11b - Sepsis Case Studies - Randy Wax
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Transcript of 11b - Sepsis Case Studies - Randy Wax
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Sepsis: An Update on Pathophysiology and
Treatment Approaches
Case Studies: An Overview
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Learning objectives
Review real cases to understand when to use
activated Protein C
Note important differences between cases that
influence decision to use or not use aPC
Discuss red flags for particular patients that
could make you nervous about using aPC
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Starting from common ground
Appropriate supportive care
ABCs
Fluids
Vasopressors/inotropes Organ support (ventilation, dialysis, etc.)
Appropriate empiric and adjusted antibiotics
Source control
Avoiding delays in diagnosing severe sepsis/septic shock,
providing supportive care
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Case #1
26 year old female
Past history of seizure disorder, on phenytoin
Presents with 12 hour history of fever/chills/rigors, lower
abdominal pain, no dysuria, no cough
39.4 degrees C
HR 125, BP 75/40 --> 90/50 after 2L NS
No CV angle tenderness
No other obvious source
Urinalysis
5-20 WBC/hpf
Bacteria seen
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Investigations
Laboratory:
WBC 1.0, 22% bands, Hb normal, plts normal
LFTs normal, lytes, amylase normal
Creat 139
Radiology:
CXR clear
CT (contrast) chest & abdomen: free fluid pelvis,
edematous left kidney
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Case: Deterioration
Started on empiric antibiotics following cultures
(Cefotaxime, Cipro, Ampicillin, Flagyl)
12hrs later:
HR to 180, BP 65/P despite ++ fluids Shortness of breath, RR 40+
Hypoxemia, bilateral pulmonary infiltrates
7.23/PCO2 33/pO2 100/bic 14 on 80% O2
Metabolic acidosis, lactate 2.6 Increased transaminases, decreased urine output
Increased INR to 2.4
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Case
Intubated, mechanical ventilation, central venouscatheter, arterial catheter, vasopressor
Blood cultures: Gram negative bacillus 2/2 bottles
PA catheter
Cardiac index 2.5L/min/m2
PCWP 17
Expected mortality now >40%
Septic Shock, ARDS
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Source Control in Sepsis
Localize and treat site of infection
Undrained pockets are lethal
Reviewed details of anticonvulsant therapy
Agent known to contribute to renal stones!
Repeat CT -> non-contrasted: left ureteric stone
To OR for basket extraction
Not possible -> stent placed
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Questions about the case
Appropriate supportive care (including antibiotics)?
Timely source control?
Candidate for activated Protein C?
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Case: Activated Protein C
Infusion of activated Protein C started 24 hours
after admission to ICU
INR 2.4 -> 2.0 prior to aPC, 1.3 on infusion
Infusion x 96 hours total 12 hour window for OR (stent placed)
Stabilized clinically, inotropes weaned
Extubated day 7
Discharged for urologic followup
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Lessons from Case 1
Case history
26-year-old female presents to ER
Diagnosed with severe Gram-negative sepsis with multisystemfailure, septic shock, and ARDS
Undergoes surgery to remove kidney stone Drotrecogin alfa (activated) infusion
Significance of case
Condition initially unrecognized, resolved with treatment for
underlying condition
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Case #2
73-year-old male, retired
Heavy smoker of 2 packs/day until five years ago
Presented with increased shortness of breath,
yellowish sputum production over the last weekand slight fever at 38.3C two days prior to
admission
Chronic bronchitis on Ventolin, Atrovent
Last FEV1 in 1999 was 0.8 L/minPneumococcal pneumonia with severe sepsis, ICU
admission and mechanical ventilation in 1996
yearly vaccinations since
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Present history:
Dark urine and hasnt voided in last 8 hours
Has used Ventolininhaler 4 times in last couple of
hours
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Physical examination:
23:00
On admission, 80 kg
Laboured breathing at 35/min, prolonged expiratory
time, accessory muscle use
Temperature 38.2C
Distended internal jugulars, tachycardia at 110/min
NSR, BP 90/50
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Physical examination (contd):
Positive HJ reflux
Fine crackles at both lung bases, swollen ankles
Right sided carotid bruitRest unremarkable
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Investigations:
Outstanding lab results:
Na+ = 148
K
+
= 3.2BUN Urea = 15
PO2 = 130
Hg = 156
Hct = .47
Plat = 175 000
WBC = 12 500 no bands
ABG = 7.27/56/26/55
room air
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Investigations (contd):
CXR: hyperfiltration, suspect bronchiectasis both
lung bases and doubtful left LL infiltrate
aPTT = 35/INR 1.3
Lactates normal
ECG right axis deviation, negative T waves V1-V4
anterior leads
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Treatment, management and rationale:
23:40
BiPAP started in ER 12/5, 40% PIO2
Solumedrol 40 mg IV q 6 hours, cefuroxime 1 gm IV
q 8 hours and ICU consult
500 mL Pentaspan given over 1 hour after bladder
catheter revealed 20 cc of dark yellow urine with
absence of blood on strip reagent
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Is this SIRS, sepsis, severe sepsis, or septic shock?
Is this patient a candidate for aPC?
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Treatment, management and rationale (contd):
D5NaCl 0.9% + KCl 40 mg/L at 80 cc/hour
Not at risk for bleeding
Not a candidate for rhAPC
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Lessons from Case 2
Recognize non-specific nature of SIRS criteria
Alternative causes for hypotension, oliguria
Need for appropriate search for presumed or proven
infection (COPD exacerbation doesnt count)
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Case 2: COPD
Jean-Gilles Guimond, MD
Case history
73-year-old male presents to ER with COPD/acutetracheobronchitis, ?pneumonia
Case highlights
Patient not a candidate for drotrecogin alfa (activated) therapybecause suffering from COPD exacerbation not sepsis
Significance of case
Patient follows SIRS criteria but does not have sepsis
Patient recovers; not treated with drotrecogin alfa (activated)
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Case 3: Pneumococcal pneumonia
Bruce Light, MD
Case history
26-year-old woman, alcoholic, drug user
Taken to emergency by friends; in confused state, bad cough withyellow, bloody sputum, febrile
Obvious right lower lobe pneumonia on chest x-ray
Case highlights
Diagnosis: acute pneumococcal pneumonia with hypoxemic respiratoryfailure, septic shock requiring vasopressor infusion, acute renalinsufficiency, and mild coagulopathy
Treated with drotrecogin alfa (activated)
Patient transferred to rehabilitation ward after 4 weeks
Significance of case
Typical scenario
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Case 4: Post-op infection
Claudio Martin, MD
Case history
67-year-old male undergoes coronary artery bypass surgery 3weeks prior to presentation
Re-admitted 3-weeks post-surgery for management of sternaldehiscence associated with infection
Develops respiratory distress; requires intubation and admittedto ICU
Started on drotrecogin alfa (activated)
Requires chest tube for large pleural effusion (?infected)
Drops Hb by 30 in 12 hours
Recovers
Significance of case
When to discontinue treatment transiently vs permanently
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Case 5: AML, febrile neutropenia
Tom Stewart, MD
Case history
Patient with AML, pancytopenic with severe neutropenia andsuspected lung infection
Case highlights
Patient excluded from PROWESS study due to low plateletcount (15 000/mm3). Family approach physician about possibletreatment with drotrecogin alfa (activated)
Case taken to clinical management team. Objections fromoncologist (effect on leukemia and risk of bleeding) and
pharmacist (cost and concern about use outside of guidelines) Drotrecogin alfa (activated) not given; patient dies
Significance of case
Example of scenario where drotrecogin alfa not used