Case PresentationPresented by: Dr.Safaa fadhl

Supervised by: Dr.Kamal Marghani

29 yrs male presented to ED at 1:40pm complaining of cough , SOB, and fever.

At triage :

RR Pulse rate

temp Bp Oxygen saturation

22 166 40.2 - 86

Pt was admitted to room A at 2:00pm

29 yrs old male whose known to be DM for 7yrs on mixtard insuline presented with cough , SOB, and fever for 7days prior to the presentation for which he received amoxicillin \clavunate tabs without any significant improvement .

OE: pt looks ill tachypnic vitals signs :- Pulse 144- Bp 160\80- SPO2 65% on room air- RBS 257- Chest : bronchial breathing ,and decrease air entery on the

RT side.

Plane :- Give oxygen via NRM rate 15 L\min.- Normal saline 1000ml.- Samixon 1g BD- Clarithromycin 500 BD - insulin mixtard- Take investigation, ABG,CXR

ABG on NRM:

PH PaCO2 PaO2 HCO3 PSO2

7.45 22.2 63 15.5 80.3

HG TWBCS

PLT PT PTT INR UREA

CREATININ

K NA

11.5 10.2 116 24.7 29.2 1.8 26.0 0.9 3.6 135

SO , the pt was diagnose as pneumoniaAt 9:30 pm pt was admitted to CCR .On admission he was looking ill ,tachypnic on

NRM.A : his airway was patent, on NRMB : RR 39, SPO2 85, both sides of the chest

moving equally, there was bronchial breathing and decrease breath sounds on Rt side.

C : pulse 130, BP 119\80 D : GCS 15\15 , RBS 296E : examination of all other systems were

unremarkable.

ABG on arrival:

The diagnose was sever sepsis( type I respiratory failure)

Plan :-NPO.-add DVT prophylaxis .-add peptic ulcer prophylaxis.-DNS 125 ml\hr.-RBS\4hr + sliding scale.-ABG \4hrs + when ever indicated

PH PCO2 PO2 HCO3 SPO2

7.47 26.5 51 19.3 86

Day 2 CCRA : airways patentB : distress using accessory muscle, RR 40,

SPO2 87C :pulse 128, BP 114\79 MAP 88, good UOP.D : GCS 15\15, RBS 98

PH PaCO2 PaO2 HCO3 SPO2

7.45 22.0 52 15.5 83.1

At 12:45pm , pt became more distress and not responsive , he was intubated and connected to MV .

Initial settings were:

mode

TV RR PS PEEP FIO2 Platue

SIMV 400 18 15 5 100 19

1hr after the intubation his ABG:

MV setting :

PH PaO2 PaCO2 HCO3 SPO2

7.24 78 47.9 20.9 92.9

mode TV RR PS PEEP FIO2SIMV 400 24 15 5 100

The plan was to keep the pt MASS zero.

1 hr later the pt became hypotensive ,

he received 2 L of nomal saline without improvement , so

noreadrenaline was added, then the BP was maintain on max dose of

inotropse ..

A clinical response arising from a nonspecific insult, with 2 of the following: HR >90

beats/min RR >20/min WBC

>12,000/mm3 or <4,000/mm3 or >10% bands

T >38oC or <36oC

SIRS = systemic inflammatory response syndrome

SIRS with a presumed or confirmed infectious process

Chest 1992;101:1644.

SepsisSIRSSevere Sepsis

SepticShock

Sepsis with organ dysfunction

Refractoryhypotension

Identifying Acute Organ Dysfunction as a Marker of Severe Sepsis

TachycardiaHypotension

CVP PAOP

Jaundice Enzymes Albumin

PT

Altered Consciousness

ConfusionPsychosis

TachypneaPaO2 <70 mm Hg

SaO2 <90%PaO2/FiO2 300

OliguriaAnuria

Creatinine

Platelets PT/APTT Protein C D-dimer

Early Goal-directed Therapy in the Treatment of Severe Sepsis and Septic Shock

To Examine whether Early Goal Directed Therapy (EGDT) before admission to the

ICU is superior to standard hemodynamic therapy in patients with

sever sepsis and septic shock

Critical Influence of the Time to 1st Antibiotic Dose on Mortality in Septic Shock

Patient survival with delayed antibiotic administration in septic shock

5%

39%

48%50%58%

71%

33%

10%

0%

20%

40%

60%

80%

100%

0 5 10 15 20 25 30 35 40

Time to first appropriate antibiotic dose (hour)

Perc

ent S

urvi

val

Kumar et al. HSC and St. Boniface General Hospital. August 2003

N = 1004 patients

Every one-hour delay… you drop survival by 7.5%

Initial Resuscitation, Diagnosis, and Antibiotic Therapy

Recommend early goal-directed therapy

Give early appropriate antibioticsGive early appropriate fluidsGive appropriate inotropic supportTake early culturesTake early lactate levelTake early central venous oxygen

saturation(SVO2)

Inotropes in septic shock Noradrenaline Adrenaline Vasopressin Dopamine( selected cases)

NO RENAL DOSE DOPAMINE

Intensive insulin therapy

Target glucose 140 -200 mg

Improved survival Decreased infections Decreased organ failure

At this stage the pt went from sever sepsis to septic shock.

Plane :- NPO- N.S 125 ml\hr - Meropenum 1g TDS (given within 1hr of

diagnosis)- Noreadrenaline infusion titrated to keep map

more than 65mmhg- For septic screening .- VBG- RBS\4hrs + give insulin according to sliding

scale( Target 140-200)

2hr later the ABG:

PH PaO2 PaCO2 HCO3 SPO2

7.34 83 35.1 19.2 95.7

Day 3

- As the pt had a refractory hypoxymia ,he was kept MASS zero for another 48hrs.

-Noreadrenaline : weaned to off But the pt still febrile so vancomycine was

added

PH PaO2 PaCO2 HCO SPO2

7.52 51 35.4 28.9 89.5

Day 4Off Noreadrenaline.Sedation vacation done, GCS 11\15

MV setting:

DAY MODE TV RR PS PEEP FIO2

5 SIMV 500 15 15 8 100

6 SIMV 380 18 15 10 100

7 SIMV 380 12 15 10-5.5 90-55

8 SPONT 400 18 15 5.5 55

Day 9 CCR:

-Pt on spont for more than 24 hrs on minimal ps

- fully conscious communicating in tube. -Good cough reflex .- NPO .EXTUBATED AT 11:00 am and put on

simple mask

Timing

THE Message Time is life

Thank you for your

attention