SEPSIS:

A CATASTROPHE FOR PATIENT

AND
CARE-PROVIDER
PRESENTATION:
• Rumis,27 years old, Booked at LHMC, admitted on 6-01-2022.
• Primigravida at 40+4 weeks gestation with oligohydramnios (AFI-4) with mild anemia (thal minor)
• Covid negative, Bishop’s score – 4 , NST reactive.
• Induced with Foley’s catheter on 6/1/2022 at 3:00 PM.
• Followed by Miso on 7/1/2022 at 7:00 PM (total 4 doses)
• One episode of fever on 8/1/2022 at 8:00 AM.
• Emergency LSCS i/v/o grade 3 MSL with fetal distress on 8/1/2022 at 5:30 PM.
• Per-op: blood loss- 1200 ml, one unit blood transfusion given, membranes sent for culture in view of pre-op fever.
• Induction to delivery time - 50 hours
• Membranes absent to delivery time - 21.5 hours.
• Number of p/v Examinations- 4
• Duration of hospital stay-33 days
DATE COMPLAINTS TEMPERATURE TLC NEUTROPHILS C/S ANTIBIOTIC ACTION

6-1-22 Crossed EDD afebrile 10.8 76 % - - Induction done

@ oligohyd K
admission

8-1-22 Leaking p/v 100- 2 spikes- 8 29.2 85% - Inj. Ampi , Metro started
Pre-op Labour pains am, 12 am K ( urine and blood C/S –
Fever spikes negative)

Post-op recurrent fever Added Inj. Amikacin

spikes

10-1-22 Persistent fever 101 17.2 91% - Inj. Monocef, Metro, Amika Inv of fever sent
POD 3 K

Abdominal 102 Inj. Monocef, Metro, Amika USG - dilated bowel loops , minimal
11-1-22 distension + fever inter bowel fluid
POD 4 X Ray-multiple air fluid levels.
Imp : subacute intestinal obstruction

NPO, RT, ENEMA

13-1-22 Stitch line Afebrile 13.5 87% Inj. Monocef, Metro, Amika ASR done, 60 ml of purulent
POD 6 tenderness K ( wound swab C/S- MRSA discharge drained --> sent for C/S
+ve) Imp: Wound sepsis

Inj Piptaz + Clinda started

date complaints temperature TLC Neutrophils culture ANTIBIOTIC ACTION

15-1-22 Abdominal distension 101 18.6 K 93 Wound Piptaz, Clinda CSR burst
POD 8 Swab C/S- abdomen C/S sent
MRSA +ve
CECT: dilated
jejunal loops, i/v/o
septic ileus,
mesenteric fat
stranding.
Surg ref: VAC
dressing was put.
DATE COMPLAINTS TEMPERATURE TLC NEUTROPHILS CULTURE ANTIBIOTIC ACTION

16-1-2022 Shortness of breath, afebrile 19.3 K 85 % - Piptaz, Clinda INR- 1.69

POD 9 increased BP (160- Azithro Plt- 4.88 L
170/ 90-100), ABG:
saturation dropping to CXR- patchy opacities
89% on room air in b/l mid zones
Pro-BNP- 8382 ng/ml
- Put on 6 L/min O2
- RTPCR repeat sent
( negative)

17-1-22 INCREASED PEDAL - - - HVS, Piptaz, Clinda + CTPA-b/l segmental &

POD 10 OEDEMA Placental Genta added sub-segmental
C/s- branches involved,
MRSA+ve b/l pleural effusion
(S) to genta with underlying lung
collapse With
consolidation.
Shifted to SICU
Inj. Enoxaparin 60 mg
S/c BD + T. Warfarin 5
mg OD
DATE COMPLAINTS TEMPERATUR TLC NEUTROP CULTUR ANTIBIOTIC ACTION
E HILS E / DRUGS

18-1-22 - Afebrile 16.4 K 83% Wound Metro, Genta Vac dressing changed
POD 11 swab C/S- Wound better
Plt-5.9 L MRSA +ve
INR- 1.62
 Clinical picture at a glance:
Chart Title
103 13.5/87 10.7/80
2.59 18.7 8.7
102 14.9/84 6.2 14.1/89.7 12.9/77
5.06 7.3 9.73
101 17.2/91
3.01
100 HVS/Pl. C/S-
18.6/84.2 MRSA +ve- 15.8/71.5 13.6.81
99 2.32 Linezolid 8.62 8.94
19.3/85 added.
HVS C/
Temp. 98 4.88 S-Kleb-
125/1.76 siella
CRP-219
97 +ve.
Wound
96
18.6/93 16.4/84 swab ,
3.98 5.98 Urine,
95 CRP/PCT-212/7.4 69.7/0.97 Blood
C/S- No
94 growth

93
8-Jan 10-Jan 11-Jan 12-Jan 14-Jan 16-Jan 18-Jan 19-Jan 20-Jan 21-Jan 22-Jan 23-Jan 24-Jan 25-Jan 26-Jan 27-Jan 28-Jan

Series1 Series2
28-01-2022
POD 21:
• Persistent fever spikes
• Thrombocytosis
• Repeat HVS C/S-
klebsiella +ve
• Red granulation tissue
present over the wound
• Patient taken up for
peritoneal wash and
resuturing
Per-op

• Minimal pus flakes present over the

uterine surface
• Flimsy adhesions present between
bowel loops & the uterus
• No pus in the abdomen
• Peritoneal wash given with 2.5 litres
of fluid
• Fibrosed edges of the wound
excised & margins freshened
• 2 Drains inserted in the POD and
subcutaneous area
Post-op:
Inj. Amoxy-Clav for 48 hours.

Afebrile after day-2

Wound swab C/S sent per op showed- GNB

POD-3 – Dressing Dry

Patient tested Chikunguniya +ve ( Tested on the 27/1/22)

 RISK FACTORS
- Pre-existing infection (recurrent fever spikes)
- Thalassemia minor

Lessons learnt - Blood loss in OT

- Asepsis in OT
- Hypoproteinemia
- Compromised ambulation

- Wound sepsis Burst abdomen

- Pulmonary embolism
ACTION NEEDED: High protein diet in the ante & postnatal period

Identify cause of pre-existing fever  ? Chorio?

Vaginal infection ? UTI ? Multiple PV
RISK FACTORS
-Thalassemia minor Asepsis in the OT - clean OT scrubs, adequate
- Hypoproteinemia scrubbing time, instrument handling, minimum OT
- Pre-existing infection (recurrent fever spikes) traffic, tissue handling, hemostasis

- Intra-op Blood loss

- Asepsis in OT Early ambulation
- Compromised post-op ambulation
Watchful infection screening and treatment
Antibiotics to be given/changed as per counts,
neutrophils and C/S reports