A 73-year-old female presented to the emergency room by ambulance with abdominal pain, shortness of breath, weakness, and lightheadedness. She had a history of various medical conditions including colitis, hiatal hernia, lupus, myelodysplasia, osteoporosis, and stage 4 renal disease. Initial workup found sepsis secondary to a diverticulitis infection and autoimmune processes. She developed disseminated intravascular coagulation, heart damage, and hemolytic anemia from the sepsis. She underwent partial sigmoid colectomy surgery and received a colostomy bag. Blood and culture tests found Salmonella, E. coli, and VRE bacteria. She required multiple blood transf

1. Angela Thetford
MLT 2015
Professor Gill
December 14, 2015
CSM

2. Signs, Symptoms, History and Allergies
Length of Stay 9/16/15-10/18/15

3. Patient Information
 73 year old female presented to ER by Ambulance
○ Feeling light headed
○ Low abdominal pain
○ Pain scale 10
○ Short of breath
○ Weakness
 Initial Assessment
○ BP 119/47
○ Pulse 95
○ RR 16
○ SPO2 93

4. Patient History
 History
○ Colitis
○ Hiatal hernia
○ Lupus
○ Myodysplasia
○ Osteoporosis
○ Stage 4 Renal disease
 Allergies
○ Moxifloxacin
○ Neomycin

5. Sepsis secondary to diverticulitis & autoimmune processes
UTI secondary to diverticulitis and catheterization
Diabetes Mellitus

6. Possible Diagnosis
 Sepsis:
 DIC
 Heart damage
 Hemolytic anemia
 Hypoxia
 Resolution:
 Surgery-Partial Sigmoid Left Colectomy
 Colostomy Bag
 Diabetes Mellitus
 UTI

7. Diverticulitis

8. Abnormal results proving possible diagnosis
CBC, CMP, U/A, PT,PTT, D-Dimer, Troponin, CK-MB, ABG, Cultures

9.  CBC
 RBC
○ Sepsis with Hemolytic Anemia
 Acanthocytes
 Normocytic/Normochromic Anemia
 WBC
○ Sepsis
 Leukocytosis
 Increased Bands
 Decreased Lymphocytes
 Toxic Granulation
 Platelets
○ Sepsis associated DIC
 Thrombocytopenia
 Giant Platelets

10.  Coagulation
 Disseminated Intravascular Coagulation
○ Increased PT/PTT
○ Grossly Increased D-Dimer
○ Grossly Increased Fibrin Degradation Products
 Chemistry
 Hemolytic Anemia
○ Increased TBIL
 Heart Damage due to Sepsis
○ Increased AST
○ Increased CK-MB
○ Increased Troponin-T
 Diabetes Mellitus
○ Critically Increased Glucose

11.  Arterial Blood Gas
 Hypoxia Secondary to Sepsis
○ Increased Anion Gap
○ Decreased HCO3
○ Decreased pCO2
○ Base Excess <-3
 Urinalysis
 UTI secondary to Diverticulitis and Catheterization
○ Cloudy
○ WBC TNTC and clumps
○ Bacteria present
○ Protein
○ RBC

12.  Microbiology Cultures
 Diverticulitis Abcess Culture
○ Sepsis
 Salmonella Positive
 E.coli Positive
 VRE Enterococcus Positive
 Urine Culture
○ UTI secondary to Diverticulitis and Catheterization
 Salmonella Positive
 E.coli Positive
 VRE Enterococcus Positive
 Citrobacter Positive
 Stool Cultures
○ Sepsis
 Salmonella Positive

13. Patient had surgery to remove abscess

14. Possible Prognosis
 Prognosis poor due to renal failure, autoimmune
disease, possible heart damage and clot formation
 Surgical Partial Sigmoid Left Colectomy with
Colostomy Bag for treatment of abcess
 Follow up with proper diet
 Diabetes hard to control with renal failure
 Dialysis could prolong life
 She is a poor candidate for kidney transplant
 Increased risk of cancer due to Myelodysplastic
syndrome
 High mortality rate due to DIC secondary to sepsis

15. IV medications
Antibiotics, Autonomics, Blood Derivatives, Blood
Formation/Coagulation, Cardiovascular, CNS agents, Electrolytes,
Gastrointestinal, Hormones/Synthetic Substitutes

16. Antibiotics
 Ampicillin Sub lactam
Sodium
 Cefepime HCL
 Treat E.coli
 Treat Citrobacter
 Ceftriaxone Sodium
 Treat Salmonella
 Treat Kleb pneumonia
 Linezolid
 Treat VRE Enterococcus
 Meropenem
 Metronidazole/Sodium
 Micafungin Sodium
 Nystatin
 Vancomycin HCL

17.  Autonomic Drugs
 Norepinephrine
 Succinylcholine
 Blood Derivatives
 Albumin Human
 Blood Formation/Coag
 Darbepoetin Alfa
 TBO-Filgrastrim
 Cardiovascular
 Metoprolol Tartrate
 CNS Agents
 Acetaminophen
 Etomidate
 Fentanyl Citrate
 Lorazepam
 Oxycodone
 Electrolyte/Caloric
 Calcium Carbonate
 Sodium Chloride
 Sodium Polystyrene
 Gastrointestinal Drugs
 Aluminum Hydroxide
 Calcium Carbonate
 Famotidine
 Magnesium Oxide
 Ondansetron HCL
 Pantoprazole
 Hormones/Synthetic Sub.
 Hydrocortisone
 Insulin Aspart
 Insulin Determir
 Methylprednisolone
 Prednisone

18. Patient Specimens
 Blood Culture bottles-Blood Culture
 Sodium Citrate-Coagulation
 SST-CMP, Cardiac Profile
 Sodium Heparin-Arterial Blood Gas
 EDTA-CBC and Type and Screen
 Urine-Urinalysis and Urine culture
 Stool-Anaerobic/Aerobic Culture
 Abcess culture-Anaerobic/Aerobic culture

19. CBC with Differential
RBC, WBC and Platelet Clinical Implications

20. CBC RR *Sept 16
Sepsis Protocol
Sept 17 Sept 20 Oct 06
WBC 4.6-11.0 22.5 H 35.3 CH 30.2 CH 8.6
RBC 3.9-5.10 3.21 L 3.24 L 3.02 L 2.93 L
Hgb 12.0-15.5 9.7 L 9.8 L 9.2 L 9.0 L
Hct 35.0-46.0 31.3 L 31.8 L 28.8 L 26.8 L
MCV 82.0-97.4 97.6 H 98.3 H 95.2 91.2
MCHC 33.0-35.6 31.0 L 30.7 L 32.0 L 30.8
RDW 11.0-14.0 31.2 H 31.5 H 31.6 H 15.3
Platelets 160-400 137 L 87 L 133 L 40 L
Myelocyte 0 1
Metamyelocyte 0 1 1 2
Bands 0-6% 6 31 H 26 H 3
Neutrophils 40-75% 76 H 62 65 78 H
Lymphocytes 20-50% 7 L 2 L 3 L 11 L
Monocytes 2-9% 11 H 3 5 6
Polychromasia 0 1+ 1+
Baso Stippling 0 1+ 1+
Microcytes
Macrocytes
0
1+
1+ 1+ 1+
Schistocytes,
Tear Drop,
Ovalocyte
0 1+ 1+
Other 0 Giant Platelets Toxic Granules Giant Platelets Giant Platelets

21. RBC Clinical Implications
Hemolytic Anemia
 ↓↓ RBC-Erythropenia
 ↓Hgb and Hct-Anemia
 Acanthocytes-Hemolytic Anemia
 Basophilic stippling-Iron deficiency
 Schistocytes-DIC
 Tear Drop cells-Myelofibrosis
 Target cells-Anemia
 Normocytic/Normochromic-Hemolytic Anemia

22. WBC Clinical Implications
Sepsis
 ↑↑↑ WBC-Leukocytosis
 ↑ Neutrophils-Bacterial infection
 ↑↑Bands-Sepsis, shift to the left
 ↑Monocytes-Chronic inflammation
 ↓↓Lymphocytes-Sepsis
 Immature cells-Rapid cell turnover
 Toxic Granulation-Sepsis

23. Platelet Clinical Implications
DIC or Sepsis
 ↓↓Platelets-Thrombocytopenia
 Autoimmune (Lupus)
 DIC
 GI bleeding
 Sepsis

24. PT, INR, PTT, D-Dimer, FDP
Clinical Implications

25. COAG Sept 17 Sept 18 Oct 03
PT
0.0-17.0
sec
20.2 H 25.4 H 19.3 H
INR 1.8 2.3 1.7
PTT
0.0-35.0
sec
39.2 H 57.9 H 39.3 H
D Dimer
200-280
ng/ml
2653 H 679 H
FDP
<10
ug/ml
>40 <10
0
10
20
30
40
50
60
17-Sep 18-Sep
PT
PTT
Clinical Implications
Acute sepsis associated Disseminated Intravascular Coagulation
↑PT ↑↑↑D-dimer
↑PTT ↑↑↑Fibrin Degradation Products
↓Platelets

26. Comprehensive Metabolic Panel
Troponin, CK-MB
Clinical Implications

27. CMP RR 9/16 9/18 9/21
Surgery
9/23
TP 6.2-8.1 5.7 L 3.9 L 3.9 L 3.7 L
ALB 3.2-4.6 3.9 2.5 L 2.6 L 2.4 L
Ca 8.8-10.2 8.6 L 6.5 L 6.3 L 6.5 L
ALK Phos 39-117 38 L 32 L 34 L 35 L
TBIL 0.2-1.1 2.2H 1.5 H 1.3 H 0.7
ALT 10-28 15 17 14 14
AST 8-20 19 32H 16 14
Glucose 82-115 90 139 H 211 H 350 H
BUN 8-23 27 H 42 H 52 H 58 H
CREA 0.6-1.2 1.4 H 2.7 H 1.8 H 1.8 H
eGFR >60 37 L 17 L 28 L 28 L
eGFR Afr
Am
>60 45 L 21 L 33 L 33 L
Na 136-145 133 L 133 L 142 142
K 3.2-5.0 4.2 4.8 2.4 cL 3.5
Cl 98-107 94 L 101 103 108 H
CO2 23-31 26.5 17.4 L 26 21.4 L

28. Clinical Implications
Diabetes Mellitus, Hemolytic Anemia and Heart
damage
 ↑↑↑ Glucose: Diabetes, renal failure
 ↑ TBIL: Hemolytic anemia, CHF
 ↑ AST: Heart damage, bile blockage
 ↑↑ BUN: Renal failure, severe infections, CHF
 ↑↑ CREA: Renal failure, bacterial infections, CHF
 ↓↓ TP and ALB: Renal failure, shock, malabsorption
 ↓ ALP: Malnutrition, protein deficiency
 ↓ Ca: Renal disease, malabsorption

29. Clinical Implications
Heart damage due to Sepsis
↑Troponin T ↑CK-MB
CPK WNL
9/20/15 0805 am 1309 pm 1858 pm
CPK
0-211
70 48 84
CK-MB
<4.4
9.4 H 7.1 H 8.0 H
Troponin T
< or = 0.01
0.11 H
Critical call
0.08 H 0.07 H

30. pCo2, HCO3-, Base excess
Hypoxia

31. ABG Sept 17 Sept 18 Sept 20
pH
7.35-7.45
7.37 7.38 7.45
pCO2
35-45
mmHg
33.0 L 28.2 L 22.9 CL
pO2
80-100
mmHg
84 77 L 76 L
HCO3-
22-26
mmol/L
19 L 17 L 16 L
Base
Excess
-2.0-2.0
-5.4 L -7.9 L
acidosis
-7.5 L
O2 Sat %
94-100%
97% 96% 96%
0
5
10
15
20
25
30
35
pCO2
HCO3-
Clinical Implications
Hypoxia
↑Anion Gap Base Excess <-3
↓HCO3- ↓pCO2

32. Automated and Microscopic Results
Clinical Implications

33. U/A Sept 16 Sept 17
Color Yellow Yellow
Clarity Cloudy Cloudy
Blood Negative Trace
Protein 100 100
Leukocyte
Esterase
Negative Moderate
WBCs
0-10 /hpf
1-4 TNTC
Clumps
RBCs
0-5 /hpf
1-4 5-9
Bacteria Negative Present
C/S criteria
Met?
No Yes
Sent for
Culture
 Sept 17 Collection
 Urinary Catheter
 Urine sent to Culture
 TNTC WBC clumps
 Bacteria
 RBC
 Protein
Clinical Implications
UTI due to diverticulitis and urinary catheterization

34. Urine, Stool, Blood and Abcess cultures
Clinical Implications

35.  Urine catheter culture
Salmonella species
o Escherichia coli
o VRE Enterococcus
faecium
o Citrobacter
amalonaticus
 Stool Culture
Salmonella species
 Diverticulitis abcess culture
left lower abdominal-pelvis
Salmonella species
o Escherichia coli
o VRE Enterococcus faecium
 Blood cultures
o 9/16 Negative
o 10/01 Negative

36. Clinical Implications
 Sepsis
 Perforation
 Peritonitis
 Salmonella enterocolitis
 UTI

37. Type and Screen
Transfusion Time Line

38. Type-O POS
Screen-Negative
 9/20 Pre-Op
 Type and Screen
 9/21 Anemic
 4 units RBC-LR
 9/28 Anemic
 Type and Screen
 1 unit RBC-LR
 10/3 Anemic
 Type and Screen
 1 unit RBC-LR

40. References
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41. References
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42. References
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