Management of Septic Shock caused by Diabetic Foot Ulcer At Intensive Care Unit :

A Case Report
dr. Erica G. Simanjuntak, Sp.An, KIC1; Dopang Andrianto2; dr. Kurniyanto, Sp.PD3; dr. Golda Simanjuntak1; Putrianifedora Resje Hartman3; Irvan Christian Wemben3; Vania Elvira3
1Departement
of Anesthesiology, Christian University of Indonesia Hospital
2Co-Assitant of Departement of Anesthesiology, Christian University of Indonesia Hospital
3Departement of Internal Medicine, Christian University of Indonesia Hospital

Introduction
Foot diabetic infection (DFI) is a chronic health problem for
15% of diabetes mellitus (DM) patients in the world. The
mechanism of DFI occurrence is based on neuropathy and
ischemia in tissues, which increase morbidity and mortality in DM
patients. Ulcers in diabetic foot act as a port de entry of
microorganisms to enter the body and may cause septic shock in
DM patients.1 Septic shock is sepsis, a life threatening organ
dysfunction caused by a dysregulated host response to infection,
Physical examination (taken soon after arriving in the ICU) :
BP = 80/50 mmHg; Temp = 38,9 C, HR = 82x/minute (weak); RR
33x/ minute; SpO2 = 88%, GC : critical, GCS = E2M3V2; Thorax
= breath sound bronchial, coarse crackles +/+; Extremities =
diabetic foot ulcer on pedis sinistra digiti I & II, edema = -/-/+/+.
Laboratory results : SOFA score = 10; PaO2 = 226.4 (2 = ≤ 300
mmHg), Platelets = 447 (1 = ≥ 150 thousand/uL), bilirubin = 1.5
(1 = 1.5 mg/dL), MAP = 60 (1 = <70 mmHg), GCS = E2M3V2 (3 =
6-9), Creatinine = 2.1 (2 = 2-3.4 mg/dL).
Discussion The purpose of resolving the patient’s septic shock was to improve the patient’s ASA
score so that it is feasible to carry out the best treatment option; amputation, as the
The patient’s condition has met the criteria of sepsis with a source of main control for the patient’s DFI.3 The goal was achieved, and the patient
documented infection source (DFI and HAP) and a SOFA score of 10, was moved to a normal ward to resume surgery preparations.
which corresponds to the patient’s mortality chance of 50%. The
patient’s sepsis was suspected to have progressed into a septic shock outcomes
as the MAP on ICU admission was 60 mmHg. Unfortunately, one more
criterion of diagnosis was not obtained; blood lactate concentration.2 Laboratory results of Mr. KM
450
Sepsis markers need to be examined because metabolic changes 400 395

with the addition of persistent hypotension that requires

350

cause by DM in patients with septic shock may result in an increase in 300

325

275
vasopressors to maintain MAP ≥ 65 mmHg and serum lactate level 250

advanced glycation end products (AGES), activation of protein kinase C 200

226,4
188
222 215,4
177,8
> 2 mmol/L (18 ng/dL), despite adequate fluid resuscitation. The Intervention
150 152,7

isoforms and the hexosamine pathway, which will increase superoxide 100
115 106
88,3 98,3

diagnosis of sepsis in a patient can be made using SOFA scoring.2 50 60

43
in the tissue that triggers an inflammatory reaction.4 Sepsis can also 0
35,8
23 26,4 22,3 21,5

Management of patients with DFI resulting in septic shock vary 01-Nov-19 03-Nov-19 05-Nov-19 07-Nov-19 09-Nov-19

cause an increase in nitric oxide (NO) which reduces the sensitivity of PO2 (mmHg) MA P (mmHg) GDS (mg /dL) Leukosit (ribu/uL)

from antibiotics administration based on culture results to foot

01/11/2019 03/11/2019 05/11/2019 07/11/2019 09/11/2019 myocardium to calcium influx and inflammation in the tissues resulting Table 1. Laboratory results of Mr. KM Figure 1. Bronchopneumonia
amputation.3
in the emergence of oxygen free radicals (i.e. superoxide) and nitrogen
Norepinferine Norepinferine Norepinferine
Purpose stopped
free radicals (i.e. peroxin trite), which can damage any type of cells
ANTIBIOTICS : ANTIBIOTICS : ANTIBIOTICS : ANTIBIOTICS : ANTIBIOTICS :
Cefoperazone Cefoperazone Cefoperazone Levofloxacin Levofloxacin around it, including erythrocytes as the main component of oxygen
To improve the management of sepsis, especially in DM patients, in Meropenem Meropenem Meropenem Metronidazole Metronidazole
Levofloxacin Levofloxacin Levofloxacin (+)Ceftriaxone Ceftriaxone carriers. As a result, cardiovascular dysfunction, such as decreased left
the Intensive Care Unit at UKI General Hospital. (+) Metronidazole Metronidazole
ventricular performance, is a common complication of severe sepsis.5,6
Ventilator : Ventilator : Ventilator : Ventilator stop
Purpose Mode v-simv Mode v-simv Mode v-simv Thus, the patient's cardiovascular condition was assessed through an
Vt : 370 Vt : 370 Vt : 370
Fio2 : 60 Fio2 : 50 Fio2 : 40 ICON examination; low heart contractility, low left ventricular ejection
PEEP : 5 PEEP : 5 PEEP : 5
Ps: 10 Ps: 8 Ps: 8
Anamnesis : Mr. KM, 60 years old, was admitted to UKI RR : 10 RR : 10 RR : 10
time, and low oxygen delivery was discovered.
Ptgr : 2 Ptgr : 2 Ptgr : 2 Figure 2. Diabetic Ulcer
General Hospital through the Emergency Unit. For the last 2 As a management effort, the patient has been given broad
GV each day with O2 T-piece 10 lpm O2 T-piece 10 lpm
days, there were complaints of nausea, vomiting, cough with metronidazole installed installed spectrum antibiotics, such as meropenem, cefoperazone, levofloxacin
References :

thick, white sputum and fever. dan metronidazole. The antibiotics given is in accordance with the 1. Forsyth JM. Diabetic foot sepsis. InnovAiT: Education and Inspiration for General Practice 2016;9:687–93. doi:10.1177/1755738016665133.
2. Rhodes A, et al. 2017. Suriviving sepsis campaign: international guidelines for management of sepsis and septic shock. 2016. Intensice Care Med.
After a few days of treatment in the ward, the patient’s Infectious Diseases Society of America (IDSA) and the International 3. Boulton AJM, Armstrong DG, Kirsner RS, Attinger CE, Lavery LA, Lipsky BA, et al. American Diabetes Asscoiation. Diagnosis and management of diabetic foot complications
2018:1–20.
condition worsened, accompanied with sudden loss of Working Group on the Diabetic Foot (IWGDF), where DFI patients are 4. Frydrich LM, Fattahi F, He K, Ward PA, Delano MJ. Fontiers in Endocrinology. Diabetes and sepsis : risk, recurrence, and ruination. 2017:8:1-22. doi : 10.3389/fendo.2017.00271.
5. Greer J. Pathophysiology of cardiovascular dysfunction in sepsis. BJA Education 2015;15:316–21. doi:10.1093/bjaceaccp/mkv003.
consciousness. History of type II DM (+) in the last 5 years, included in group IV, in which the main etiology include 6. Drosatos K, Lymperopoulos A, Kennel PJ, Pollak N, Schulze PC, Goldberg IJ. Pathophysiology of Sepsis-Related Cardiac Dysfunction: Driven by Inflammation, Energy
Mismanagement, or Both? Current Heart Failure Reports 2015;12:130–40. doi:10.1007/s11897-014-0247-z.
controlled with insulin Staphylococcus aureus and Streptococcus sp.1,3,7 7. Kwon KT, Armstrong DG. Microbiology and Antimicrobial Therapy for Diabetic Foot Infections. Infection & Chemotherapy 2018;50:11. doi:10.3947/ic.2018.50.1.11.