bacterial sepsis

Hospital Day 0: The Call

64 YO African American female, found unconscious by staff in her nursing home this morning. She was arrived via EMS and is currently on the vent. Please come and assess

Hospital Day 0: Inital Assessment

CC: unobtainable due to Pt. being ventilated and sedated

HPI: 64 YO AA Female with a past medical history significant for: HTN, DM II, COPD, CKD (baseline Cr. 5.2), dyslipidemia, CHF (EF - 27% per Echo: 4/2010), presents to the ECC via EMS with acute onset of seizures. Pt was noted to have decreased oxygenation and difficulty protecting her airway, and was intubated in the ECC.

Nursing home was contacted and they noted the Pt appeared sluggish and weak by staff one day prior to admission. This morning, pt was found unresponsive and "twisting" with no fecal or urinary incontinence.

Hospital Day 0: HistoryAllergies: NKDA

Family HX: Hypertension in sisters (as per medical record)

Past Medical HX: HTN, DM II, COPD, CKD (baseline Cr. 5.2), dyslipidemia, CHF (as per medical record)

Past Surgical HX: none

Social HX: (-) EtOH / (+) tobacco - 4 cig./day x years / (-) drugs (as per medical record)

Living Condition: currently lives in a nursing home.

Code Status: Full code

Hospital Day 0: PhysicalPhysical Exam:

Vitals: BP: 90/60 HR: 61 Tc: 32.5 RR: 12 (vent) O2: 100% (on vent)

General: lethargic / sedated

HEENT: 1mm fixed pupils (B), anicteric sclera

Neck: (-) cervical, supraclavicular lymphadenopathy, supple, (-) JVD

CV: decreased heart sounds, (+) S1 / S2, (-) S3 / S4

Abdomen: (-) organomegally, NT, (+) rebound/guarding

Musculoskeletal: Unable to assess full ROM

Skin: deferred

GU: (-) stool guaic, normal tone, (-) fissures, (+) visible external hemorrhoid noted

Hospital Day 0

4.97.523.8

76

92

30.6 47.5

2.46

144

5.2

125

6

72

9.8197

Ca: 4.8 Mg: 2.8 Phos: 11.5Seg: 4.6Mon: 0.1Eos: 0Lym: 0.2

T. Bili: 0.6D. Bili: 0.1

CPK Total: 263CPK MB: 14.6Troponin I: 0.02

AST: 18ALT: 22

Alk. Phos: 263

ABG: 6.75 / 188 / -30.4 / 29 / 98% on 100% FiO2

Labs on Arrival: 0730

Hospital Day 0: Assessment

i. Urosepsis: suspected to be secondary to UTI.

Pt. started on Vancomycin 1 gm IV Q Daily

Pt. started on Zosyn 4.5 gm IV Q Daily

f/u cultures

ii. Renal Failure

Begin dialysis today

Hospital Day 0: ECC Course

730Pt. arrives to ECC via EMSGCS on arrival, 3

743 Initial labs drawn

745Pt. given propofol @ 5mcg/kg/hrPt. given Ativan @ 2mg IC x 1Pt. given Succinylcholine @ 50mg IV x 1 dosePt. intubated

Vent Settings: Rate 12, FiO2: 100%, Peep 5, TV: 400

747 CXR: confirmed placement of Endotracheal Tube

800(R)IJ TLC placed. initial attempt was unsuccessful, and had to reattempt

Hospital Day 0: ECC Course

810(L) femoral arterial line placed. Initially attempted a (R) and (L) radial arterial line. Both radial arterial line placements failed.

810 Pt. taken to CT Scan

1110Temp: 90.8Warming blankets and water warming usedRectal probe in place

1123Zosyn 4.5 IV x Q DailyVancomycin 1gm IV Q DailyVersed 2mg/hr (titrated to MAAS 3)Hydrocortisone 100 mg IV x 1

1251 Morehouse MICU Team Called

ICU Day I

Events over the past 24 hours: Pt had systolic blood pressures in the 170’s and diastolic blood pressures in the 80s. IVF were initially titrated down from 125 cc/hr to 75 cc/hr and subsequently discontinued when the Pt. remained hypertensive.

Pt. was transfused 1 unit of PRBC overnight and Hb /HCT went from 7.5/23.8 to 10.8 /33.2

Pt. remains on the vent.

Neuro: (+) gag reflex, (+)1 DTR x 4, (+) right corneal reflex

ICU Day 1: Labs

7.610.833.2

162

90

20.2 43.9

1.65

145

3.9

122

8

62

8.5322

Ca: 4.6 Mg: 2.2 Phos: 9.0Seg: 71%Mon: 2%Eos: 2%Lym: 4L


CPK Total: 249CPK MB: 14.7TroponinI: 0.04

AST: 24ALT: 24

Alk. Phos: 133

ABG: 7.26 / 151 / -18.1 / 32 / 98% on 100% FiO2

0001 AM

ICU Day IIEvents over the past 24 hours: Pt. had a vascath placed and received dialysis. Pt. remains unresponsive. Pt. started on BP medications

Vitals: BP: 122-134 / 54-82, HR: 74-92, RR: 12 - 18, O2: 100%,

Vent Settings: AC / Tv: 400 ml / FiO2: 50% / Rate: 12 / Peep: 5.0

Plan:

Urosepsis: Elevated WBC noted. Urine culture contaminated. Resend urine for culture. Pt. remains anuric.

Respiratory Failure: Pt. now breathing over the vent. Still not responsive. Consider weaning in preparation for breathing trials

2D Echo

Coagulopathy: Transfuse 2 Units FFP and d/c bicarbonate drip

AMS: Consider EEG

Renal Consult: removed 1,300 ml via dialysis. Continue to monitor.

ICU Day 2: Labs

9.610.631.8

158

87

30.7 55.2

2.46

138

2.5

98

26 4.6291

Ca: 5.2 Mg: Phos:Seg: 80%Mon: 5% Eos: Lym: 3L

T. Bili:D. Bili:

CPK Total:CPK MB: TroponinI:

AST:ALT:Alk. Phos:

ABG:

0202 AM

28

0033 AM

0033 AM

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ICU Day 2: Labs

138

2.1

97

25 4.7184

Ca: 7.1 Mg: Phos:



AST: 36ALT: 25

Alk. Phos: 118

ABG: 7.55 / 224 / 5.2 / 32 / 98% on 50% FiO2

0840 AM

29

ICU Day 2: Labs

142

2.7

103

29 2.681

Ca: 7.8 Mg: Phos:



AST: 35ALT: 26

Alk. Phos: 112

ABG: 7.54 / 141 / 7.9 / 37 / 96% on Room Air

1421: Post Self-Extubation

14

ICU Day III

Events over the past 24 hours: at 1530, nursing staff contacted MICU and indicated that the Pt. had self extubated as well as removed the NGT. Nurse indicated that Pt. A/O x 1 (person) and able to follow commands. Nurse was instructed to replace NGT but was unable to do so due to elicitation of strong gag reflex.

Assessment:

Urosepsis: awaiting cultures

Respiratory Failure: resolved

Patient transferred

ICU Day 2: Labs

14.39.428.4

117

89

30.7 55.2

2.46

143

3.0

105

27 3.3158

Ca: 7.9 Mg: Phos:Seg: 65%Mon:% Eos: Lym: 3L

T. Bili:D. Bili:


AST:ALT:Alk. Phos:

ABG: 7.48 / 71 / 4.2 / 39 / 98% on room air

0001 AM

17

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bacterial sepsis

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