This document describes the case of a 77-year-old man who presented with fever, left leg swelling and redness, and altered mental status. He had a history of diabetes and was initially treated for cellulitis with antibiotics but his condition deteriorated with confusion and delirium. He developed septic shock and refractory hypotension despite supportive management and antibiotics. He had multiple organ dysfunction and died after cardiac arrest despite resuscitative efforts. The case discusses the patient's hospital course, clinical findings, investigations and management of sepsis.

1. Mortality Meeting

2. Mr Vargheese 77/M from presented
with
1. fever 2 weeks duration
2. Swelling and redness of left leg of 2 weeks
3. Altered Mental state of 2 day duration

3. Chief complaint
77/M who is a known diabetic on Rx for the
past 20 years. Developed fever with painful
red swelling of the left leg. Fever was low
grade .The patient went to a local hospital and
was sent home with some oral antibiotics.
There was some improvement but fever was
still persisting

4. Assosiated
There was assosiated reddish painful swelling
suggestive of cellulitis with treatment there
was some reduction in the pain

5. Progression
1. Patient was becoming increasingly drowsy
and there was reduced food intake.
2. Later the patient became confused, couldn’t
identify relatives, began screaming out, using
incomprehensible sounds,
3. Breathing of the patient was deep

6. contd
4. Patient was taken to local hospital were he
was admitted and was told that his sodium
levels were low (S.Na = 129mg/dl)
5. As the patient was not improving they were
reffered here.

7. Past history
20 year back gives history of drainage of a
pancreatic abscess
History of Diabetes Mellitus on treatment for
20 years

8. Personal history
Smoker – 40 years
Alchoholic – 20 year duration stopped 20 years
back.
Bowel and bladder habits were regular
Apetite was reduced for a period of 2 weeks

9. Family History
No relevant family history

10. Socio economic
Low socio economic status

11. General examination
Patient was conscious
Disoriented to time, place and person
Irrelevant speech and incomprehensible
sounds( May be delusions)
Takin deep breaths
Patient was also biting objects bite marks on
both forearms were seen

12. cont
Pallor+, Clubbing +
No edema No palpable Lymph nodes
No cyanosis
Left leg – red and swollen till just below the
knee with local rise of temp
Oral cavity – poor hygeine multiple caries
teeth

13. Vitals
Pulse – 128/mt
Bp – 80/60 mm Hg
RR – 28/mt
T – 100deg F

14. Respiratory system
Chest moving equal with respiration
Trachea central
Liver dullness at 6th Ics in the MCL
Cardiac dullnes obliterated
Bilateral basal crackles
No other added sounds

15. CVS
S1 S2 +
No murmurs

16. CNS
HMF – patient disoriented
Motor – deep tendon reflexes ++
Bilateral flexor plantar response
Sensory – not assesible
No s/o menigeal irritation
Skull and spine - normal

17. GIT
No contributary findings

18. Provisional diagnosis
Febrile delirium – Due to Left leg cellulitis and
Lower respiratory tract infection precipitaing
COPD. Patient in Septic shock, Type 2 DM

19. Patient was started on
Inj Cefaperazone sulbactam 1.5 g IV BD
Inj Metrogyl 500 mg IV Q8h
Supportive management
IVF crystalloid @ 100 ml/hr
As BP was not maintaine started on Dopamine
support

21. Investigations

22. inv 17/7/15 18/7/15 19/7/15
Hb
Pt
TC
DC
S.Cr 0.8
urea 33
s.Bil T=2.9 D=0.7 T= 4.2 D= 1.53
SGOT 44
SGPT 29
ALP 702
s.protein Alb=1.8,G=3.5 A/G=.5 6/2.1/3.9/0.5
S.Elec Na = 148 K=4.3
S. Amylase 62
S. Lipase 40
PT/INR PT28.2/14.9 INR – 1.89 26.1/14.9 Inr = 1.94

23. URE
Albumin – trace
Sugar – greenish yellow
m/s – RBC – 2 to 3, Pus cells 20- 25,
epithelial cells + bacteria +

24. Day 2
BP = 110/70 mm Hg on dopamine support
In view of UTI,LRTI and cellulitis leading to
septic shock
Patient was started on
Inj Piperacillin 4.5g iv tid
Inj Metrogyl
Cloxacillin
Other supports maintained

25. Day3
Patient on continous Bp Monitor recorded Bp
fall 80/40 mm Hg.
Noradrenalin support was initiated
BP was still rising
Went in to cardiac arrest
5 cycles of CPR was given
Expired at 3.30 am on 19/7/15

26. Condition
Bacteremia
SIRS
Sepsis ( Severe sepsis)
Septic shock
Refractory septic shock

27. Bacteremia – presence of bacteria in blood

28. SIRS – fever >98.6 F
hypothermia <96.6 F
Tachypnoea >24 /Mt
Tachycardia >90/mt
Leucocytosis >12000
Leucopenia <4000
2/more of the above conditions

29. Sepsis – SIRS + some deg of organ dysft
CVS – sys BP <= 90 MAP <= 70 resp to IVF
Renal – Urine output <0.5ml/kg/hr
RS – PaO2/FiO2 <= 250
Hematological – platelet < 80000
Unexplained met acidosis

30. Septic shock – sepsis with hypotension for
atleast 1 hour despite IVF
or
Need of vasopressor to maintain systolic BP
>90 mmHg

31. Refractory septic shock – septic shock >1hr

32. Predisposing factors
1. Extremes of age (<10 y and >70 y)
2. Primary diseases: Liver cirrhosis ,Alcoholism, DM,
CRF, Cardiopulmonary diseases, Solid & Hematologic
malignancy
3. Immunosuppression:Neutropenia,
Immunosuppressive therapy, Corticosteroid therapy,
Intravenous drug abuse, Compliment deficiencies &
Asplenia
4. Major surgery, trauma, burns

33. 5. Invasive procedures
Catheters
Intravascular devices
Prosthetic devices
Hemodialysis and peritoneal dialysis catheters
Endotracheal tubes
6. Prior antibiotic treatment
7. Prolonged hospitalization

35. Treatment
Initiation – with in 1hr of presentation
rapid assesment mandatory
time interval between the onset
of hypotension and initiation of
appropriate antibiotic therapy

36. Culture may be negative in up to 40 percent
cases
If positive 2 samples from 2 diff sites

37. Objective – Empirical antibiotic therapy for
both G+ and G- organisms
Max recommended doses should be used
IV antibiotics only adjusted according to renal
function

38. If culture + try to use monotherapy
Only in Pseudomonas combine therapy with
aminoglycoside and antipseudomonal beta
lactam was found superior

39. Emperic antifungal should be added if
Broad spectrum antibiotics
Parenteral nutrition
Neutropenic > 5days
Long term Central venous catheter

40. Hemodynamic and resp supp
Goal
• restore oxygen to tissues

41. • Monitor
BP, mentation, urine output , skin perfusion
Spo2

42. • Initial hypotension
1-2 L of NS over 2 hours with CVP maintained at
8 -12 cm H20. maintain sys BP >90
• Titrated doses of NE keeping the sys bp>90
• If ass myocardial dysft dobutamine can be
used
• Urine output at 0.5ml/kg/hr titrate the
diuretics

43. • CIRCI suspected in patients with no increased
BP with ionotropes hydrocortisone 500 mg IV
Q6h
• Ventillatory therapy if progressive
hypercapnea, hypoxia and neurological
deterioration
• Sedation, elevation of head end to prevent
nosocomial pneumonia

44. • Stress ulcer prophylaxis using H2 receptor
blockers
• Erythropoetin transfusion if Hb <7g/dl
• Compression stokings if the patient is
ventilated to prevent DVT
• Don’t be aggressive in correcting the blood
sugars only reduce it below 180 mg/dl