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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