Sepsis Case File

https://medical-phd.blogspot.com/2021/04/sepsis-case-file.html

Eugene C. Toy, MD, Manuel Suarez, MD, FACCP, Terrence H. Liu, MD, MPH

Case 19
A 59-year-old woman with a history of Type 2 diabetes mellitus was found unconscious at home by
her family members. In the emergency center, she was noted to have a temperature of 38.6°C, pulse
rate of 112 beats/minute, blood pressure of 96/50 mm Hg, and respiratory  rate of 26 
breaths/minute. After 2 L of nor mal saline, the patient became more alert and began to answer
questions more  appropriately.  Laboratory  values reveal WBC 26,000/mm3,  hemoglobin 12 g/dl, 
normal platelet count, and a serum glucose level of 280 mg/dL. A Foley catheter was  placed and
showed return of concentrated and cloudy urine. The  urinalysis revealed 50 WBC per high-power
field. A CT scan of the abdomen without contrast
revealed no free fluid in the abdomen and an inflamed right kidney with perinephric fat stranding.
Shortly after the patient was transferred to the ICU, her nurse notifies you that her blood pressure is
78/50 mm Hg and heart rate is 120 beats/minute. 

⯈What is the most likely diagnosis?

⯈What are the priorities in this patient's management?
⯈How would you monitor and support this patient's status?

ANSWER TO CASE 19:

Sepsis

Summary: A 59-year-old diabetic woman is found to be unconscious, febrile, with tachycardia and
hypotension. Laboratory analysis reveals a leukocytosis with likely urinary tract infection, and
imaging shows involvement of the upper genitourinary system. In the ICU, she develops sudden
hypotension and tachycardia. 

 Most likely diagnosis: Acute urinary tract infection related sepsis and septic shock. 
 Priorities in management: Fluid resuscitation and antimicrobial therapy. 
 Monitoring and support of organ perfusion: Intravascular fluid status can be assessed and
monitored with CVP catheters or echocardiography. Mean arterial pressure and mixed-
venous O2 measurements are helpful to determine patient's responses to therapy. The
patient's mental status, urine outputs, and serum lactate levels during the course of
resuscitation are also useful indicators of response to resuscitation. Specific monitoring and
support guidelines are available in the Surviving Sepsis Campaign publications.

ANALYSIS

Objectives
 1. To learn the guidelines and principles for the management of septic patients.
2. To learn the monitoring and strategies for patients with septic shock.
3. To learn the pharmacologic support for patients with septic shock.
4. To learn the role of glucocorticoid therapy for septic shock.

Considerations
This patient is suffering from shock. Shock is defined as inadequate oxygen delivery to meet the
patient's tissue metabolic demands. Her initial altered mental status and concentrated urine are overt
signs of inadequate end organ perfusion. There are many ways to classify shock. One useful way to
think about the etiologies of shock is to divide them into hypovolemic, cardiac, or distributive
processes. Hypovolemic shock is caused by hemorrhage or dehydration. Cardiac processes include
intrinsic cardiac dysfunction as well as extrinsic causes such as tamponade or tension
pneumothorax. In contrast, sepsis is a distributive process caused by acute vasodilation without an
accompanying increase in fluid volume. The acute vasodilation leads to an increase in the
capacitance of the circulatory system without an increase in volume, leading to a relative
hypovolemia. Other distributive causes of shock include anaphylaxis, neurogenic shock, and third
spacing seen with systemic inflammation. Sepsis is related to the systemic inflammatory response
syndrome (SIRS) , which is characterized by hypo or hyperthermia (temperature <36°C or >38°C) ,
tachycardia, tachypnea, leukocytosis, or leukocytopenia. Sepsis can be diagnosed when the features
of SIRS are present and an infection is the suspected cause. The diagnosis of sepsis does not
necessarily mean that shock is present. Septic shock is the diagnosis when there is ongoing
hypotension despite fluid resuscitation. Antimicrobial therapy should be initiated to address the
infectious process. The initial approach toward the correction of hypotension is to restore
intravascular volume with crystalloid administration, and once this is accomplished, persistent
hypotension is further addressed with the addition of vasoactive pharmacologic agents and
corticosteroids as indicated.

Approach To:
Sepsis

DEFINITIONS

SHOCK: Inadequate oxygen delivery to meet the needs of the body's tissues.

CENTRAL VENOUS PRESSURE: The pressure measured in the superior vena cava reflecting
right ventricle end diastolic pressure. It is measured with a centrally inserted venous catheter
usually inserted in the internal jugular or subclavian vein. CVP is used clinically to assess volume
status in critically ill patients. The CVP is not reliable in patients with tricuspid valve disease.

SIRS: The systemic inflammatory response is a clinical syndrome describing the derangement of

the body's inflammatory response. A patient with 3 or more of the findings below meets criteria for
the diagnosis of SIRS:

 Temperature <3 6°C or >38°C 

 Heart rate >90 beats/minute 
 Respiratory rate >20 breaths/minute  
  White blood cell count >12,000 or <4,000/mm 3

SEPSIS: When the etiology of SIRS is presumed to be infectious in origin, the diagnosis of sepsis
is made.
SEVERE SEPSIS: Sepsis with at least 1 organ system dysfunction.
SEPTIC SHOCK: Septic shock is present when there is ongoing hypotension despite fluid
resuscitation.
EARLY GOAL-DIRECTED THERAPY: A treatment strategy for sepsis with the goal of rapid
restoration of tissue perfusion by manipulation of cardiac preload, afterload, contractility as well as
oxygen-carrying capacity.