Critical Care Case Presentation

27th Nov,2013

Done By:

Sara AlArfaj

Outlines:

• Topic Review.

1) Background

2) Etiology

3) Epidemiology

4) Diagnosis

5) Treatment

• Case Components.

Diabetic Foot Infections

Background:

• Diabetes mellitus is a disorder that primarily affects

the microvascular circulation.

• Worldwide, diabetic foot infections are the most

common skeletal and soft-tissue infections in

patients with diabetes.

• Diabetic foot ulcers in diabetics occur as a result of

various factors, such as peripheral neuropathy, and

atherosclerotic peripheral arterial disease, pressure,

and foot deformity.

"Diabetic Foot Infections ." Diabetic

Foot Infections. N.p., n.d. Web. 23

Nov. 2013

4

Diabetic foot infections typically take

one of the following forms:

Cellulitis

Deep-skin and soft-tissue infections

Acute osteomyelitis

Chronic osteomyelitis

"Diabetic Foot Infections ." Diabetic

Foot Infections. N.p., n.d. Web. 23

Nov. 2013

Etiology:

• Microvascular disease due to "sugar-coated capillaries" limits the blood supply to the superficial and deep structures.

• Diabetics are predisposed to foot infections because of this compromised vascular supply.

• Impaired microvascular circulation hinders WBC migration into site of infection, limits the ability of antibiotics to reach the site in a good concentration.

"Diabetic Foot Infections ." Diabetic Foot

Infections. N.p., n.d. Web. 23 Nov. 20136

Cont’d

• Superficial infections like Cellulitis can be caused by

Strept (group A and B).

Staph Aureus.

• Deep soft-tissue infections in diabetic patients can

be associated with gas-producing Gm-ve Bacilli.

• Chronic Osteomyelitis:

Strept (group A and B), Gm-ve Bacilli.

Bacteroids Fragilis, E.Coli, Proteus Marbilis and Klebsella

Pneumoniae.

"Diabetic Foot Infections ." Diabetic Foot

Infections. N.p., n.d. Web. 23 Nov. 20137

Epidemiology:

• More than 50% of lower limb

amputations are due to DM.

• Up to 80% of diabetic foot

amputations can be prevented.

• About 325 amputations are likely to

occur annually in Jeddah compared

to 741 in Riyadh and 3970 in KSA.

The rule of 15 *

15% of people with diabetes develop ulcers

15% of ulcers develop osteomyelitis

15% of ulcers result in amputation

* Armstrong, David G. and Lavery, Lawrence A. (2005).

Clinical Care of the Diabetic Foot. American Diabetes

Association. ISBN- 10: 1580402232

The Journal of Diabetic Foot

Complications, 2011; Volume 3, Issue

3, No. 3, Pages 55-61

8

www.smj.org.sa Saudi Med J 2006;

Vol. 27 (2)9

Diagnosis:

History, signs and symptoms

WBC,ESR Blood cultures

Gmstain/cultures for aspirated

samples

Radiography, CT, or MRI

NICE clinical guideline 119 –

Diabetic foot problems 201210

Treatment and Management:

IDSA Guideline for Diabetic Foot

Infections • CID 2012:54 (15 June)11

Cont’d

Treatment depends on the severity of infection:

• Cellulitis being the easiest.

• Deep skin and soft-tissue infections are curable.

• Acute osteomyelitis, depends on the infecting MO and the right antibiotic choice.

• Chronic osteomyelitis, the most difficult.

NICE clinical guideline 119 –

Diabetic foot probl ems12

Cont’d

Antimicrobial Therapy

Mild

(out patient)

Covers skin flora”strept, staph”

Dicloxacillin, Cephalexin, Augmentin,

Clinda

MRSAClinda, Bactrim,

Linezolid

Gm-ve aerobes, anaerobes

-Bactrim+Aug

- Clinda+ FQs

Mod-Severe

(hospitalized)

Broad spectrum

Amp-Sul

Mero, Erta

Tazocin

MRSAVanco

Linezolid

Surgical

Debridement

and

Amputation

IDSA Guideline for Diabetic Foot

Infections • CID 2012:54 (15 June)13

Cont’d

Manage and control other

complications and comorbidities. (DM,

CKD, HTN)

KDOQI Diabetes Guideline: 2012 Update/ADA,

DIABETES CARE, VOLUME 36, SUPPLEMENT 1, JANUARY

2013

14

Case Components

Patient’s Information:

MA is a 50 yo Saudi female, came to the OPD

nursing clinic for a follow up.

Chief Compliant:

Came for a follow up for the diabetic foot, she

was fatigued with a LL swelling.

HPI:

• The patient came for a follow up, her primary physician found she had a rising Cr and Urea levels, she was suspecting a possible sepsis as well.

• So, the patient was admitted in 8th of Nov for more renal evaluation.

• In the 10th, She aspirated while she was eating.

• She was arrested, CPR lasted about 25 minutes, with two failed attempts of intubation.

• Admitted to the ICU.She was hypoxic 60-

70%

Cr= 195 (44-80 umol/L)

U= 33.5 (2.5-6.4 mmol/L)

Past Medical history:

• DM for 25 years.

• HTN for 4 years.

• CKD

• Diabetic foot.

Family History:

No similar presentation in the family.

Social History:

Married, lives in Riyadh with the family support,

average socioeconomic status.

Allergies:

No known allergies.

Medication History:

Medication Dose Medication Dose

Amlodipine 10 mg PO OD Aspirin 81 mg PO OD

Metoprolol 5 mg PO OD Insulin Gargline 24 units AM

Hydralazine 25 mg TID PO Pregabalin 75 mg PO OD

CoAprovel

(Irbesartan/hydrochl

orothiazide)

300 mg/12.5

mg

Calciferol 500 IU/day

Atorvastatin 40 mg PO OD

Vital signs:

T= 36.6 BP= 121/65 P=65

RR=20 HR=98 O2Sat= 96%

Wt= 60.9 kg Ht=157 cm

Physical Examination:

GEN Conscious, sleepy, responds to calling, looks unwell, fatigued

and pale.

Bilateral pitting edema.

Dressing over a wound in the left leg.

HEENT Not jaundiced, not cyanotic, JVP not raised.

CHEST Shallow breathing, not rapid. Equal chest expansion.

CVS S1+ S2 +O

ABD Soft not tender, no organomegaly, +ve bowel sounds.

CNS Conscious, drowsy, responds and opens eyes with loud

voices.

Laboratory Tests:

Electrolytes:

10 11 12 13 14 16 18 20 22 25

Na 145 144 143 145 141 143 147 150 145 148

K 4.8 4.2 4.0 3.6 3.6 4.4 4.4 5.1 5.1 4.6

Mg .92 .93 .95 .91 1.0 1.08 1.06 1.14 1.12 1.01

Ca 2.16 2.11 2.19 2.31 2.30 2.27 2.38 2.36 2.31 2.23

U 32.4 31.4 33 33 32 33 35 34 34.9 30

Cr 181 194 197 195 178 167 157 148 142 123

CBC:

Coagulation:

11 13 14 15 16 18 20 22

WBC

11.9 13.7 15.6 11.6 8.8 7.19 8.16 8.34

RBC 3.17 3.01 2.95 2.86 2.8

4

2.62 3.14 2.91

Hg 8.50 8.20 8.00 7.8 7.7

0

7.10 8.9 7.70

Hct 25.6 24.3 23.9 23.3 23 21 27.7 24

Plt 180 191 176 144 125 113 115 121

10 11 12 13 14 15 16 18 20 22

PT 19.8 18.8 19.3 18.9 17.3 17.5 17.3 16.

5

15.9 16.3

APTT 36.4 39.3 38.9 37.3 36.8 1.5 37.8 44 40.3 50

INR 1.7 1.6 1.7 1.6 1.5 41.3 1.5 1.4 1.3 1.3

Cardiac Enzymes:

Liver:

10 12 13 20 22 25

Trop 284 235 226

.2

349 316

.4

305

.3

LDH 437 368 330

10 12 13 14 15 16 18 20 22

ALT 30 18 12 10 17 35 29 32 31

AST 77 28 25 66 147

ALB 27 30 27 22 25 24 21 22 24

Medications

medication medication

Sch. Omeprazole 40 mg IV daily Phenytoin 100 mg IV Q8h

Vit D 10 drops NGT daily Docusate Sodium 100 mg

NGT twice daily

Atorvastatin 40 mg NGT daily PRN Fentanyl 25 mcg IV Q1h

Aspirin 81 mg NGT daily Hydralazine 10 mg IV Q1h

Sodium Carbonate 650 mg

NGT Q8

Infusion Insulin

Heparin 5000 unites SQ BID Midazolam 3 mg/hr

Levetiracetam 500 mg IV

daily

Norepinephrine .053

mcg/kg/min

Refresh eye drops

Stat Medications:

- Lasix

- Albumin

- Lorazepam

- KCL

Antibiotic Start date Discontinuation

Date

Restart Date

Tazocin 3.35 mg

IV Q8h

10/11/13 11/11/13

Vancomycin 10/11/13 10/11/13 17/11/13

Imepenem 250

mg IV Q6h

11/11/13 11/11/13

Meropenem 500

mg IV Q8h

12/11/13 14/11/13 17/11/13

Augmentin 1.2 g

Q12h

14/11/13 17/11/13

Problem List:

1) Post CPR ( cardiac arrest and

Respiratory failure).

2) Post Aspiration Pneumonia.

3) Diabetic Foot Ulcer, Osteomyelitis.

4) Worsening CKD.

5) DM.

6) HTN.

Day 1 (10th Nov)

S The patient was brought to the ICU after she aspirated and got

arrested (CPR 25 minutes).

O • T= 36 BP= 126/75 HR=70 O2Sat=95% HGT=4 Na= 145

alb=27

• High Cr and Urea levels (181, 32.4 respectively).

• High INR of 1.7

• On Inotropes.(Dopamine 20 mcg/kg/min)

A Possible sepsis (DF, Osteomyelitis)

P • For more cardiac, renal and liver work up.

• Tazocin 3.35 mg IV Q8h.

• Albumin 5% (500 ml) IV.

• Hold Aspirin.

11th Nov

S ICU day 2

O • T= 36.1 BP= 118/63 HR=80 O2Sat=97% HGT=8.2 Na= 144

alb=29 K=4.2 Cr=194 U=31.4 INR=1.6 WBC=11.98.

• Low HGB=8.50, RBCs= 3.17 and HCT= 25.60

• GCS 3/15, intubated, sedated on Midazolam, NGT feeding.

A Post CPR, DFU, seizure, AKI on top of Chronic

P • DC Levetiracetam.

• Start Phenytoin 20 mg/kg stat over 1 ½ hrs, then continue with

100 mg IV Q8hrs.

• Discontinue Imepenem and switch to Meropenem 500 mg

Q8hrs IV for 14 days.

• EEG: status epilepticus.

• CT: no hypoxic ischemic brain insult, no intracranial

hemorrhage or infarction.

• US: moderate ascites at the upper and lower

abdomen

12th/ 13th Nov

S ICU day 3 and 4

O • T= 36 BP= 137/66 HR=92 O2Sat=99% HGT=12.6 alb=23

Cr=195 U=33 INR= 1.6 WBC= 13.74

• Phenytoin level= 21.51

• Urine output 100-200 ml/hr

• Culture results.

A Hemodynamically stabel, no inotropic support, no siezures

P • Close observation for seizures.

• Meropenem frequency changed to Q12hrs. ( CL= 28.47

ml/min)

• If culture came ESBL –ve, deescalate duration from 14 days to

7 days.

- Blood: negative.

- Feet wound: heavy

growth of gm-ve bacilli,

not yet identified.

* She’s a known carrier of ESBL

If CrCl 26-50

ml/min: 0.5-1 g IV

Q12 hrs

14th-16th Nov

S ICU day 5,6 and 7.

O • T= 36.8 BP= 132/57 HR=77 O2Sat=99% HGT=10.1 alb=24

Cr= 174 U=33 WBC=8.2 INR= 1.5.

• Culture results.

• DDIM= 9.1 ug/ml (0.0-.5 μg/ml)

A Patient is stable.

P 14/11

• Stop Meropenem, Start Augmentin 1.2 g IV Q12hrs for 7 days.

• Heparin 5000 units SQ Q12hrs.

16/11

• Change Omeprazole 40 mg daily from IV to NGT.

Wound (14/11):

- Heavy growth of klebsiella Pneumoniae

- Heavy growth of Proteus Mirabilis

- Heavy growth of SA.

* All sensitive to Augmentin.

17th Nov

S ICU day 8.

O • T= 35.2 BP= 132/57 HR=77 O2Sat=99% HGT=10.1 alb=21

Cr= 163 U=34 WBC=7.55

• HGB= 7.10 HCT=21.6 INR=1.4 PLT= 109

A HD stable, off inotropes.

Left leg bleeding.

Cellulitis on the LL in the skin surrounding the wound.

P • Stop Augmentin, Start on Meropenem 1g Q12 hrs and give

Vancomycin 1g IV stat.

• Hold Heparin morning and night doses.

18th-20th Nov

S ICU day 9,10 and 11

O • T= 36.1 BP= 134/60 HR=84 O2Sat=98% HGT=12.3 Cr= 148

U=34 WBC=8.16 INR=1.2

• Phenytoin level= 23.3

• Vanco level= 11.30

A Patient is stable.

Experienced episode of seizure.

P 18/11

Add Levetiracetam 500 mg Q12hrs.

20/11

Cont Vancomycin 1g IV OD.

According to her Vanco

level, she was supposed

to be restarted on 1 g

Q48 hrs.

21st-23rd Nov

S ICU day 12,13 and 14.

O • T= 36.3 BP= 135/57 HR=94 O2Sat=98% HGT=11.3 Cr= 142

U=34.8 WBC=8.34 INR=1.3

• Vanco level (22-23/11)= 20.62 and 17.64

• Phenytoin level= 33.54

A Patient is stable.

Went through suction and drainage. (22/11)

For a second look.

P Hold Vancomycin and re-level. (22/11)

24th ,25th Nov

S ICU day 15 and 16

O • T= 36 BP= 141/57 HR=96 O2Sat=98% HGT=10 Cr= 123

U=30.1 WBC=6.12 INR=1.1

• Vanco levels= 13.79 and 11.92

A For OR.

P 24/11

Levetiracetam 750 mg IV BID

25/11

Vancomycin every 48 hours.

Phenytoin 100 mg NGT Q8hrs

Levetiracetam 750 NGT Q12hrs.

Thank You..Questions?