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morbidity and mortality conference

morbidity and mortality conference. ❀ Antonio Chua, M.D. ❀ Anne Marie Kathryn Ingente, M.D. ❀ Marizen Lim, M.d. Objectives. To present a case of an acute systemic infection that caused severe sepsis and disseminated intravascular coagulation in an immunocompetent patient

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morbidity and mortality conference

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  1. morbidity and mortalityconference ❀Antonio Chua, M.D. ❀Anne Marie Kathryn Ingente, M.D. ❀Marizen Lim, M.d.

  2. Objectives • To present a case of an acute systemic infection that caused severe sepsis and disseminated intravascular coagulation in an immunocompetent patient • to present a case report of severe sepsis caused by a microorganism known only so far to cause disease in avian and bovine species • to briefly discuss on the recent guidelines on the management of sepsis

  3. Identifying Data • CC • 69 y.o. /Female • married • Roman Catholic • Pasay City • Chief Complaint: • Fever and chills of few hours duration

  4. History of Present Illness • ~12 hours PTA • tmax 37.8C, (+) chills, (+) back pain & difficulty walking; (-) urinary symptoms, (-) abdominal pain/diarrhea; (-) cough/colds/sore throat; (-) rashes/signs of bleeding • 2 hours PTA • 1x Vomiting • Consult with AMD (CBC, U/A) • Ad

  5. History of Present Illness • CBC • Urinalysis: NORMAL (rbc: 5.5, wbc 0, epith. cells 0, bacteria 13.62) • ADMISSION

  6. past medical history • HPN, on Metoprolol 50mg OD • Osteoporosis • abdominal surgery(?) • Family History • Unremarkable • Personal & Social History • non smoker/non alcoholic beverage drinker • hx of travel to tagaytay (2 wks PTA) • Works in a Wet Market (butcher/ sells beef products)

  7. physical examination • General Survey: conscious, coherent, not in cardiorespiratory distress • VS: BP 90/60 HR: 102/min RR 20/min Temp 38.6C • HEENT: anicteric sclerae, pink palpebral conjunctivae, supple neck, no tonsillopharyngeal wall congestion • Skin: no pallor, no jaundice, no rashes

  8. physical examination • CVS: adynamic precordium, tachycardic, regular rhythm, distinct heart sounds, no murmurs • Lungs: symmetrical chest expansion, clear breath sounds • Abdomen: Flabby, (+) infraumbilical scar, NABS, soft, non tender, no organomegaly • Extremities: no pedal edema, full and equal pulses

  9. Neurologic examination • Oriented to 3 spheres • CN intact • No cerebellar deficits • Motor 5/5 on all extremities • No sensory deficits • No neck rigidity • negative brudzinky and kernig’s sign

  10. SALIENT FEATURES • 69F • (-) DM • Butcher/sells beef products • fever x few hours PTA • low platelet count • no signs of bleeding/rashes • no urinary/respiratory/abdominal symptoms

  11. ADMITTING IMPRESSION • SYSTEMIC VIRAL INFECTION • R/O DENGUE FEVER • HYPERTENSION, CONTROLLED

  12. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis & Septic Shock: 2008 • grade system: sequential assessment of the quality of evidence • A: high • B: moderate • c: low • d: very low • strength of Recommendation: • 1: strong • 2: weak • the grade of strong & weak is of greater clinical importance than a difference in letter level of quality of evidence

  13. COURSE IN THE WARDS • 00:00 • BP 90/60 HR 102 • RR 20 Temp 38.6 • paracetamol • IV Hydration • Esomeprazole 40 IV oD • Metoclopromide 10mg prn • 02:00 • dizziness after using the commode • BP 60 palpatory (+) fever (+)tachycardic • Fluid challenge • BP responded • O2 2lpm nasal canula • ECG: non specific ST T wave changes • Cardiology Referral • Trop I 0.06 • K 3.3 Crea 1.7 • CXR: normal • Blood CS x 2 sites

  14. PROBLEM #1: HYPOTENSION DIFFERENTIAL DIAGNOSES • SIRS • Fever • Tachycardia • WBC count • Hypotension • (CXR, Urinalysis, Blood CS) • Acute Coronary Syndrome • no chest pain, no difficulty of breathing • ECG: NSTTWC • Troponin I: 0.06

  15. ACUTE CORONARY SYNDROME • 2007: AHA, ACC defined Myocardial Infarction as: • Evidence of myocardial necrosis (elevated cardiac biomarkers) • Clinical setting consistent with myocardial ischemia • ECG changes • Important because not all troponin elevations are due to ACS • Other Causes of Troponin elevations • sepsis • Hypovolemia • AF • Heart failure • Renal failure • Myocarditis • Pulmonary embolism

  16. INITIAL RESUSCITATIONS (1ST 6 HOURS) • SEPTIC SHOCK (HYPOTENSION PERSISTING AFTER INITIAL FLUID CHALLENGE OR BLOOD LACTATE LEVEL ≥4 MMOL/L) • Goals: (1C) • CVP 8-12, MAP ≥ 65 • U.O ≥ 0.5mg/kg/hr • Central venous oxygen saturation ≥ 70% or mixed venous ≥ 65% (Hct > 30, dobutamine) • Diagnosis (1C) • 2 or more cultures • Imaging studies • Antibiotic therapy (1D) • Begin w/in 1st hour • Broad spectrum • Consider combination therapy in pseudomonas infection, neutropenicpxs • 7- 10 days duration Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008

  17. INITIAL RESUSCITATIONS (1ST 6 HOURS) • Source identification and control • Fluid Therapy • Crystalloids or colloids (1B) • CVP >8mmHg (1C) • Vasopressors • Maintain MAP >65mmHg (1C) • Norepinephrine and Dopamine as 1st choice of vasopressor (1C) • Inotropes • Dobutamine may be administered in the presence of myocardial dysfunction (1C) Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008

  18. PROBLEM #2: ACUTE RENAL FAILURE • 06:00 • 60 palpatory HR 112 RR 20 Temp 39C • mottled skin, petechiae on her face and arms • Dopamine • Referral ID service • piperacillin-tazobactam 2.25g IV q8 • Referral Nephrology Service • Central line inserted (initial CVP 1-2; iv hydration continued); Levophed drip • Urine Na: 68 mmol/L; urine crea: 130.3 mg% • FENa: 0.006 • 07:30 • BP 70/40 • progression of petechiae on trunks, mottled skin, gcs15, no signs of meningeal irritation • for ICU transfer • Piperacillin-Tazobactam shifted to Cefepime 1g IV q12 • Metronidazole 500mg IV q8 hours • Hydrocortisone 50mg IV q6 hours

  19. PROBLEM #3: ADRENAL INSUFFICIENCY & SEPSIS • mech of dysfxn of HPA axis during acute illness are complex & poorly understood (prob. due to ↓ prod’n of CRH, ACTH & cortisol, & dysfxn of their receptors • Corticosteroids • Consider IV hydrocortisone for adult septic pxs when hypotension responds poorly to adequate fluids and vasopressors (2C) • ACTH stimulation test is not recommended (2B) • HYDROCORTISONE DOSE SHOULD BE ≤ 300 MG/DAY (1A) • Dexamethasone should not be given (2B) • Corticosteroids should not be given in the absence of shock (1D) Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008

  20. PROBLEM #4: SKIN MANIFESTATIONS • PurpuraFulminans • Purpuric lesions • Disseminated Intravascular Coagulation • CAUSES: • Meningoccoccal infections • Streptococcal infections • Staphylococcal infections • Meningoccemia • The most common cause of purpurafulminans • meningitis • Meningitis + meningococcemia • Meningococcemia – meningitis • Non specific s/sx • Classic clinical features • Rash, meningisimus, impaired consciousness

  21. PROBLEM #4: SKIN MANIFESTATIONS • Streptoccocal Infections • 2nd most common cause of purpurafulminans • Pharyngitis, cutaneous infections, pneumonia, meningitis, invasive infections- bacteremia • Staphylocccal Infections • Not common • Presentation is similar with meningoccemia • Staphylococcus aureus strains that produce high levels of the superantigens TTST-1, SEB, SEC

  22. COURSE IN THE WARDS • 09:00 REPEAT BLOOD WORKS:

  23. PROBLEM #5: COAGULOPATHY • dengue duo, malaria, leptospira: negative • fdp: >80 ug/ml • LDH: 859 U/L • PBS: normocytic, normochromic RBC; leucocytosis w/ sl. shift to L; ↓ platelets

  24. COURSE IN THE WARDS • Hematology Referral • 8U FFP transfused • Vit. K OD

  25. BLOOD PRODUCT ADMINISTRATION • FFP: should not be used to correct lab clotting abnormality unless (+) bleeding or (+) plan of invasive procedure/s (2D) • platelet transfusion: • if with severe sepsis & plt count <5T/mm3; • or plt count 5-10T/mm3 + significant risk of bleeding; • or goal platelet count ≥50T/mm3 if surgery or invasive procedures are contemplated (2D) Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008

  26. BLOOD PRODUCT ADMINISTRATION • RBC TRANSFUSION (1b) • if hgb <7g/dl • target: 7-9 g/dl • EPO (1B): • not specific tx of anemia in severe sepsis • no effect in clinical outcome • Anti-thrombin III • should not be used (1B) Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008

  27. VITAMIN K • cofactor required for the activity of coagulation factors VII, IX, X, and prothrombin, and regulatory proteins (proteins C & S), & proteins of mineralized tissue (bone Gla protein and matrix Gla protein) • depending on the cause of deficiency, it can be administered in doses of 1 to 25 mg PO, IM, SQ, or IV routes www.uptodate.com Vitamin K, gamma carboxyglutamic acid, and the function of coagulation. Bruce Furie, MD, et al

  28. PROBLEM #6: HYPOXIA & METABOLIC ACIDOSIS • MVM 0.5 • NaHCO3 drip

  29. BICARBONATE TX • Not recommended to improve hemodynamics or decreasing vasopressor requirements in patients w/ hypoperfusion-induced lactic acidosis with ph ≥ 7.15 (1B) • its effect for ph < 7.15 is unknown Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008

  30. LACTIC ACIDOSIS IN SEPSIS • plasma lactate conc: > 4 - 5 meq/l • due to marked tissue hypoperfusion in shock (e.g. sepsis, hypovolemia, cardiac failure) • prognosis is poor unless tissue perfusion can be readily restored www.uptodate.com Causes of Lactic Acidosis. Burton D Rose, MD, et al

  31. COURSE IN THE WARDS • 15:30 • BP 50 palpatory • dobutamine drip • 16:00 • gasping • o2sat 90-92% MVM 50% • intubated • PULMONARY Referral (azithromycin 500 IV OD, Ipatropium Br, Acetylcysteine) • CBG monitoring q6 hrs

  32. PROBLEM #7: ACUTE RESPIRATORY FAILURE • CXR post Intubation

  33. mechanical ventilation of sepsis-induced ALI/ARDS • target: Vt 6ml/kg (1B) • plateau pressure: upper limit: ≤ 30 cm H2O (1C) • allow permissive hypercapnea (1C) • PEEP > 5 cm H2O is usually required to avoid lung collapse (1C) • Head elevation (1B) • NIV: if w/ mild-mod hypoxia, stable hemodynamics, able to protect/clear airways (2B) • weaning (1A) • pulm. artery catheter: NOT recommended (1A) • conservative fluid strategy if w/o evidence of hypoperfusion (1C) Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008

  34. GLUCOSE CONTROL • IV insulin tx (1B) • for severe sepsis w/ hyperglycemia & admitted in the icu • use a validated protocol for insulin dose adjustments (2C) • target glucose levels: < 150 mg/dl (2C) Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008

  35. Course in The Wards • 19:30 • BP 80/60, HR 160’s sinus • O2sat 96% at FIO2 80 • still with metabolic acidosis • CVP 3-4 • restless, follows commands • Referral to Anesthesiology for sedation (not done) • 1 dose of Vancomycin 1g IV

  36. sedation, analgesia & NM blockade in sepsis • use sedation protocols in critically ill ventilated pxs to reduce duration of mech. vent. & icu stay (1B) • intermittent bolus sedation or continuous infusion sedation w/ daily interruptions (1B) • NM blocking agents: should be avoided, if possible (1B) • reduces tissue utilization of O2 thereby decreasing formation of lactic acid Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008

  37. other tests done • Glu: 71.89 mg/dL • HbA1C: 6.5% • SGOT: 142 U/L (15-37) • TB: 2.8 mg/dL(0-1) • TP: 5.2 g/dL(6.4-8.2) • alb: 2.8 g/dL (3.4-5) • UA: 6.83 mg/dL (2.6-6) • HDL: 30.5 (40-60) • LDL: 102.14 (0-100) • repeat ecg: sinus tachycardia • 2DE: IVSH w/ NLVWMC. EF 76% • abdominopelvic USG: consider liver parenchymal disease. Thick gallbladder wall, non specific in etiology. Normal biliary tree, spleen and kidneys

  38. COURSE IN THE WARDS

  39. course in the wards

  40. COURSE IN THE WARDS

  41. Course in the wards • 19:30 • Anuric: HD not done (unstable hemodynamics; coagulopathy)

  42. Renal Replacement Therapy • continuous RRT & intermittent HD is suggested in severe sepsis and ARF (2b) • use of cont. rrt is suggested to facilitate management of fluid balance in hemodynamically unstable septic pxs (2b) Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008

  43. course in the wards • 27:00 • transferred to icu • BP 60 palpatory • Epinephrine drip started • CP arrest 20 min CPR • GCS 3, BP 40 palpatory (Quadruple vasopressors) • 31:00 DNR signed

  44. consideration for limitation of support • advance care planning including communication of likely outcomes & realistic good treatments should be discussed with patients and families (1D) Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008

  45. course in the wards • 40:00 • patient expired • autopsy done

  46. Preliminary autopsy report • Immediate cause of death: disseminated intravascular coagulation, 2° to septicemia • contributory cause of death: • hemorrhage, adrenals, lungs and pericardium • acute respiratory distress syndrome • acute bacterial meningitis • extensive tubular necrosis, bilateral kidneys

  47. preliminary autopsy report • non contributory cause of death: • hypertrophy of the heart, predominantly left ventricle • atherosclerosis of the aorta with calcification • micro and macrosteatosis, liver

  48. disseminated intravascular coagulation • consumption coagulopathy & defibrination syndrome • systemic process producing both thrombosis and hemorrhage • a complication of an underlying illness occurring in ~1% of hospital admissions

  49. dic: etiology • sepsis (40%) • trauma & tissue destruction • malignancy • ob complications

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