bacterial sepsis
Post on 07-Apr-2015
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Hospital Day 0: The Call
64 YO African American female, found unconscious by staff in her nursing home this morning. She was arrived via EMS and is currently on the vent. Please come and assess
Hospital Day 0: Inital Assessment
CC: unobtainable due to Pt. being ventilated and sedated
HPI: 64 YO AA Female with a past medical history significant for: HTN, DM II, COPD, CKD (baseline Cr. 5.2), dyslipidemia, CHF (EF - 27% per Echo: 4/2010), presents to the ECC via EMS with acute onset of seizures. Pt was noted to have decreased oxygenation and difficulty protecting her airway, and was intubated in the ECC.
Nursing home was contacted and they noted the Pt appeared sluggish and weak by staff one day prior to admission. This morning, pt was found unresponsive and "twisting" with no fecal or urinary incontinence.
Hospital Day 0: HistoryAllergies: NKDA
Family HX: Hypertension in sisters (as per medical record)
Past Medical HX: HTN, DM II, COPD, CKD (baseline Cr. 5.2), dyslipidemia, CHF (as per medical record)
Past Surgical HX: none
Social HX: (-) EtOH / (+) tobacco - 4 cig./day x years / (-) drugs (as per medical record)
Living Condition: currently lives in a nursing home.
Code Status: Full code
Hospital Day 0: PhysicalPhysical Exam:
Vitals: BP: 90/60 HR: 61 Tc: 32.5 RR: 12 (vent) O2: 100% (on vent)
General: lethargic / sedated
HEENT: 1mm fixed pupils (B), anicteric sclera
Neck: (-) cervical, supraclavicular lymphadenopathy, supple, (-) JVD
CV: decreased heart sounds, (+) S1 / S2, (-) S3 / S4
Abdomen: (-) organomegally, NT, (+) rebound/guarding
Musculoskeletal: Unable to assess full ROM
Skin: deferred
GU: (-) stool guaic, normal tone, (-) fissures, (+) visible external hemorrhoid noted
Hospital Day 0
4.97.523.8
76
92
30.6 47.5
2.46
144
5.2
125
6
72
9.8197
Ca: 4.8 Mg: 2.8 Phos: 11.5Seg: 4.6Mon: 0.1Eos: 0Lym: 0.2
T. Bili: 0.6D. Bili: 0.1
CPK Total: 263CPK MB: 14.6Troponin I: 0.02
AST: 18ALT: 22
Alk. Phos: 263
ABG: 6.75 / 188 / -30.4 / 29 / 98% on 100% FiO2
Labs on Arrival: 0730
Hospital Day 0: Assessment
i. Urosepsis: suspected to be secondary to UTI.
Pt. started on Vancomycin 1 gm IV Q Daily
Pt. started on Zosyn 4.5 gm IV Q Daily
f/u cultures
ii. Renal Failure
Begin dialysis today
Hospital Day 0: ECC Course
730Pt. arrives to ECC via EMSGCS on arrival, 3
743 Initial labs drawn
745Pt. given propofol @ 5mcg/kg/hrPt. given Ativan @ 2mg IC x 1Pt. given Succinylcholine @ 50mg IV x 1 dosePt. intubated
Vent Settings: Rate 12, FiO2: 100%, Peep 5, TV: 400
747 CXR: confirmed placement of Endotracheal Tube
800(R)IJ TLC placed. initial attempt was unsuccessful, and had to reattempt
Hospital Day 0: ECC Course
810(L) femoral arterial line placed. Initially attempted a (R) and (L) radial arterial line. Both radial arterial line placements failed.
810 Pt. taken to CT Scan
1110Temp: 90.8Warming blankets and water warming usedRectal probe in place
1123Zosyn 4.5 IV x Q DailyVancomycin 1gm IV Q DailyVersed 2mg/hr (titrated to MAAS 3)Hydrocortisone 100 mg IV x 1
1251 Morehouse MICU Team Called
ICU Day I
Events over the past 24 hours: Pt had systolic blood pressures in the 170’s and diastolic blood pressures in the 80s. IVF were initially titrated down from 125 cc/hr to 75 cc/hr and subsequently discontinued when the Pt. remained hypertensive.
Pt. was transfused 1 unit of PRBC overnight and Hb /HCT went from 7.5/23.8 to 10.8 /33.2
Pt. remains on the vent.
Neuro: (+) gag reflex, (+)1 DTR x 4, (+) right corneal reflex
ICU Day 1: Labs
7.610.833.2
162
90
20.2 43.9
1.65
145
3.9
122
8
62
8.5322
Ca: 4.6 Mg: 2.2 Phos: 9.0Seg: 71%Mon: 2%Eos: 2%Lym: 4L
T. Bili: 1.0D. Bili: 0.1
CPK Total: 249CPK MB: 14.7TroponinI: 0.04
AST: 24ALT: 24
Alk. Phos: 133
ABG: 7.26 / 151 / -18.1 / 32 / 98% on 100% FiO2
0001 AM
ICU Day IIEvents over the past 24 hours: Pt. had a vascath placed and received dialysis. Pt. remains unresponsive. Pt. started on BP medications
Vitals: BP: 122-134 / 54-82, HR: 74-92, RR: 12 - 18, O2: 100%,
Vent Settings: AC / Tv: 400 ml / FiO2: 50% / Rate: 12 / Peep: 5.0
Plan:
Urosepsis: Elevated WBC noted. Urine culture contaminated. Resend urine for culture. Pt. remains anuric.
Respiratory Failure: Pt. now breathing over the vent. Still not responsive. Consider weaning in preparation for breathing trials
2D Echo
Coagulopathy: Transfuse 2 Units FFP and d/c bicarbonate drip
AMS: Consider EEG
Renal Consult: removed 1,300 ml via dialysis. Continue to monitor.
ICU Day 2: Labs
9.610.631.8
158
87
30.7 55.2
2.46
138
2.5
98
26 4.6291
Ca: 5.2 Mg: Phos:Seg: 80%Mon: 5% Eos: Lym: 3L
T. Bili:D. Bili:
CPK Total:CPK MB: TroponinI:
AST:ALT:Alk. Phos:
ABG:
0202 AM
28
0033 AM
0033 AM
0033 AM
ICU Day 2: Labs
138
2.1
97
25 4.7184
Ca: 7.1 Mg: Phos:
T. Bili: 0.5D. Bili: 0.1
CPK Total:CPK MB: TroponinI:
AST: 36ALT: 25
Alk. Phos: 118
ABG: 7.55 / 224 / 5.2 / 32 / 98% on 50% FiO2
0840 AM
29
ICU Day 2: Labs
142
2.7
103
29 2.681
Ca: 7.8 Mg: Phos:
T. Bili: 0.9D. Bili: 0.1
CPK Total:CPK MB: TroponinI:
AST: 35ALT: 26
Alk. Phos: 112
ABG: 7.54 / 141 / 7.9 / 37 / 96% on Room Air
1421: Post Self-Extubation
14
ICU Day III
Events over the past 24 hours: at 1530, nursing staff contacted MICU and indicated that the Pt. had self extubated as well as removed the NGT. Nurse indicated that Pt. A/O x 1 (person) and able to follow commands. Nurse was instructed to replace NGT but was unable to do so due to elicitation of strong gag reflex.
Assessment:
Urosepsis: awaiting cultures
Respiratory Failure: resolved
Patient transferred
ICU Day 2: Labs
14.39.428.4
117
89
30.7 55.2
2.46
143
3.0
105
27 3.3158
Ca: 7.9 Mg: Phos:Seg: 65%Mon:% Eos: Lym: 3L
T. Bili:D. Bili:
CPK Total:CPK MB: TroponinI:
AST:ALT:Alk. Phos:
ABG: 7.48 / 71 / 4.2 / 39 / 98% on room air
0001 AM
17
0033 AM
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