1. K Y L E C R I S C O
I P P E - I I I I N P A T I E N T R O T A T I O N
P R E C E P T O R : D R . W O O D S
Case Presentation

2. Sepsis
 SIRS (Systemic Inflammatory Response Syndrome)
 Temperature
38°C or 36°C
 HR 90 beats/min
 Respirations 20/min
 WBC 12,000/mL or 4,000/mL or >10% immature neutrophils
 Sepsis
 ≥2 SIRS criteria + active infection
 Severe sepsis
 Sepsis + organ dysfunction (cardiovascular, CNS, hemostasis,
hepatic, renal, respiratory, or unexplained metabolic acidosis)
 Septic shock
 Sepsis + refractory hypotension
Bone RC, et al. Chest 1992;101:1644
Opal SM, et al. Crit Care Med
2000;28:S81

3. Sepsis
 Most common pathogens
 In order of decreasing occurrence
 Gram (+)
 Staphylococcus aureus, Staphylococcus epidermidis,
Streptococcus pneumoniae
 Gram (-)
 E. coli, Pseudomonas, Enterobacter, Serratia, Proteus,
Citrobacter
 Mixed
 Fungi
 Candida

4. Signs/Symptoms
 Hyperventilation
 Hypothermia
 Tachycardia
 Tachypnea
 Lesions
 Erythema
 Altered mental status
 Pyrexia
 Leukocytosis
 Blood cultures (+)

5. Complications
 Acute Respiratory Distress Syndrome (ARDS)
 Disseminated Intravascular Coagulation (DIC)
 Adrenal insufficiency

6. Treatment
 Resuscitation
 Antibiotics
 Broad spectrum
 Identify source
 Correcting hypotension
 Vasopressors
 Norepinephrine
 Vasopressin
 Dopamine
 Dobutamine
 Epinepherine
 Phenylepherine
 Corticosteroids
 Hydrocortisone
 Prednisone
 Methylprednisolone
 Dexamethasone
 Fludrocortisone

7. Supportive Care
 Mechanical ventilation
 Fluids/nutrition
 Glycemic control
 Electrolyte corrections
 Pain management
 Sedation
 Stress ulcer prophylaxis
 VTE prophylaxis

8. Subjective

9. Overview
 KA – 37 y/o Caucasian male
 CC/HPI
 KA arrived at the ED on 10/21 with fever, dyspnea, and
tachycardia. Possible preliminary diagnoses included
respiratory failure and sepsis so patient was started on broad
spectrum antibiotics. KA is mentally handicapped secondary to
cerebral palsy and resides at the Brian Center. On 10/25, KA
experienced intermittent brownish, orange emesis. Originally
this was suspected to be related to a malfunction of his G-tube,
however after replacing the G-tube and then problem
continued KA was transitioned to a J-tube on 10/31 and the
feed rate was slowed. Still, emesis continued, until the J-tube
was replaced on 11/2 and the problem ceased.

10.  SH – lives at Brian Center
 FH – sister is his medical decision maker
 NKA
 Other pertinent information
 Multiple admissions for aspiration pneumonia
 Recurrent UTIs requiring hospitalization
 Bilateral hip pinning to repair hip fracture
 On Oct 3rd, patient received treatment for sepsis

11. Home Medications
 PMH
 Cerebral palsy
 Seizures
 Spasticity
 GERD
 Miscellaneous
 Medications
 bethanechol 25 mg PO Q6H
 bromocriptine 2.5 mg PO BID
 clorazepate 3.75 mg PO TID PRN
 Levetiracetam 500 mg PO BID
 lamotrigine 100 mg PO QHS
 baclofen 20 mg PO TID
 lansoprazole 30 mg PO QD
 bisacodyl 10 mg PR QD
 calcium carbonate 1250 mg PO BID
 docusate 100 mg PO BID
 lorazepam 2 mg PO TID PRN (HR>120
BPM and diaphoresis)
 ondansetron 4 mg PO Q6-8H PRN N/V

12. Objective

13. Vitals
 Ht = 142.24 cm (56 inch)
 Wt = 47 kg (103.4 lbs)
 Pain – at most 4, but difficult to assess throughout given mental
disability
21-Oct 22-Oct 23-Oct 24-Oct 25-Oct 26-Oct 27-Oct 28-Oct 29-Oct 30-Oct 31-Oct 1-Nov 2-Nov 3-Nov 4-Nov
Temp 99.5 99.3 100.4 99.1 98.5 98.4 98.8 97.8 99.0 99.2 97.6 98.0 98.5 98.2 98.5
BP 93/55102/65111/83115/79120/73 95/53103/56120/65108/54104/62 84/54102/59 95/60 93/59102/68
HR 93 107 121 117 110 105 120 106 87 100 65 61 80 66 73
RR 14 17 21 24 29 21 23 19 21 26 15 13 18 20 20
O2 Sat 100 100 99 98 98 94 94 96 94 95 93 96 93 96 95

14. Physical Exam
 WNL except
 Resp: rhonchi (+)
 Cardio: irregular heart rhythm
 GU: condom catheter and PEG tube in place
 Skin: abrasions on left knee and right toes
 Neuro: spasticity in LUE, RUE, LLE, and RLE, paralyzed
 Psych: mentally handicapped, does not respond or interact
 Extremities: contracted, wearing bilateral unna boots, L
peripheral IV

15. Urine Analysis
 amber, hazy appearance
 (-) for glucose and bacteria
 specific gravity = 1.028
 RBC>100
 pH = 8.5
 urobilinogen = 4.0
 leukocyte esterase = small
 WBC = 18
 mucus = many

16. CBC
21-
Oct 22-Oct 23-Oct 24-Oct 25-Oct 26-Oct 27-Oct 28-Oct 29-Oct 30-Oct 31-Oct 1-Nov 2-Nov 3-Nov 4-Nov
WBC 11.2 8.1 7.1 9.0 4.6 6.3 6.4 7.0 5.9 6.0 4.7 3.8 4.1 3.2 3.8
neut 81 72 73 66 69 70 61 51 48 53 52
lymph 7 18 16 20 18 19 30 34 38 33 35
mono 11 7 10 13 11 10 8 12 10 10 6
eosino 0 3 1 1 1 1 1 3 4 4 6
baso 1 0 0 0 1 0 0 0 0 0 0
Hgb 13.2 8.2 8.0 9.4 9.2 11.2 9.9 8.4 8.4 9.2 8.5 8.3 9.8 10.1 9.6
Hct 41 26 25 29 28 35 31 26 26 28 27 26 31 31 30
Platlets 327 183 157 182 187 242 226 253 253 300 273 270 247 314 364
MCV
RBC 4.58 2.85 2.81 3.26 3.17 3.93 3.48 2.93 2.96 3.20 2.94 2.88 3.44 3.53 3.41
RDW 16.9 16.7 17.0 17.0 17.3 17.5 17.2 17.2 17.0 17.3 17.6 17.1 16.4 17.1 16.7

17. CMP
21-
Oct
22-
Oct
23-
Oct
24-
Oct
25-
Oct
26-
Oct
27-
Oct
28-
Oct
29-
Oct
30-
Oct
31-
Oct
1-
Nov
2-
Nov
3-
Nov
4-
Nov
Na 152 151 138 135 138 136 143 141 144 139 139 141 137 139 139
K 5.1 2.9 3.8 3.8 3.3 4.9 3.6 3.6 3.7 3.4 4.4 3.7 3.6 3.1 4.6
Cl 111 120 109 101 106 102 111 112 112 104 102 102 101 105 105
CO2 13 24 25 27 26 22 21 19 23 28 28 29 27 29 25
Glucose 107 93 93 99 87 87 91 76 96 98 87 88 77 119 106
BUN 24 15 3 5 3 4 7 6 3 2 3 3 3 4 8
SCr 0.75 0.52 0.33 0.38 0.37 0.51 0.59 0.90 0.78 0.7 0.68 0.66 0.66 0.58 0.58
Ca 9.9 6.9 8.1 8.2 8.7 9.8 9.2 8.7 8.7 9.3 8.8 8.7 8.5 8.7 8.5
Albumin 2.5
Ca
(corrected)

18. Diagnostics
 CT
 Left kidney: 1 cm stone in collecting system, no obstruction
 Bladder: calcification
 Bony structures: severe left convex thorocolumnbar scoliosis; chronic
degenerative changes at hips; internal bilateral fixation of promixal femora
 Lungs: consolidation at right lung base; peribronchial thickening
 EKG
 Lead II: sinus arrhythmias
 PR = 0.12 sec
 QRS = 0.08 sec
 tachycardic
 CXR
 Elevated right hemidiaphram; left-sided venous catheter terminates in SVC
 Heart appears mildly enlarged

19. Cultures
Date Site Result
10/23/13 Resp MRSA (+)
10/23/13 Urine (-)
10/23/13 Blood (-)
*MRSA strand was susceptible to rifampin, TMP/SMX, and
vancomycin

20. Assessment and Plan

21. Sepsis
 Sepsis was likely a result of aspiration pneumonia
 HCAP (healthcare-associated pneumonia)
 Patient was hospitalized <90 days earlier
 Patient resides in a long-term care facility
 Complicated by residual build up from the enteral feeds
 Emesis prolonged patient’s stay in the hospital
 Patient no longer needed vancomycin after treatment for 5 days,
afebrile for 48-72 hrs, and no more signs of clinical instability
 WBC stabilized
 Afebrile
 baseline HR, BP, RR

22. Empiric Antibiotics
 Anti-pseudomonal beta-lactam
 pip/tazo 3.375 gm IV – STAT
 Additional anti-pseudomonal agent
 ciprofloxacin 400 mg IV STAT
 gentamicin 310 mg IV Q24H
 meropenem 1 gm IV Q8H
 Anti-staphylococcus agent for MRSA
 vancomycin 1 gm IV – STAT

23. Day 1 Medications
 acetaminophen 650 mg PR QD - STAT
 bethanechol 25 mg PO TID
 bromocriptine 2.5 mg PO BID
 heparin 5000 units SUBQ Q8H
 lamotrigine 100 mg PO QHS
 levetiracetam 500 mg Q12H
 lorazepam 2 mg PO TID PRN
 midazolam 10 mg IV push – STAT
 propofol 10 mcg/kg/min

24. Active Medications (Scheduled)
 albuterol 0.083% 2.5mg/3mL INH BID
 10/24-11/4
 albuterol 90 mcg/inh 8 puffs Q4H
 10/22, 10/23
 baclofen 5 mg PO TID
 10/22, 10/23
 baclofen 20 mg PO TIDAC
 10/23-11/4
 calcium carbonate 1250 mg PO BID
 10/21-11/4
 lansoprazole 30 mg PO QD
 10/21-10/23, 11/1
 magnesium sulfate IV
 1 gm (11/1)
 2 gm (10/22-10/25, 10/28-10/29, 10/31)
 metoclopramide 5 mg IV push Q6H
 10/25-10/29
 pantoprazole 40 mg PO QD
 11/1-11/3
 polyethlyene glycol 17 gm BID
 10/27-10/30
 KCl 40 mEq PO BID
 10/22-10/25, 10/28, 10/29-10/31
 scopolamine 1.5 gm transdermal patch
q72
 10/26 – 11/1
 vancomycin 750 mg IV
 Q12H (10/22)
 Q8H (10/23-10/28)

25. Active Medications (PRN)
 acetaminophen 650 mg PO Q4H
 10/22 – once
 bacitracin topical 500 units/g
 10/25
 furosemide 20 mg IV
 10/24
 furosemide 40 mg IV push
 10/23, 10/25
 lorazepam 2 mg PO TID
 10/22 – once
 metoclopramide 5 mg IV push
Q6H
 10/24 – once
 10/25 – once
 ondansetron 4 mg IV push Q6H
 10/26 – once
 10/30 – once
 11/1 – once
 promethazine 12.5 mg PR Q4H
 10/30 – once
 norepinephrine 4 mcg/min
 10/22
 propofol 10 mcg/kg/min
 10/22

26. Meropenem
 Monitoring
 SCr, LFTs, CBC, anaphylactic reactions
 AEs
 Increased seizure risk, CNS effects
 CrCL
 At lowest was 74 mL/min
 Ranged from 74 – 115+ mL/min

27. Gentamicin
 Monitoring
 SCr, BUN, urine output, peak concentrations
 Peak concentrations of 4-6 mcg/mL
 Draw after 3-5 half-lives or after 3rd dose
 Must reach steady-state
 Concentration-dependent killing
 AEs
 Ototoxicity, nephrotoxicity, neuromuscular blockade
 Poor infusion into the lungs

28. Vancomycin
 Monitoring
 SCr, UA, WBC, trough concentrations
 Trough concentrations of 15-20 mcg/mL
 Draw after 3-5 half-lives or after 3rd dose
 Must reach steady-state
 Time-dependent killing
 AEs
 Ototoxicity, nephrotoxicity
 Redman Syndrome – histamine-mediated reaction
 Correct by slowing infusion rate or antihistamines prior to
infusion

29. Adverse Effects
 Drugs with cholinergic effects
 Increased likelihood of causing N/V and/or emesis
 bethanechol
 levetiracetam
 lamotrigine
 Other AEs for scheduled medications AEs
 HA, drowsiness, insomnia, hypotension, fatigue

30. Discharge Medications
 PMH
 Cerebral palsy
 Seizures
 Spasticity
 GERD
 Miscellaneous
 Medications
 bethanechol 25 mg PO Q6H
 bromocriptine 2.5 mg PO BID
 clorazepate 3.75 mg PO TID PRN
 levetiracetam 500 mg PO BID
 lamotrigine 100 mg PO QHS
 baclofen 20 mg PO TID
 lansoprazole 20 mg PO QD
 bisacodyl 10 mg PR QD
 calcium carbonate 1250 mg PO BID
 docusate 100 mg PO BID
 lorazepam 2 mg PO TID PRN (HR>120 BPM and
diaphoresis)
 ondansetron 4 mg PO Q6-8H PRN N/V
 albuterol 2.5mg/3mL (0.083%) inh BID
 scopolamine ER patch 1.5 mg transdermal Q72H

31. Counseling
 Patient transferred back to Brian Center
 Barrier to communication with patient due to mental
disability
 Timely administration of drug is necessary
 Patient should be monitored often for any seizure
activity and further emesis
 Based on labs, may be beneficial for patient to be
taking an iron supplement daily
 More iron studies and blood testing is recommended

32. References
 Bone RC, et al. Chest 1992;101:1644
 Opal SM, et al. Crit Care Med 2000;28:S81
 Dellinger RP., et al. International guidelines for
management of severe sepsis and septic shock.
Critical Care Medicine 2013 Feb; 41(2):588-93
 Lexi-comp
 Micromedex