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Septic Shock and Antibiotic Therapy

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Hong Wu

on 3 October 2013

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Transcript of Septic Shock and Antibiotic Therapy

Severe Sepsis and Antibiotic Therapy
SSSM 03-10-13
Hong Wu

32yo M presents w fever, abdominal pain
SIRS with infective focus
Severe Sepsis
Sepsis-induced hypotension
Elevated Lactate
Urine output <0.5 mL/kg/hr for >2 hrs despite fluid resuscitation
Acute lung injury: PaO2/FIO2 <200 w pneumonia, or <250 w/o pneumonia
Creatinine > 176.8 micromol/L
Bilirubin >34.2 micromol/L
Platelet count <100
Coagulopathy (INR >1.5)
64yo F unwell for 2/52, fever and cough, found by neighbour this am with increasing drowsiness
Mr NM - into the cubicle
An unwell looking pale man
Rigid abdomen

Focused Hx:
Unwell for 5/7
Central umbilical pain, migrating to RIF on day 2
Nausea, vomiting, LOA
Minimal oral intake
Decr urine output

Nil regular
Mr NM - focused examination
Urine dipstick Ketone ++
Finerprick BSL 9.7
Pale, unwell looking, rigouring
HR 120 Regular BP 100/60 Temp 39.3 RR 26 Sats 98% RA
Dry mucus membranes
JVP not visible

Tender over RIF
Percussion+ Rebound+
Rovsing +
Smoker 15 pack-years
Occasional EtOH
Mr NM - initial Ix+ Mx
Vascular access
Bloods and blood cultures
Let the seniors know
Fluid resuscitation
Ceftriaxone + Metronidazole
89yo M sent in by GP
Temperature <36 °C or >38 °C
Heart rate >90bpm
Respiratory rate >20/min or PaCO2<32 mmHg
WBC <4x10^9/L, >12x10^9/L, or >10% bands
Mortality from Sepsis
Appears to be decreasing

Poor prognostic factors:
Old (>40yo)
Crumbly (immunosuppression, immunocompromised)
Inappropriate Abx use
Principles of Mx of severe sepsis
Early recognition
Early resuscitation
Early and adequate Abx
Identify and treat
Source control
Monitoring and support
Tissue oxygenation
HR 110 BP 90/60 Temp 38 RR 16
Sat76%RA 84%15L Hudson mask
Antimicrobial therapy
Empirical therapy
Unknown source of infection
Flucloxacillin + gentamicin
Known/suspected source of infection
Line: Fluclox/Vanc + gent
Chest: Ceftriaxone/benpen + gent + azithromycin*
Urine: Amox + gent
GI: Amox, gent + metro

Practical tips on MCS and directed antimicrobial therapy
Check previous MCS!!
Understand the relevant focal risk factors
community vs hospital acquired
de novo vs catheter related
natural vs prothetic
any potential exposure to resistant organisms?
"Thank you for seeing Mr BD, who is an 89yo gentleman. He presented to me with a history of increasing fatigue on exertion and lower limb oedema in last 1/52. However he was found to be in rapid AF with HR of 152 in clinic. He does not complain of palpitation or chest pain, and the
rest of his vitals are normal
. Your management of this man would be much appreciated."
COPD BPH Osteoarthritis Mild dementia Hypertension Hypercholesterolaemia Obesity
Urinary incontinence Osteoporosis
Mr BD, nil chest pain
Mr BD - Into the cubicle
Elderly man, SOOB, does not look too unwell
On examination
Central obesity +++
Cool peripheries
JVP 3+
Tachycardic, HSDNA
Lung fields clear
Abdo soft, non-tender
Peripheral oedema up to knee, pitting
FBE 151/18.5/365
UEC 142/3.5/101/33 Creatinine 102 eGFR 62 Urea 7.0
CMP 2.14/0.8/1.04

CXR Essentially normal
Urine MCS pending
2 hours later...
metoprolol 5mg IV

HR 80 BP 85/50 Patient drowsy
HR 160 Irreg irreg, BP 135/80, RR 20
Sat 92% RA Temp 36
"Fatigued" for 1/52, LL swelling, SOBOE,
No fevers, chills, cough, sputum,
urinary frequency/dysuria (uses incontinence pads)
1 day of diarrhoea 1/52 ago, nil further
A little more confused than usual
Urine dipstick: leuks+ RBC - nitrates -
BSL 4.3
Directed therapy
24 hrs later...
HR 120 BP 85/50 despite 3L +ve fluid balance Temp 35 Sat 94% 10L

FBE 137/18.8/300
UEC 138/4.8/101/33 Creatinine 151 eGFR 42 Urea 9.8
LFT ALP 400 GGT 548 AST 1232 ALT 1135 Bili 18
BC, Urine culture still pending

Bedside Echo: Normal LV systolic function. Right heart failure.
Ms YS - immediate Ax + Mx
Quick "primary" survey:
A: own
B: Lungs: crackles bilaterally, reduced air entry, L
C: JVP not visible, dry+++, HSDNA
D: moving 4 limbs, PEARL
E: Abdo: apparently soft
Skin: intact
High flow oxygen -> CPAP -> ETT
IV access, bloods + cultures -> Fluid resus
CXR, IDC -> Urine MCS
Art line -> ABG
Ms YS - time for some collaterals
COPD - no previous exaccerbations requiring hospital admission
Smoker - 70 pack-years

Widowed. Home alone, last seen 3/7 ago.
pH 7.20
PaO2 85
PaCO2 85!!
HCO 20
Hb 132
Lactate 1.8
K 5.1
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