11b - sepsis case studies - randy wax

7/28/2019 11b - Sepsis Case Studies - Randy Wax

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Sepsis: An Update on Pathophysiology and

Treatment Approaches

Case Studies: An Overview


2/25

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


4/25

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


6/25

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


8/25

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


11/25

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


15/25

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)


22/25

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


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


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


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


Example of scenario where drotrecogin alfa not used

11b - sepsis case studies - randy wax

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