Sepsis Case management discussed in monthly clinical meeting of hospital

1. Presented by: Lt Anana Mohamed
(Intern)
Discussed by: Col Bharat Malhotra
Senior Advisor (Medicine)

2. Patient Particulars
Male, Age: 68 years Date of Adm: Jan 2022
Occupation: Farmer
Post Traumatic T3-T4 Compression fracture
with Paraplegia
Underwent T3-T4 Posterior Stabilization and
decompression on 19/1/22.

3. Chief Complaints
Stable initially in Ortho Ward
Shifted to ICU on 02 Mar 22 with:
Cough - 8 days
Breathing difficulty - 2 days
Stridor - 1 day
Alter Sensorium – 1 day

4. History of Present Illness
COUGH
• Since 8 days
• Productive, Yellowish green
DYSNOEA
• Since 2 days
• Progressive  dyspnea at rest
• No PND
STRIDOR
ALTER
SENSORIUM
• Since 1 day
• Wheeze on inspiration, No cyanosis
• Developed Alter Sensorium

5. Stridor

6. No History of
• Fever
• Chest pain, Hemoptysis, Syncope
• Seizures
• Vomiting, Pain abdomen, Diarrhea
• Dysuria, Hematuria
• No Bed sores, No skin rash/ulcers, Arthralgia

7. CourseinHospital tillhispresent problem
Injury: 09 Jan 2022: Fell from a Bullock cart
Developed a low back ache  Progressed to an
inability to bear weight on his lower limbs
Post Traumatic T3-T4 Compression fracture with
Paraplegia
On 19 Jan 2022: Underwent T3-T4 Posterior
Stabilization and Decompression

8. CourseinHospital tillhispresent problem
On 02 Feb 2022 Odynophagia
ENT assessment: Right Vocal cord mobility
restricted with Cystic swelling on the posterior
pharyngeal wall.
Assessment by CXR, CECT Neck & Chest
Final Diagnosis: Retropharyngeal Retention Cyst
On 3 Feb 2022: Debulking of Cyst under GA

9. Pleural effusion
(Left)

10. 1) Heterogeneously enhancing collection in the retropharyngeal space
2) Pleural effusion (Left), with mediastinal adenopathy

11. Pleural Tapping - USG Guidance
Pleural fluid Cytology and biochemistry revealed:
An exudative, Hemorrhagic fluid
With lymphocyte predominance.
No growth in the GM and ZN stain
Normal ADA levels

12. Recurrent UTIs
USG KUB: Bladder wall thickening.
Managed with culture guided parenteral antibiotics
(Likely CAUTI)
• Inj Imipenem 12 days
Pseudomonas
Aeruginosa
• Inj Meropenem 7 days
Proteus Mirabilis
• Inj Magnex 7 days
Proteus Mirabilis

13. Persisting Odynophagia
Regular follow up by ENT spl
Advised  UGIE after Barium swallow – could
not be done due to high risk of aspiration (GE)
Nasogastric Support
Other Supportive care

14. PAST HISTORY : No prior comorbid illness
FAMILY HISTORY : NIL Relevant
PERSONAL HISTORY : Vegetarian
Smoker 30 yrs (½ to 1 pkt)

15. Summary
68 yr Male sustained Post Traumatic T3-T4 Compression fracture
with Paraplegia on 19/1/22 Underwent T3-T4 Posterior
Stabilization and decompression.
Developed Recurrent UTI  treated with multiple IV antibiotics
Developed Exudative Hemorrhagic Pleural Effusion
Developed Retropharyngeal Cyst – optd on Feb 2022
Persistent Odynophagia – GE consult – UGI high risk (Not done)
Developed on 28 Feb 22 he developed Cough, Dyspnea hence
shifted to ICU. He deteriorated on 02 Mar 22 with Stridor and
alter sensorium

16. GENERAL EXAM
DISORIENTED WITH ALTER SENSORIUM,
GCS E2V2M3 (7/15)
AFEBRILE
PULSE 162/MIN FEEBLE, BP 80/40 mmHg
Respiratory Rate: 40/min, SpO2 98% on 5L O2
Pallor present, No pedal edema, No cyanosis,
clubbing, L Nodes, No bed sores, No rash, ulcers

17. SYSTEMIC EXAM
UPPER RESPIRATORY TRACT & ORAL
Alae Nasi flaring
Mouth & Throat: Base of tongue bulky almost
touching posterior pharyngeal wall.
Sinus – Nontender, Ear No discharge

18. SYSTEMIC EXAM
Respiratory System
Using accessory muscle of respiration
Supraclavicular indrawing
Tracheal tug present, Trachea central
Percussion dull infrascapular area Lt
Crackles B/L axillary & infrascapular region
Inspiratory wheeze present

19. SYSTEMIC EXAM
Nervous system
Disoriented, GCS 7/15
Paraparesis bilateral lower limbs
Reflexes normal
Per Abdomen: No Hepatosplenomegaly
CVS: S1 S2 normal, No murmur

20. INVESTIGATIONS
Hb:11.0 g/dL  7.9 g/dL
PCV: 30 %
TLC: 23,100/ cumm
DLC: 79/15/5/1
Platelet Count:
6.75 Lakh/cumm
PT:13/20, INR:1.98
PTTK:30/34
Urea:17 mg/dL
Creatinine: 0.6 mg/dL
Na+: 131 mmol/L
K+: 4.8 mmol/L
Total bilirubin: 0.6 mg/dL
Total protien:7.9 mg/dL
Albumin:3.9 mg/dL
Globulin:4.0 mg/dL
AST: 25 IU/L
ALT: 21 IU/L
SUGAR (R) : 175 mg/dl

21. INVESTIGATIONS
ABG
PH: 7.12,
PCO2: 100.5,
PO2:110.2, HCO3-:33.5
Partially compensated
respiratory acidosis with
type 2 respiratory failure
FOL ( ENT REVIEW)
Bilateral Cord moving
equally and bulge base of
Tongue
Lactate Level 2.8 mmol/L
Tracheal Tip C/S:
Acinetobacter
Blood Culture - NAD
D-Dimer: 2431 ng/ml
Procalcitonin Levels
(4 d later) – 0.2 ng/ml
Cyst microscopy – Benign

22. ECG

23. CXR

24. DIAGNOSIS
Pneumonia Rt Lower Zone
with Severe sepsis
in type 2 respiratory failure
Prior– Inhospitalcaresince02monthsdue
toposttraumaticT3-T4Compression
fracturewithParaplegia(optd)

25. MANAGEMENT – INITIAL
Sepsis focus identified, Serum Lactate & ABG
Fluid Resuscitation (1500 ml N/S over 3 h)
Norepinephrine infusion IV(titrate to effect) (2d)
Airway protection  Mechanical Ventilation
Vasopressin infusion IV (few hrs)
Inj Hydrocortisone 50mg IV q6h x2d
Central Venous catheterization

26. MANAGEMENT - ANTIBIOTICS
Inj Meropenem IV TDS (10 d)
Inj Amikacin 750 mg IV OD (7d)
Inj Tecoplanin IV BD day1 and OD (7d)
Inj Caspofungin 50mg IV OD (7d)  THEREAFTER
Tab Fluconazole (7d)

27. MANAGEMENT - SUPPORTIVE
Maintenance of IV Fluid & electrolytes
Nutritional Support
2 PRBC transfused (Hb 7.9 g/dL)
Frequent Nebulization – Asthalin, Ipravent, Budecort
Chest physiotherapy
Mechanical DVT prophylaxis, Inj LMWH

28. COURSE IN HOSPITAL
Antibiotics, Antifungals, Nebulization
Nutrition & Supportive care
Mechanical Ventilation (3d)  Extubated
Intermittent BiPAP (PS 8 PEEP 5 FiO2 30%) in
view of CO2 retention (Target SpO2 92%)

29. COURSE IN HOSPITAL
Respiratory Consult @ MH K
COPD with type 2 failure and respiratory stridor
likely due to supraglottic cause
ENT @ MH K (12 Mar 22)
Persistent dysphonia
B/L vocal cord in paramedian position.
No abduction seen, 3 to 4 mm phonatory gap

30. Bilateral Adductor Nerve Palsy

31. Decrease in mediastinal LN compared with previous imaging.
No fresh findings.

32. DISCHARGE STATUS - DAMA
Patients NOK are unwilling to continue treatment
to further assess supraglottic cause of stridor.
Unwilling for tracheostomy (care of tube)
RT Feed and nutritional support explained
Skin and patient care explained
Tab Apixaban, Supportive care

34. Surviving Sepsis Guidelines

35. Define
Sepsis is
• life-threatening organ dysfunction
• secondary to dysregulated host response
• to infection
Septic shock is a
• subset of sepsis
• with circulatory and cellular/metabolic dysfunction
• associated with a higher risk of mortality

36. Initial Resucitation
Sepsis Tools : qSOFA, SIRS, SOFA, NEWS, MEWS
Serum Lactate Levels
Crystalloid Fluids: 30ml/kg over 3 h
Dynamic Measures, Capillary Filling time
Airway Management & Assisted ventilation

37. Vasoactive Agent

38. Antibiotics - Timings

39. Antibiotic – Which One?
 Age
 Nature of the clinical syndrome
 Properties of antimicrobials to penetrate at
pathology site
 Patient comorbidities
 Invasive devices
 Immune defects
 Prolonged hospital/chronic facility stay
 Prior hospitalization, colonization MDR
 Recent antimicrobial use
 Pathogens within the hospital
 Receipt of antimicrobials previous 03 m
 Resistant patterns
 IV Meropenem
 IV Imipenem
 IV Cefepime
 IV Ceftazidime
 IV Piperacillin/Tazobactam
 IV Ticarcillin/Clavilunate
 IV Ciprofloxacin
 IV Levofloxacin
 IV Amikacin
 IV Tobramycin
 IV Colistin
EmpiricalAntibiotics What?
PLU
S
Any
01
Any
01

40. Antibiotic – Which One?
 Prior history of MRSA
 Recent hospital admissions
 Severity of Illness
 Infection or colonization,
 Recent IV antibiotics
 Recurrent skin infections
 Chronic wounds,
 Invasive devices,
 Haemodialysis
 Vancomycin
 Teicoplanin
 Linezolid
PossibleMRSA What?

41. Empirical Antifungal
 Candida Colonization at Multiple
Sites
 Surrogate Markers – B D-Glucan
Assay
 Neutropenia
 Immunosuppression
 Severity of Illness (High APACHE
score)
 Longer ICU Length of Stay
 Central Venous Catheters
 Other Intravascular Devices
 Total Parenteral Nutrition
 Broad Spectrum Antibiotics
 Prior Surgery
 GI Perforations and Anastomotic
Leaks
 Emergency GI or Hepatobiliary
 IV Caspofungin
 IV Anidulafungin
 IV Micafungin
 IV Fluconazole
 IV Voriconazole
 IV Amphotericin
When? What?

42. Ventilator care
Insufficient evidence on conservative O2 target
High flow nasal O2  NIV  Mech Ventilation
In ARDS:
Low tidal vol Ventilation strategy (6ml/kg)
High PEEP
Upper limit peak plateau 30 mmHg H2O
Recruitment maneuvers (against incremental PEEP)

43. Supportive Care
Restrictive (over liberal) transfusion strategy
Stress ulcer prophylaxis
VTE prophylaxis: Mechanical /LMWH/ both
Insulin if blood sugar > 180 mg/dL
Early (within 72hr) initiation of enteral nutrition
AKI: continuous or intermittent RRT
Sodium bicarbonate therapy (if septic shock & pH < 7.2)