PakMediNet Discussion Forum : Medicine : septic shock
septic shock
51 yr old healthy women presented to her physicians office at 1pm with fever and weakness. In the clinic her BP was 80/40 and heart rate of 120. Iv was established and pt was transfered to near by hospital.
Hers Labs revealed a WBC of 3, bicarbonate of 12, aniongap of 18, Normal A-a gradiant on ABG with a Ph of 7.2 primarily due to severe anion gap acidosis.
no clear source of infection. She has a history of splenectomy due to trauma several years ago.
She recieved third eneration cephalosporin, vancomycin and imipenam and was intubated and mechanically ventilated in the ICU.
Patient was then transfered to our hospital for tertiary care.
On presentation she was on dopamine at maximum dosage of 20ukg/kg/min. A central line was placed and her Central venous pressure was low. Low systmic vascular resistance and high cardiac output on swan ganz catheter. Levofed was started.
2l of normal saline was pumped in and she was started on bicarbonate drip. Her ventilator was set accordingly on volume cycle ventilation with a rate of 20 , tidal volume of 800 and PEEP of 5 with PEFR of 80 to decrease the sense of dyspnea.
Because of suspected pneumococcal sepsis antibiotics were changed to zyox (linazolid) and cephalosporin.
Her last Hco was 11 lactic acid level was 6.6
her d dimers are elevated, low fibrinogen, nl creatinine, poor unrine output
SHE is ICU right now
i want you guys to go through the diffrential and
1. what other steps we need to take
2. what is her prognosis
3. any new medications in sepsis we can use
4. steps towards correction of her coagulopathy
5. effects of use of pressors
Is all that i am doing worth it?
middle aged women with 4 kids?
ill keep you posted on how she does over the next few days
Posted by: icumicuccuPosts: 16 :: 30-04-2004 :: | Reply to this Message
Re: septic shock
Well i want to know regarding:
1. Blood Cultures (? sensitivity pattern of pneumococcus, H.influenze)
2. Urine Cultures
3. X-ray Chest reports
You are right regarding pneumococcal sepsis, gram negative septicemia, but what is the source? and unfortunately she's heading towards MOF.
Other steps include:
1. Use of protein C or other latest treatment options in case of severe sepsis
2. Consideration for Steroids ??
Prognosis of this patient is bad. APACHE III scoring sheet should be maintained.
Once her sepsis comes under control, her coagulopathy gets controlled. However, cryoglobulins, vitamin K or fresh frozen plasmas can be tried.
I would also recommend start of Dobutamine with renal dose dopamine, and pressor dose of Adrenaline infusions.
Posted by: yasirPosts: 90 :: 30-04-2004 :: | Reply to this Message
Re: septic shock
you have made some interesting comments and observations
Today all her 4 sets of blood cutures are positive for strep pneumo as expected in a patient with splenectomy
She is still on assist control but only on 40%
She is also still on levofed and had an echo that showed an EF of 20%. No vavular abnormalities or vegetations. Poor EF is most likely due to the presence of myocardial depressant effect of septicemia. So i changed her dopamine to dobutamine to improve her cardiac index and DO2 (oxygen delivery) which is being measured by the PA catheter. The PA catheter that is in use also gives continous cardiac index and ABG's.
We started her on Xigris which is the activated protein C. It improves mortality by around 14%. You should review the PROWESS trial published in NEJM. Now APC use is relatively contraindicated in DIC. So attempted to correct her coagulopathy with FFP prior to its institution.
She was also hydrated by goal directed therapy keeping her PCWP around 8 to 12. This study was also published in NEJM in 2003.
She is on Lung protective strategy utlizing low tidal volumes. This was based on the protocol generated by the ARDSNET study.
A vas cath was placed and she is recieving CRRT (continous renal replacement therapy)
She started bleeding from the catheter sites and required bld transfusions and has recieved 10 U of FFP and several packs of Platelets.
Her extremities are cold and are starting to look cyanotic. She still has significant lactic acidosis but her electrolyes and normal because of continous dialysis
She is still awake and follows simple commands and is recieving morphine for sedation.
Due to bleeding Xigris (APC) was stopped.
Because she is still in DIC and the continous dialysis has a tendency to clot she is recieving low dose heparin
You are right her mortality based on her MSOF is close to 70%. She has limb threating ischemia.
So we do have a long way to go.
I know how the system works in our gov hospitals
my purpose to give you this example is to hope for the best and utilize resources correctly
try to practice evidence based medicine
and
value human life
Posted by: icumicuccuPosts: 16 :: 01-05-2004 :: | Reply to this Message
Re: septic shock
let me answer your other questions.
her urine was negative
Cxr showed mild cephlization
We did a ACTH stimulation test and her cortisol level was suboptimal
so she has relative adrenal insufficiency and is recieving stress dosages of hydrocortisone
Posted by: icumicuccuPosts: 16 :: 01-05-2004 :: | Reply to this Message
Re: septic shock
Excellent Management, but unfortunate patient. It is glad to know that you have tried all possible means to save the patient.
Cardian depression can also be due to Pneumococcal induced Myocarditis. And use of dobutamine in this case is recommended.
I wanted to know details about PROWESS trial as it is not available in NEJM.
What to do if you dont have all these facilities available? We see such paitents daily in our emergencies, and start treatment empirically most of the time, our patients and hospitals both are poor.
What is the recommendation of starting Steroids in sepsis?
Posted by: yasirPosts: 90 :: 01-05-2004 :: | Reply to this Message
Re: septic shock
Let me tell you about a few studies to read
Rivers (author) Early goal directed therapy in NEJM; 2001; 345; PAGE 1368-77
Bernard (author)PROWESS trial on Drotrecogin alfa - recombinant activated protien C; NEJM;2001;344;PAGES 699-709
Vincent (author)Follow up paper on APC ; Critical care Medicine (journal) 2003;31;634-40.
Also read the ARDSNET study in NEJM 2000 on lung protection strategy. They also have a web site ARDSNET.
Te patient is relatively better.
Off pressors.
Still recieving inotropes
and CRRT (continous dialysis)
normal mentaion
still on ventilator
APC stopped because of bleeding through cathter sites
now on low dose heparin for DIC
I think with the clinical skills that you have acquired in the face of limited resources you can achieve good outcome by a positive attitude and care for details
after graduating from SMC in karachi in 1993 i left housejob and started residency in the US. i had passed my USMLE in 4th and 5th year. Spent 7 years in trainig in internal medicine, pulmonary medicine and then critical care and now have 3 board certification.
i still see 40 pts a day and work 14 hrs 6 days a week in a tertiary care hospital with 160 monitored and 70 ICU beds.
and i think i still have a lot to learn and continue to do so as i take care of patients.
take care of patients sincerely and with the best possible means and those that have life to live with the grace of allah will live. But your efforts should be relentless and there should be no negligence on your part intentionally.
take care
Posted by: icumicuccuPosts: 16 :: 02-05-2004 :: | Reply to this Message
Re: septic shockI wonder why in USA, for pneumococcus, 3-4 antibiotics are used, just like killing an ant with an elephant. In UK they have different way of using antibiotics. They use simple ones, like for this bacteria, benzyl penicillin or a vancomycin can work easily. I think imipenam as one of the powerful antibiotic, can cover almost all bacteria (except some anaerobes).
Posted by: docosamaPosts: 333 :: 05-05-2004 :: | Reply to this Message
Re: septic shock
Interesting point
the principle of use of antibiotics in critical care is to start with a broad spectrum coverage and narrow it down as the organisms are recovered.
There is a study that looked at outcome (in terms of mortality) of broad spectrum antibiotic in septic shock as an intial regimen vs use of appropriate antibiotics based on clinicians best judgement (which was broad spectrum in most cases as well). Pts who were given abxs to cover large spectrum of infections survived more then those with limited spectrum based on clinicians best judgement.
Based on the sensitivities results on bld cultures the antibiotics were changed.
In that study also the change of antibiotic after isolation of organism in the clinicians judgement group did not improve mortality.
there is also a study looking at the timing of antibiotic administration on presentation to the emergency room and outcome. In that those pts who recieved antibiotic within 4 hrs of presentation did better then those in which dose was delayed.
so here in a patient where you may not get a second chance if you turn out to be wrong this type of intervention is standard of care.
USA is the only country in my knowledge with formal 2yrs training programs seperate from pulmonary programs where intensivist are trained.The training now also includes ultrasonography and echos in addition to the usual PA catheters vents IV pacers etc.
in the end your decisions also depend of your level of comfort. in USA the society in general is very litiginous and therefore i agree that we tend to go over board to be absolutely certain
So your point is valid and reasonable when resources are limited.
thanks for your input
Posted by: icumicuccuPosts: 16 :: 06-05-2004 :: | Reply to this Message
Re: septic shock
I agree with your point.
We, in our hospitals, used to start broad to extended spectrum antibiotics. We rarely used that you have mentioned. We used amoxycillin 2gm qid, ceftriaxone 2gm bd and metronidazole 500mg tds. And even, sometimes we start basic triple regime ie. amoxycillin, gentamicin and metronidazole. We never used Vancomycin (possibly because proportion of MRSA in our settings is less, and 2ndly, vancomycin here is an expensive drug). The triple regime i have described here, is mentioned in almost all text books of Uk, but what i see in books written by US doctors, is different. Like, CMDT tells to use antibiotics as you have mentioned.
So i thought to discuss this issue over here as well.
Posted by: docosamaPosts: 333 :: 06-05-2004 :: | Reply to this Message
Re: septic shockIs this a black woman? and is she still alive?
Posted by: chameedPosts: 173 :: 09-05-2004 :: | Reply to this Message
Re: septic shock
No she is white
now hemodynamically stable
off the ventilator
neurologically intact
undergoing daily but regular hemodialysis as apposed to CRRT. We will attempt to space out dialysis timing to see if her electrolytes stay stable and she makes any urine
she has developed extensive excoriation and bullous skin lesions in her extremities requiring burn type care they are presumably a result of hypoperfusion
has pulses in her extremities but a few cyanotic digits not gangrenous yet we are closely observing those
so there is hope
thanks for asking
Posted by: icumicuccuPosts: 16 :: 12-05-2004 :: | Reply to this Message
Re: Re: septic shock
quote:
yasir wrote:
Excellent Management, but unfortunate patient. It is glad to know that you have tried all possible means to save the patient.
Cardian depression can also be due to Pneumococcal induced Myocarditis. And use of dobutamine in this case is recommended.
I wanted to know details about PROWESS trial as it is not available in NEJM.
What to do if you dont have all these facilities available? We see such paitents daily in our emergencies, and start treatment empirically most of the time, our patients and hospitals both are poor.
What is the recommendation of starting Steroids in sepsis?
Posted by: amujtabaPosts: 2 :: 23-07-2004 :: | Reply to this Message
Re: septic shock
How is the Patient now. Please update us. Have you learnt any thing from this case? Would you manage it any different next time?
Aamir
Posted by: memonPosts: 28 :: 29-08-2004 :: | Reply to this Message
Re: septic shockThe patient is doing well and has no disability
Posted by: icumicuccuPosts: 16 :: 21-11-2005 :: | Reply to this Message