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Sepsis and SIRS

By Jill Freeman,2014-05-09 22:23
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Sepsis and SIRS

    Sepsis and SIRS

    Practice Cases Key

Case 1

    An 82 year old nursing home resident is brought to the ER by ambulance for an intermittent fever that has lasted about 36 hours. She is currently complaining of some chills and a sensation of thirst. Her past medical history is significant for diabetes, hypertension, and COPD. Her vitals on exam: T=38.6, HR=95, BP=128/65, RR=16, O sat=94% on RA. She is 2

    mildly diaphoretic, but the remainder of her exam is otherwise normal.

1. How would you classify this woman’s physiologic state at this time (i.e. SIRS, sepsis,

    severe SIRS, severe sepsis, septic shock, or none of the above)?

    Based on her elevated temperature and elevated HR, she qualifies for SIRS. More data is needed before stating something more specific.

2. What risk factors does she have for SIRS?

    Old age, diabetes.

3. What studies should be ordered at this time?

    CBC, chem 7, UA, urine and blood cultures, and CXR are all clearly indicated. A strong argument can also be made for LFTs and INR/PTT.

    4. While you are waiting for the results of these studies, should any treatment be started? If so, what?

    Her BP appears good, but given that she is experiencing SIRS, she most likely has some degree of peripheral vasodilation and could benefit from some IVF, preferably something like 500-1000cc normal saline. Although an argument could be made to give antibiotics at this time, it is probably best to wait until additional evidence of infection (i.e. elevated WBC, infiltrate on CXR, positive UA, etc…)

    5. The studies that were ordered on question 3 are now back. Her WBC=15,000 (90% neutrophils), Hct=40%, and her chem. 7, LFTs, and CXR are all normal. A UA is remarkable for 50 WBC/HPF, 3+ leukocyte esterase, and +nitrates. How would you classify her physiologic state now?

    Given that she has evidence of infection, she qualifies for sepsis.

6. What additional treatment(s) should be begun at this time?

    In addition to continuing fluids, antibiotics should be started at this time. Ciprofloxacin, ampicillin+gentamicin, ceftriaxone, and zosyn are all acceptable choices. There is no obvious need for additional modalities of treatment at this time.

Case 2

    A 45 year old homeless IV drug user is brought to the ER by a friend because “he looked really sick today and wasn’t making any sense”. He has had recent admissions to the

    hospital for alcohol withdrawal, and is known to have early cirrhosis without a history of encephalopathy. His vitals on presentation: T=39.5, HR=137, BP=114/40, RR=18, O 2

    sat=96% on RA. On exam, he appears both acutely and chronically ill, and is lethargic and only oriented to self. He has crackles at the right lung base, a 2/6 systolic murmur at the right upper sternal border. His abdomen is benign, however he has a severe cellulitis with underlying fluctuance beneath his right forearm.

    1. How would you classify this man’s physiologic state at this time (i.e. SIRS, sepsis, severe SIRS, severe sepsis, septic shock, or none of the above)?

    Based on her elevated temperature and elevated HR, she qualifies for SIRS. He also has an obvious source of infection on his arm, qualifying him for sepsis. In addition, due to his altered mental status, he also qualifies for severe sepsis.

2. What risk factors does he have for SIRS?

    Male, alcoholism, cirrhosis, malnutrition

3. What studies should be ordered at this time?

    As with almost all patients presenting with fever, CBC, chem 7, UA, urine and blood cultures, and CXR are all clearly indicated. A strong argument can also be made for LFTs and INR/PTT. In addition, given the risk of endocarditis (heart murmurs in an IV drug user), an echocardiogram should be performed (looking for valve vegetations), as well as an EKG (looking for conduction abnormalities). Given that he is a substance abuser and is currently confused, a urine toxicology screen and blood alcohol level are also appropriate.

    4. While you are waiting for the results of these studies, should any treatment be started? If so, what?

    As with the patient in question 1, despite the BP appears good, he is also likely experiencing some degree of peripheral vasodilation and is able to maintain adequate BP only through a high cardiac output. Thus, he could benefit from some normal saline, even though he is cirrhotic (predisposing him to fluid overload), and is potentially predisposed to developing heart failure (given his probable valvular lesions). Unlike the patient in question 1, as the exam alone makes it appear clear that a severe infection is present, antibiotics could be started immediately once cultures are drawn. (In some patients with suspected endocarditis, it may be beneficial to delay antibiotics until serial blood cultures can be drawn, but given this patient’s degree of illness, it is probably best to start antibiotics now). Given that he is an IV

    drug user, and has a cutaneous source of infection, vancomycin plus zosyn is probably the best antibiotic combination. Since his BP is currently adequate, there is no need for pressors at this time, however intubation could be considered if his mental status appeared to compromise his airway.

    5. Some of the studies that were ordered on question 3 are now back. His WBC=23,000 (95% neutrophils), Hct=32%, creatinine=1.7, AST=94, ALT=56, total bilirubin=2.4, and INR=1.6. CXR and UA are normal. An EKG shows sinus tachycardia with no conduction problems. What therapeutic steps should be taken at this time?

    Given the apparent severity of his cutaneous infection, a surgical consultation is warranted for incision and drainage, and possibly a more extensive debridement as necessary.

Case 3

    As the on-call intern, you are called to attend to a cross-cover patient on a non-monitored bed a 56 year old alcoholic admitted yesterday for alcoholic pancreatitis. Upon admission, he was placed on D5 ?NS at 125cc/hr, made NPO, and given morphine prn for pain control. During sign-out, you were told he had “mild pancreatitis” and that there “is nothing to do”. However, when the nursing assistant went in to take his vitals, she found him to be in mild to moderate respiratory distress and “looking bad”. His vitals at this time: T=36.5, HR=140, BP=125/50, RR=34, O sat=85% on 4L. Upon exam, he is tremulous, but alert and oriented. 2

    His lungs have diffuse crackles bilaterally. His abdomen is moderately tender in the epigastric region, but without peritoneal signs. The patient is currently complaining of shortness of breath and states that he feels “terrible”.

1. How would you classify this man’s physiologic state at this time?

    Based on his elevated HR and RR, he qualifies for SIRS. Given the above information, there is no clear evidence of infection at this time. Although O sat is not strictly part of the 2

    definition of severe SIRS, he would almost certainly qualify once an ABG is checked.

    2. What is one potential mistake made by the admitting team in their treatment strategy? For a patient with true pancreatitis, 125cc of D5 ?NS was probably not adequate fluid resuscitation, though this error is probably unrelated to the development of respiratory distress.

    3. What should be the first step taken (either diagnostic or therapeutic)? Additional help should be called (i.e. the on-call resident +/- ICU fellow).

4. Why might this patient have developed respiratory distress?

    There are several possibilities including aspiration, nosocomial pneumonia, pleural effusion, myocardial infarction, and an arrhythmia, however the available information would suggest that the patient may be developing ARDS, a common complication of pancreatitis.

5. What studies should be ordered at this time?

    CBC, chem. 7, cardiac enzymes, CXR, ABG, and EKG. LFTs, INR/PTT, blood and urine cultures could also be considered. Although the patient was admitted with pancreatitis, there is probably little utility in rechecking lipase or amylase.

Case 4

    A 67 year old man with metastatic colon cancer is brought to the ER by his wife because he developed a “high fever” and was “just not looking very well” for the past day. She became stuck in traffic on the way to the hospital, and during the 60 minute trip he has become confused and “sweaty”. His vitals upon arrival: T=40.5, HR=135, BP=76/30, RR=34, O 2

    sat=84% on RA. On exam, he appears cachectic and acutely ill. He is lethargic and is mumbling incoherently. His lung exam is significant for moderate bilateral crackles. Cardiac exam is significant only for a regular tachycardia. His abdomen appears mildly tender diffusely, but without peritoneal signs. The remainder of the exam is unremarkable.

    1. How would you classify this man’s physiologic state at this time (i.e. SIRS, sepsis, severe SIRS, severe sepsis, septic shock, or none of the above)?

    He has severe SIRS, as well as shock, most likely distributive shock. He doesn’t strictly meet criteria for septic shock, as there is not direct evidence of infection at this time.

2. What risk factors does she have for SIRS?

    Male, malignancy

3. What studies should be ordered at this time?

    As with almost all patients presenting with fever, CBC, chem 7, UA, urine and blood cultures, and CXR are all clearly indicated. Given his tachypnea and hypoxia, an ABG is also warranted. LFTs should be ordered due to the abdominal tenderness, and amylase and lipase could also be considered. Given the severity of illness INR/PTT should be checked (combined with the platelet count, serves as a rough screening tool for DIC), as well as a lactate level. If the patient can be stabilized enough for the procedure, an abdominal CT should also be performed to look for possible sites of infection.

    4. While you are waiting for the results of these studies, should any treatment be started? If so, what?

    I. For a patient who is probably in septic shock, aggressive IVF are absolutely essential.

    This patient should receive an immediate normal saline bolus in the neighborhood of

    2L, with frequent boluses as needed thereafter to keep his CVP 8-10mmHg.

    II. Unless he has a great response to the fluid bolus, a vasopressor should be started as

    well norepinepherine or phenylepherine are probably the best agents.

    III. Regardless of whether he needs pressors, a central venous line should be placed to

    monitor CVP. An arterial line should be placed as well for continuous BP

    measurement, as well as easy access for serial ABG measurements.

    IV. As he is experiencing respiratory compromise, he should receive supplemental oxygen

    with strong consideration given to mechanical ventilation.

    V. Even without direct evidence of infection at this time, given his critical state, antibiotics

    should be started at this time. As there is no obvious source, antibiotic choice should

    be extremely broad. Zosyn plus either vancomycin (if there was concern over soft

    tissue source of infection) or metronidazole (if there was concern over an abdominal

    source of infection) could be considered. Imipenem +/- vancomycin is also a good

    alternative.

5. Some of the studies that were ordered on question 3 are now back. His WBC=14,000 -(90% neutrophils), Hct=28%, platelets=85,000, HCO=12, creatinine=2.3, AST=42, ALT=46, 3

    total bilirubin=3.1, and INR=1.8. CXR shows multiple nodules bilaterally, consistent with metastatic disease, as well as bilateral pulmonary edema. ABG (on room air): pH=7.16, PCO=32, PO=45. Lactate is moderately elevated. An abdominal CT shows a large mass 22

    adjacent to the sigmoid colon and numerous hepatic metastases. After 2.5L of normal saline and moderate doses of phenylepherine, his BP=84/46, CVP=3mmHg, and he has produced no urine. What additional therapeutic steps should be taken at this time?

    This patient is experiencing all major manifestations of severe sepsis: altered mental status, hypotension, hypoxia, metabolic acidosis, renal failure, hyperbilirubinemia, and coagulopathy. He is experiencing failure of 4 organ systems (with each failure leading to a ~15-20% increase in mortality during this hospitalization). Given his critical condition, and poor long-term prognosis due to metastatic cancer, the most appropriate next step may be a goals-of-care discussion with his family, if at all possible. If his family elects to proceed with full care (or is currently unavailable), his continued low BP and CVP indicates that he requires more fluid. Although the minimal improvement with phenylepherine may be due to the patient’s continued hypovolemia, a second pressor could be started at this time. Either norepherine or vasopressin are good choices. The combination of hypoxia, altered mental status, and severe acidosis necessitates intubation (if not already done). Although activated protein C has been shown to have the greatest benefit in the most critically ill, it may not be appropriate in this patient given his poor long-term prognosis.

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