Mortality Meeting

Mr Vargheese 77/M from presented with 1. fever 2 weeks duration2. Swelling and redness of left leg of 2 weeks3. Altered Mental state of 2 day duration

Chief complaint

77/M who is a known diabetic on Rx for the past 20 years. Developed fever with painful red swelling of the left leg. Fever was low grade .The patient went to a local hospital and was sent home with some oral antibiotics. There was some improvement but fever was still persisting

Assosiated

There was assosiated reddish painful swelling suggestive of cellulitis with treatment there was some reduction in the pain

Progression

1. Patient was becoming increasingly drowsy and there was reduced food intake.2. Later the patient became confused, couldn’t identify relatives, began screaming out, using incomprehensible sounds,3. Breathing of the patient was deep

contd

4. Patient was taken to local hospital were he was admitted and was told that his sodium levels were low (S.Na = 129mg/dl)5. As the patient was not improving they were reffered here.

Past history

20 year back gives history of drainage of a pancreatic abscessHistory of Diabetes Mellitus on treatment for 20 years

Personal history

Smoker – 40 yearsAlchoholic – 20 year duration stopped 20 years back.Bowel and bladder habits were regularApetite was reduced for a period of 2 weeks

Family History

No relevant family history

Socio economic

Low socio economic status

General examination

Patient was consciousDisoriented to time, place and personIrrelevant speech and incomprehensible sounds( May be delusions)Takin deep breathsPatient was also biting objects bite marks on both forearms were seen

cont

Pallor+, Clubbing +No edema No palpable Lymph nodesNo cyanosisLeft leg – red and swollen till just below the knee with local rise of tempOral cavity – poor hygeine multiple caries teeth

Vitals

Pulse – 128/mtBp – 80/60 mm HgRR – 28/mtT – 100deg F

Respiratory system

Chest moving equal with respirationTrachea centralLiver dullness at 6th Ics in the MCLCardiac dullnes obliteratedBilateral basal cracklesNo other added sounds

CVS

S1 S2 +No murmurs

CNS

HMF – patient disoriented Motor – deep tendon reflexes ++Bilateral flexor plantar responseSensory – not assesibleNo s/o menigeal irritationSkull and spine - normal

GIT

No contributary findings

Provisional diagnosis

Febrile delirium – Due to Left leg cellulitis and Lower respiratory tract infection precipitaing COPD. Patient in Septic shock, Type 2 DM

Patient was started on Inj Cefaperazone sulbactam 1.5 g IV BDInj Metrogyl 500 mg IV Q8hSupportive managementIVF crystalloid @ 100 ml/hrAs BP was not maintaine started on Dopaminesupport

Investigations

inv 17/7/15 18/7/15 19/7/15

Hb

Pt

TC

DC

S.Cr 0.8

urea 33

s.Bil T=2.9 D=0.7 T= 4.2 D= 1.53

SGOT 44

SGPT 29

ALP 702

s.protein Alb=1.8,G=3.5 A/G=.5 6/2.1/3.9/0.5

S.Elec Na = 148 K=4.3

S. Amylase 62

S. Lipase 40

PT/INR PT28.2/14.9 INR – 1.89 26.1/14.9 Inr = 1.94

URE

Albumin – traceSugar – greenish yellowm/s – RBC – 2 to 3, Pus cells 20- 25, epithelial cells + bacteria +

Day 2BP = 110/70 mm Hg on dopamine supportIn view of UTI,LRTI and cellulitis leading to septic shockPatient was started on Inj Piperacillin 4.5g iv tidInj Metrogyl CloxacillinOther supports maintained

Day3

Patient on continous Bp Monitor recorded Bp fall 80/40 mm Hg. Noradrenalin support was initiatedBP was still risingWent in to cardiac arrest5 cycles of CPR was givenExpired at 3.30 am on 19/7/15

Condition

Bacteremia SIRSSepsis ( Severe sepsis)Septic shockRefractory septic shock

Bacteremia – presence of bacteria in blood

SIRS – fever >98.6 F hypothermia <96.6 F Tachypnoea >24 /Mt Tachycardia >90/mt Leucocytosis >12000 Leucopenia <40002/more of the above conditions

Sepsis – SIRS + some deg of organ dysftCVS – sys BP <= 90 MAP <= 70 resp to IVFRenal – Urine output <0.5ml/kg/hrRS – PaO2/FiO2 <= 250Hematological – platelet < 80000Unexplained met acidosis

Septic shock – sepsis with hypotension for atleast 1 hour despite IVF or Need of vasopressor to maintain systolic BP >90 mmHg

Refractory septic shock – septic shock >1hr

Predisposing factors

1. Extremes of age (<10 y and >70 y)2. Primary diseases: Liver cirrhosis ,Alcoholism, DM,

CRF, Cardiopulmonary diseases, Solid & Hematologic malignancy

3. Immunosuppression:Neutropenia, Immunosuppressive therapy, Corticosteroid therapy, Intravenous drug abuse, Compliment deficiencies & Asplenia

4. Major surgery, trauma, burns

5. Invasive procedures Catheters Intravascular devices Prosthetic devices Hemodialysis and peritoneal dialysis catheters Endotracheal tubes6. Prior antibiotic treatment7. Prolonged hospitalization

Treatment

Initiation – with in 1hr of presentation rapid assesment mandatory time interval between the onset of hypotension and initiation of appropriate antibiotic therapy

Culture may be negative in up to 40 percent casesIf positive 2 samples from 2 diff sites

Objective – Empirical antibiotic therapy for both G+ and G- organismsMax recommended doses should be usedIV antibiotics only adjusted according to renal function

If culture + try to use monotherapyOnly in Pseudomonas combine therapy with aminoglycoside and antipseudomonal beta lactam was found superior

Emperic antifungal should be added ifBroad spectrum antibioticsParenteral nutritionNeutropenic > 5daysLong term Central venous catheter

Hemodynamic and resp supp

Goal• restore oxygen to tissues

• Monitor BP, mentation, urine output , skin perfusionSpo2

• Initial hypotension1-2 L of NS over 2 hours with CVP maintained at 8 -12 cm H20. maintain sys BP >90• Titrated doses of NE keeping the sys bp>90• If ass myocardial dysft dobutamine can be

used• Urine output at 0.5ml/kg/hr titrate the

diuretics

• CIRCI suspected in patients with no increased BP with ionotropes hydrocortisone 500 mg IV Q6h• Ventillatory therapy if progressive

hypercapnea, hypoxia and neurological deterioration

• Sedation, elevation of head end to prevent nosocomial pneumonia

• Stress ulcer prophylaxis using H2 receptor blockers

• Erythropoetin transfusion if Hb <7g/dl• Compression stokings if the patient is

ventilated to prevent DVT• Don’t be aggressive in correcting the blood

sugars only reduce it below 180 mg/dl