.9 3.8 3.8 3.3 4.9 3.6 3.6 3.7 3.4 4.4 3.7 3.6 3.1 4.6
Cl 111 120 109 101 106 102 111 112 112 104 102 102 101 105 105
CO2 13 24 25 27 26 22 21 19 23 28 28 29 27 29 25
Glucose 107 93 93 99 87 87 91 76 96 98 87 88 77 119 106
BUN 24 15 3 5 3 4 7 6 3 2 3 3 3 4 8
SCr 0.75 0.52 0.33 0.38 0.37 0.51 0.59 0.90 0.78 0.7 0.68 0.66 0.66 0.58 0.58
Ca 9.9 6.9 8.1 8.2 8.7 9.8 9.2 8.7 8.7 9.3 8.8 8.7 8.5 8.7 8.5
Albumin 2.5Ca (corrected)
Diagnostics
CT Left kidney: 1 cm stone in collecting system, no obstruction Bladder: calcification Bony structures: severe left convex thorocolumnbar scoliosis; chronic
degenerative changes at hips; internal bilateral fixation of promixal femora
Lungs: consolidation at right lung base; peribronchial thickening EKG
Lead II: sinus arrhythmias PR = 0.12 sec QRS = 0.08 sec tachycardic
CXR Elevated right hemidiaphram; left-sided venous catheter terminates in
SVC Heart appears mildly enlarged
Cultures
Date Site Result10/23/13 Resp MRSA (+)
10/23/13 Urine (-)
10/23/13 Blood (-)
*MRSA strand was susceptible to rifampin, TMP/SMX, and vancomycin
Assessment and Plan
Sepsis
Sepsis was likely a result of aspiration pneumonia HCAP (healthcare-associated pneumonia)
Patient was hospitalized <90 days earlier Patient resides in a long-term care facility
Complicated by residual build up from the enteral feeds Emesis prolonged patient’s stay in the hospital Patient no longer needed vancomycin after treatment for 5
days, afebrile for 48-72 hrs, and no more signs of clinical instability WBC stabilized Afebrile baseline HR, BP, RR
Empiric Antibiotics
Anti-pseudomonal beta-lactam pip/tazo 3.375 gm IV – STAT
Additional anti-pseudomonal agent ciprofloxacin 400 mg IV STAT gentamicin 310 mg IV Q24H meropenem 1 gm IV Q8H
Anti-staphylococcus agent for MRSA vancomycin 1 gm IV – STAT
Day 1 Medications
acetaminophen 650 mg PR QD - STATbethanechol 25 mg PO TIDbromocriptine 2.5 mg PO BIDheparin 5000 units SUBQ Q8Hlamotrigine 100 mg PO QHSlevetiracetam 500 mg Q12Hlorazepam 2 mg PO TID PRNmidazolam 10 mg IV push – STAT propofol 10 mcg/kg/min
Active Medications (Scheduled)
albuterol 0.083% 2.5mg/3mL INH BID 10/24-11/4
albuterol 90 mcg/inh 8 puffs Q4H 10/22, 10/23
baclofen 5 mg PO TID 10/22, 10/23
baclofen 20 mg PO TIDAC 10/23-11/4
calcium carbonate 1250 mg PO BID 10/21-11/4
lansoprazole 30 mg PO QD 10/21-10/23, 11/1
magnesium sulfate IV 1 gm (11/1) 2 gm (10/22-10/25, 10/28-10/29, 10/31)
metoclopramide 5 mg IV push Q6H 10/25-10/29
pantoprazole 40 mg PO QD 11/1-11/3
polyethlyene glycol 17 gm BID 10/27-10/30
KCl 40 mEq PO BID 10/22-10/25, 10/28, 10/29-10/31
scopolamine 1.5 gm transdermal patch q72 10/26 – 11/1
vancomycin 750 mg IV Q12H (10/22) Q8H (10/23-10/28)
Active Medications (PRN)
acetaminophen 650 mg PO Q4H 10/22 – once
bacitracin topical 500 units/g 10/25
furosemide 20 mg IV 10/24
furosemide 40 mg IV push 10/23, 10/25
lorazepam 2 mg PO TID 10/22 – once
metoclopramide 5 mg IV push Q6H 10/24 – once 10/25 – once
ondansetron 4 mg IV push Q6H 10/26 – once 10/30 – once 11/1 – once
promethazine 12.5 mg PR Q4H 10/30 – once
norepinephrine 4 mcg/min 10/22
propofol 10 mcg/kg/min 10/22
Meropenem
Monitoring SCr, LFTs, CBC, anaphylactic reactions
AEs Increased seizure risk, CNS effects
CrCL At lowest was 74 mL/min Ranged from 74 – 115+ mL/min
Gentamicin
Monitoring SCr, BUN, urine output, peak concentrations
Peak concentrations of 4-6 mcg/mL Draw after 3-5 half-lives or after 3rd dose Must reach steady-state Concentration-dependent killing
AEs Ototoxicity, nephrotoxicity, neuromuscular blockade
Poor infusion into the lungs
Vancomycin
Monitoring SCr, UA, WBC, trough concentrations
Trough concentrations of 15-20 mcg/mL Draw after 3-5 half-lives or after 3rd dose Must reach steady-state Time-dependent killing
AEs Ototoxicity, nephrotoxicity Redman Syndrome – histamine-mediated reaction
Correct by slowing infusion rate or antihistamines prior to infusion
Adverse Effects
Drugs with cholinergic effects Increased likelihood of causing N/V and/or emesis
bethanechol levetiracetam lamotrigine
Other AEs for scheduled medications AEs HA, drowsiness, insomnia, hypotension, fatigue
Discharge Medications
PMH Cerebral palsy
Seizures
Spasticity GERD Miscellaneous
Medications bethanechol 25 mg PO Q6H bromocriptine 2.5 mg PO BID clorazepate 3.75 mg PO TID PRN levetiracetam 500 mg PO BID lamotrigine 100 mg PO QHS baclofen 20 mg PO TID lansoprazole 20 mg PO QD bisacodyl 10 mg PR QD calcium carbonate 1250 mg PO BID docusate 100 mg PO BID lorazepam 2 mg PO TID PRN (HR>120 BPM and
diaphoresis) ondansetron 4 mg PO Q6-8H PRN N/V albuterol 2.5mg/3mL (0.083%) inh BID scopolamine ER patch 1.5 mg transdermal Q72H
Counseling
Patient transferred back to Brian CenterBarrier to communication with patient due to
mental disabilityTimely administration of drug is necessary Patient should be monitored often for any
seizure activity and further emesisBased on labs, may be beneficial for patient
to be taking an iron supplement daily More iron studies and blood testing is recommended
References
Bone RC, et al. Chest 1992;101:1644Opal SM, et al. Crit Care Med 2000;28:S81Dellinger RP., et al. International guidelines
for management of severe sepsis and septic shock. Critical Care Medicine 2013 Feb; 41(2):588-93
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