sepsis is the leading cause of death in intensive care units Emergence of multi drug resistance micro organisms should be suspiciously considered early in critically ill patients .

1. A Case Based Approach
to the treatment of
sepsis in critical situations
Mansoor Masjedi MD
Associate prof. , Critical care consultant
Shiraz University of Medical Sciences
Shiraz - Iran
Oct 24th 2019

2. Case presentation
The patient is an 56 y/o male with past medical hx.
duodenal ulcer
He had a car accident 4 months ago which caused a
right mid femoral fracture . He needed internal fixation
with pin and plates. Ten days after operation he was
discharged.
2 mo PTA had fever , pain, redness & hotness in the
operation area. MRI : suspicious of osteomyelitis. He
was treated with IV clindamycin for ten days, and was
discharged on PO clinda. to complete 4 wks of Rx.
ESR on admission:60 & at discharge :50.
He stopped taking his antibiotic after 4 wks.
He presented one month after stopping antibiotics with
two days of fever, fatigue and confusion to the hospital.
In ED he was found to be lethargic.
A Case Based Approach
to the treatment of
sepsis in critical situations

3. Differential diagnosis ?
◦Heart problem
◦GI bleeding
◦Meningitis
◦Neuromuscular disease
◦Sepsis
◦Psychological manifestation
◦Malignancy
◦…..

4. In ED he was found to be lethargic.
Vital signs ; BP :85/50 , PR :130 , RR :35 , T:39°c
Lungs: clear
Heart : tachycardic 125/min
Abdomen: soft , no organomegaly
Ext : cold and clammy
There was redness, warmth & edema around the site of
prior surgery in Rt thigh
N/E: no signs of meningitis, lethargic
A Case Based Approach
to the treatment of
sepsis in critical situations

5. Now ;
What is the most probable diagnosis ?
Is he in shock state , which kind ?
◦ Warm shock (Hyperdynamic )
◦ Cold shock (hypodynamic)

6. On arrival to ER with symptoms of sepsis syndrome ,
the ED physician examined the pt.
His attempt to place a CVC failed & he then placed two 16 gage
needles. 2 liters of N/S was given to him in one hr.
He ordered two sets of blood cultures, CBC, lactate, U/A & U/C....
WBC =16000 , poly.75%
He ordered IV vancomycin & imepenem
One hr later repeat BP showed drop to 60/45 mmHg,
pt was started on oxygen partial rebreather for tachypnia &↓Spo2
He was transferred to ICU , 2hrs later
A Case Based Approach
to the treatment of
sepsis in critical situations

7. • What are the management faults in this case at first three hours?
• What is the role of serum lactate in the work up of septic shock?
• Is colloid solution beneficial in the treatment of septic shock?

8. A Foley catheter was placed in the ICU.
The nurse noted that antibiotics
were not given in the ED and
she prescribed them in ICU.
He remained hypotensive (MAP =58 ) &
was started on IV drips of norepinephrine.
This time a CVC was placed.
Because of tachypnea, hypoxemia and change in mental status
he was intubated and was started on mechanical ventilation.
Lungs : bilat. basilar crackles
Vasopressin was added to norepinephrine and pressers were
titrated up.
His CVC was 13 mmHg
He was transferred to ICU , 2hrs later

9. • When is admission to an ICU indicated in septic shock?
• When intubation and mechanical ventilation should be consider in
septic shock?
• How is dopamine used in the treatment of septic shock?

10. In the next 48 hrs his clinical presentation deteriorated.
He became oliguric with ↑cr.
He developed transaminitis
↓plt count with coagulopathy
Plt. 40000,Hb=8 , PT=18
plts and FFP were transfused
ECHO showed decreased contractibility
Chest X Ray showed bilat. Infiltration
Blood cultures were positive for acinetobacter . Colistin was added to
his med & vancomycin was discounted
Because of oliguria & acidosis pt was started on CRRT

11. • Echocardiogram in septic shock
• 1. Fluid therapy
• 2. Myocardial dysfunction
• 3. Response to therapy
• How are Anemia and Coagulopathy corrected in septic shock?

12. At this point the decision made to urgently
take her to OR in attempt to remove the foreign body,
however
patient could not tolerate the surgery &
had cardiac arrest & was expired despite CPR
A Case Based Approach to the treatment of sepsis in critical situations

14. Timing , Appropriateness & Duration
of Antibiotic therapy
is crucial in sepsis management
&
To Save Lives