Case Discussion Tropic Infection 1

Sterile Blood Culture in Sepsis

Patient

Monika Evelyn Hanjoyo

Moderator : Dr. dr. Hani Susianti, Sp.PK(K)

 Data Base
Male/56 yo
Chief of complaint : SOB
• Patient has suffered from shortness of breath since 2
days ago which worsened a night before admission. The
complaint still occurred when he was resting and lying.
He also had cough with white sputum and subfebris for
a week.
• The complaint accompanied by unreffered chest pain
and sweating. Naussea -, vomit -.
• He had history of SOB, fatigue, and leg edema history
everytime he do ordinary physical activity but it usually
disappear when he rest.
2
Past Medical History :
• HT + since 2014 took amlodipine 5mg regularly
• CAD  PCI 2 months ago
• CVA  Dec 2018
• High creatinine since 2019
• DM -, asthma -,TB-

Family Medical History : HT +

Social History:
• Office worker 3
 Physical Examination (21/5)
General Severely ill, GCS : 4-5-5, aggitated
status Weight 65kg; Height 165cm(BMI 23,8:Overweight)
Vital sign BP : 85/62 mmHg  110/70(Dobu +NE)
HR : 130 bpm
RR : 28 tpm T : 36,0 °C
SpO2: 89% (NRBM 10Lt)  ventilator
Head & Anemic conjunctiva -/-, Icteric sclera -/-
Neck JVP : R+0 cm H2O
Thorax P: symmetrical, VBS +/+, Rh +/+, Wh -/-
C: ictus at 5th ICS LMCS, single S1/S2, murmur (-)
Abdomen Flat, soepel, BS +, Liver & spleen unpalpable
Extremities CRT <2”, cold, edema -/-
4
 CBC 21/5 24/5 25/5 27/5 28/5 29/5 Reference
CVC PRC 1
Hb 10,4 8,1 9,2 9,2 8,8 10,5 13,4 – 17,7 g/dL
RBC 3,69 2,86 3,23 3,22 3,13 3,77 4 – 5.0 x 106/µL
WBC 21,24 7,89 11,17 8,96 6,67 9,4 4.3 – 10.3 x 103
/µL
Ht 32,5 24,4 28,5 27,9 27,4 32 40 – 47 %
PLT 366 180 222 200 176 211 142 – 424 x
103/µL
MCV 88,1 85,3 88,2 86,6 87,5 84,9 80 – 93 fL
MCH 28,2 28,3 28,5 28,6 28,1 27,9 27 – 31 pg
MCHC 32,0 33,2 32,3 33 32,1 32,8 32 – 36 g/dL
RDW 14,5 14,6 14,7 15 15,1 16 11.5 – 14.5 %
Diff -/-/ -/-/ 1/-/ 1/0/ -/-/ -/-/ 0-4/0-1/51-
86/9/ 93/4/ 86/8/ 85/6 80/11/ 83/9/ 67/25-33/2-5
5 3 5 /8 8 8

5
Chemistry 21/5 24/5 25/5 27/5 29/5 1/6 Reference
Ureum 47,2 58,5 57,3 80 174,9 249 16,6-48,5 mg/dL
Creatinine 2,1 1,92 2,07 2,53 4,85 5,33 < 1,2 mg/dL
eGFR(CKD-EPI) 34,2 38,1 34,7 27,3 12,4
Uric acid 8,3 3,4 – 7 mg/dL
hsCRP 92 < 0,3 mg/dL
Troponin I 0,5 <1,0
CK-NAC 88 39 – 308 U/L
CK-MB 27 7 – 25 U/L
NT Pro BNP 32016 16049 <210 pg/mL
Tot. Chol 96 <200 mg/dL
Trigliseride 90 <150 mg/dL
HDL 26 >50 mg/dL
LDL 65 <100 mg/dL

SOFA Score 5 8 8 8 9 10 6
Chemistry 21/5 22/5 Reference
Pk 20.01 Pk 03.00
RBS 271 < 200 mg/dL
FBS 325 60 – 100 mg/dL
Hb-A1C 5,5 < 5,7 %

Glucose POCT Result

21/5 Pk 17: 38 246
21/5 Pk 18 : 49 210
22/5 Pk. 08 : 38 241
25/5 Pk. 07:35 103
26/5 Pk. 09:09 175

7
Chemistry 21/5 22/5 23/5 28/5 29/5 Reference
AST/ SGOT 201 0 – 32 U/L
ALT/SGPT 41 0 – 33 U/L
Bil. Total 0,68 <1 mg/dL
Bil. Direk 0,54 <0,25 mg/dL
Bil. Indirek 0,14 <0,75 mg/dL
Albumin 3,11 3,5 – 5,5 g/dL
Lactic Acid 5,1 2,6 2,2 Arteri: 0.5 – 1.6

SE 21/5 24/5 25/5 27/5 Reference

Na 132 135 138 142 135 – 145 mmol/L
K 4,43 3,29 4,19 3,7 3.5 – 5.0 mmol/L
Cl 100 108 110 106 98 – 106 mmol/L
8
Immunoserology 21/5 25/5 27/5 Reference
Procalcitonin 15,7 22,55 24,04 < 0,5 low risk
> 2 high risk for severe
septic or shock septic

Coagulation 21/5 Reference

PPT patient 1,03
control 11,3 9,4 – 11,3
INR 1,27 <1,5
APTT patient 35,3
control 25,2 24,6 – 30,6

9
 Natrium Bicarbonat bolus 50 mEq
BGA 21/5 22/5 23/5 24/5 25/5 26/5 27/5 Reference
pH 7,18 7,32 7,45 7,49 7,46 7,45 7,4 7,35 – 7,45
pCO2 44,3 39,0 27,3 27,6 31 35,1 42 35 – 45
mmHg
pO2 105,8 136,4 170,1 115,9 261,6 175,4 128,7 80 – 100
mmHg
Bicarbonat 16,7 20,1 19,2 21,2 22,1 24,7 26,4 21 – 28
(HCO3) mmol/L
Base -11,9 -6,3 -5,0 -2,3 -2,0 0,6 1,4 (-3) – (+3)
excess(BE)
O2 sat 96,4 98,8 99,4 98,7 99,9 99,9 99,9 > 95%

Uncompensated Respiratoric Normal

Metabolic acidosis Alkalosis

10
 ECG (21/5) :
Total RBBB

Chest X-Ray(21/5)
Conclusion :
• Pneumonia bilateral
• Cardiomegali
• Pulmonary edema
11
Sputum &
Blood
Culture
22/5

12
13
 Therapy
• Dobutamin • ASA 4 tab
10mcg/kgBB/min • CPG 4 tab
• Norepinephrine 0,1 • Atorvastatin 40 mg
mg/kgBB/min • Concor
• Midazolam 3mg/kgBB • Captopril
• Natrium Bicarbonat • ISDN
50mEq • Lansoprazole
• Lovenox 2x0,6cc • Cefoperazone 2x1gr iv
22/5
• Furosemide 40mg • Levofloxacin 750 mg/48 hrs
• Terbutalin 2x 0,5mg sc
14
 Data Interpretations
• Laboratory results showed anemia normochromic
normocytic, leukositosis with neutrophilia, slight
hipoalbuminemia, increases of ureum, creatinine, uric
acid, RBS, FBS, hs-CRP, NT-pro BNP, direct bilirubin,
SGOT, lactic acid and procalcitonin. BGA showed
uncompensated metabolic acidosis  respiratoric
alkalosis. Culture sputum ETT showed Staphyococcus
aureus but no bacterial pathogen in blood.
• Based on medical history, physical examination,
laboratory data & other examinations showed CHF
NYHA stage IV with shock condition dt. cardiogenic
DD/ sepsis , and renal insufficiency.
• Suggestion : peripheral blood smear, reticulosite,
SI, TIBC, 2hPPBG, urinalisis, GGT, ALP, total protein,
globulin, echocardiography, kidney USG reexamine
blood culture.

- Monitoring : CBC, Ur, Cr, Uric acid, Troponin I,

CKMB, NT-ProBNP, SOFA Score, SGOT/PT, Bil T/D/I,
Albumin, Lactic acid, FBG, procalcitonin, BGA, SE,
ECG, Thorax X-ray, Vital Sign, urine output

16
1 Establishment of the diagnosis

2 Hyperglycemia in this patient

3 Sterile blood culture in this patient

17
 1
Establishment of the diagnosis

18
 Heart Failure
• Heart failure is a chronic, progressive condition in which
the heart muscle is unable to pump enough blood to
meet the body’s needs for blood and oxygen.
• At first heart tries to compensate by enlarging,
developing more muscle mass, and pumping faster. The
body also tries to compensate with narrowing bllod
vessels to keep blood pressure up and diverting blood
away from less important tissues and organs (like the
kidneys).
• Etiology : Ischaemic Heart Disease, Hipertensive Heart
Disease, Valvular & Rheumatic Heart Disease,
Cardiomyopathy, and congenital heart disease . 19
Framingham Heart Failure Diagnostic Criteria
Major Criteria Minor Criteria
• Acute Pulmonary Edema • Ankle edema
• Cardiomegaly • Dyspnea on exertion
• Hepatojugular reflux • Hepatomegaly
• Neck vein distension • Nocturnal cough
• Paroxysmal Nocturnal • Pleural effusion
Dyspnea or orthopnea • Tachycardia (HR >120)
• Pulmonary rales
• S3 gallop rhythm
• Weight loss >4,5kg in 5 days
in response to treatment

Positive diagnosis : 2 major criteria or 1 major plus 2 minor criteria

20
21
 Cardiogenic Shock
• CS is caused by severe impairment of myocardial performance
resulting in diminished cardiac output, end‐organ hypoperfusion,
and hypoxia.
• Criteria : SBP <90 mm Hg for ≥30 minutes or use of
pharmacological and/or mechanical support to maintain an SBP
≥90 mm Hg. Evidence of end‐organ hypoperfusion including urine
output of <30 mL/h, cool extremities, altered mental status,
and/or serum lactate >2.0 mmol/L. Cardiac index (CI) of
≤2.2 L/min per m2 and a pulmonary capillary wedge pressure
(PCWP) of ≥15 mm Hg.
• Acute myocardial infarction (MI) accounts for 81% of CS patient.
STEMI 2‐fold increased risk for CS compared with NSTEMI.
Survivors CS have an 18.6% risk of 30‐day readmission after
discharge. The most common causes are CHF and new MI. 22
Male, 56 yo
• Complaint : SOB + unreffered chest pain This Patient
• Past history :HT +, PCI 2 months ago,
High Creatinine since 2019 Heart Failure NYHA class
• Anemia NN, Leukositosis, Neutrofilia IV with complication
• Normal FH Cardiogenic shock DD/
• Normal CKMB & Troponin I Septic shock
• ↑ NT-pro BNP
• ↑ SGOT Suggestion :
• ↑ RBS, FBG
Echocardiography
• ↑ hsCRP
• ↑ Lactic acid
• BGA : Metabolic acidosis Monitoring:
• ECG : Total RBBB Vital Sign, ECG,
• Physical Examination: GCS 14(agitated),
Troponin I, CKMB,
BP 100/70 (Dobu+NE), Tachycardia,
Tachypnoe, Rh +/+, cold extremities NT-proBNP, BGA,
• Chest X-ray : pneumonia, cardiomegaly, lactic acid, SE, CBC,
pulmonary edema FH, urine output 23
 SEPSIS
• Sepsis is defined as life-threatening organ dysfunction
caused by a dysregulated host response to infection.
• Organ dysfunction can be identified as an acute change in
total SOFA score ≥2 points consequent to infection.
Hospital mortality risk 10%.
• Septic Shock is a subset of sepsis in which underlying
circulatory and cellular/metabolic abnormalities are
profound enough to substantially increase mortality.
Septic shock can be identified as persisting hypotension
requiring vasopressors to maintain MAP ≥65 mmHg and
having serum lactate level >2mmol/L despite adequate
volume resuscitation. Hospital mortality is in excess 24of
 Admission

This patient SOFA SCORE : 5 25

Male, 56 yo
• Complaint : SOB, cough, subfebris
• Past history :HT +, PCI 2 months ago,
High Creatinine since 2019
• Anemia NN, Leukositosis, Neutrofilia
• Hipoalbuminemia
• ↑ Bil Dir ,↑ SGOT
• ↑ Ur, Cr
• ↑ RBS, FBG
• ↑ hsCRP
• ↑ Procalcitonin
• ↑ Lactic acid. BGA : metabolic acidosis
• SOFA score : 5  10
• Sputum ETT culture: Pseudomonas
aeruginosa. Blood culture negative
• Physical Examination: GCS 14(agitated),
BP 100/70 (Dobu+NE), Tachycardia,
Tachypnoe, Rh +/+, cold extremities
• Chest X-ray : pneumonia, cardiomegaly,
pulmonary edema
This Patient
Septic shock dt.
Pneumonia
Suggestion : reexamine
blood culture, urinalisis,
γGT, ALP, total protein,
globulin, pheriperal blood
smear, reticulosite, SI,TIBC
Monitoring:
Vital Sign, CBC, AST, ALT,
Bilirubin T/D/I, Albumin, Ur,
Cr, BGA, lactic acid, SE,
urine output, procalcitonin,
thorax X-ray, SOFA score
26
 Chronic Kidney Disease (CKD)
• CKD is defined as abnormalities of kidney structure or
function, present for >3 months, with implications for health.
Criteria for CKD (either of the following present for >3 months)
Markers of kidney damage • Albuminuria (AER ≥30 mg/24 hours;
(one or more) ACR ≥30 mg/g [≥3 mg/mmol])
• Urine sediment abnormalities
• Electrolyte and other abnormalities
due to tubular disorders
• Abnormalities detected by histology
• Structural abnormalities detected by
imaging
• History of kidney transplantation
Decreased GFR GFR <60 ml/min/1.73 m2 (GFR
categories G3a–G5)

27
Staging of CKD by GFR & Albuminuria categories

28
 Acute on CKD
• Definition : patients with CKD who fulfill any AKI
definition that is based on changes in serum Cr level
(e.g., 0.3 mg/dl per either the AKIN or
KDIGO guidelines).
• CKD is a risk factor for AKI. It is believed because some of
the connection is biological, related to diseased kidneys’
reduced renal reserve and inability to handle stress such
as abnormally low blood pressure or nephrotoxic drugs.
• Acute on CKD risk factors : hyperbilirubinemia, intensive
care unit stay, sepsis, mechanical ventilation, cardiac
surgery, and cardiac catheterization. Proteinuria—
independent of level of GFR—is also a risk factor for AKI.
29
THE ROLE OF ACUTE KIDNEY INJURY IN
CHRONIC KIDNEY DISEASE, 2017
30
 Cardiorenal Syndrome (CRS)
CRS, describing the dynamic inter-relationship between
heart and kidney malfunction, whereby acute or chronic
dysfunction in one organ may induce acute or chronic
dysfunction of the other.

31
Male, 56 yo
• Complaint : SOB
• Past history :HT +, PCI 2 months ago,
This Patient
High Creatinine since 2019
• Anemia NN, Leukositosis, Neutrofilia CKD DD/ Acute on
• Hipoalbuminemia CKD
• ↑ Ur ≥ 0,3mg/dL in 2 days
• ↑ Cr & Uric Acid Suggestion : USG,
• ↑ hsCRP
• ↑ procalcitonin Urinalisis, Pheriperal
• ↑ Lactic acid. BGA : metabolic acidosis Blood Smear,
• SOFA score : 5  10 Reticulosite
• Sputum ETT culture: Pseudomonas
aeruginosa. Blood culture negative
• Physical Examination: GCS 14(agitated), Monitoring: CBC,
BP 100/70 (Dobu+NE), Tachycardia, Ureum, Creatinin,
Tachypnoe, Rh +/+, cold extremities BGA, lactic acid, SE,
• Chest X-ray : pneumonia, cardiomegaly,
pulmonary edema
albumin, urine output
32
 2
Hyperglycemia in this patient

33
 Reactive Hyperglycemia
• Stress hyperglycemia is common in critically ill
patients and appears to be a marker of
disease severity.
• The stress response is mediated largely by the
hypothalamic-pituitary-adrenal (HPA) axis and
the sympathoadrenal system.
• In patients with shock, plasma concentrations
of epinephrine increase 50-fold and
norepinephrine levels increase 10-fold. The
adrenal medulla is the major source of these
Marik, Paul E.; Stress hyperglycemia: an essential

released catecholamines
34
survival response; Critical Care 2013
• Both epinephrine and norepinephrine
stimulate hepatic gluconeogenesis and
glycogenolysis; norepinephrine has the added
effect of increasing the supply of glycerol to
the liver via lipolysis.
• Inflammatory mediators, specifically the
cytokines TNF-α, IL-1, IL-6, and C-reactive
protein, also induce peripheral insulin
resistance.

Marik, Paul E.; Stress hyperglycemia: an essential

35
survival response; Critical Care 2013
36
 Criteria for the Diagnosis of Diabetes
ADA, 2020

FPG ≥126 mg/dL (7.0 mmol/L)

OR
2-h PG ≥200 mg/dL (11.1 mmol/L) during OGTT.
OR
A1C ≥6.5% (48 mmol/mol).
OR
In a patient with classic symptoms of hyperglycemia
or hyperglycemic crisis, a random plasma glucose
≥200 mg/dL (11.1 mmol/L).

37
Male, 56 yo
• Complaint : SOB
• Past history :HT +, PCI 2 months ago,
This Patient
High Creatinine since 2019
• Anemia NN, Leukositosis, Neutrofilia Hyperglycemia
• Normal CKMB & Troponin I reactive DD/ susp.
• ↑ NT-pro BNP
DM type 2
• ↑ RBS, FBG
• ↑ hsCRP
• ↑ Lactic acid Suggestion :
• Hipoalbuminemia 2hPPBG, Urinalisis
• ↑ Ur, Cr & Uric Acid
• ↑ hsCRP
• ↑ procalcitonin
Monitoring :
• ↑ Lactic acid. BGA : metabolic acidosis FBG & 2hPPBG
• SOFA score : 5  10
• Sputum ETT culture: Pseudomonas
aeruginosa. Blood culture negative
38
 3
Sterile Blood Culture in This Patient

39
• Blood cultures are still considered to be the ‘gold
standard’ for the detection of microbial pathogens
related to bacteraemia and sepsis.
• It is important to understand the process from
collection to obtaining a true result and to avoid false
negative or false positive.
• When we get the negative result for blood culture we
should consider some pre-analytical, analytical, or
post-analytical errors. Blood cultures taken while on
antimicrobial therapy will prevent detection of some
bacteraemias. Adequate sample volume may remains
a critical factor to detect bacteraemia. Selection of the
correct blood culture bottle is important too. Clinical
information and labelling are the first step we should
 Negative Blood Culture
False Negative Blood Culture

Pre-analytic Analytic Post-analytic

• Antimicrobial therapy • Culture media
• Information & Labeling • Incubation
• Volume of sample • Storage If the bacteria
was anaerob,
• Right culture bottle these factors
• Storage might be error

True Sterile Blood Culture

• Sepsis non-bacterial (virus or fungal)
• True sterile (no systemic infection)
41
Dreyer.A, Blood Culture Systems: From Patient to Result, 2012
 Positive Sputum ETT Culture
False Positive True Positive
• Contaminant • Pneumonia
Sputum ETT culture
False Positive S.aureus True Positive S.aureus
• Sepsis may be from • Colonisation S.aureus
another site of infection locally  non systemic
False (not pneumonia)
Negative • Sepsis may caused by
• Sepsis may caused by nonaerobic bacteria
nonaerobic bacteria
Blood
culture • Contamination sputum • Colonisation S.aureus
culture locally  non systemic
True • No systemic infection • Pneumonia cause by
Negative • Pneumonia cause by virus or fungi
virus or fungi

42
Male, 56 yo complained SOB, chest pain, cough, and
subfebris. Laboratory showed Anemia NN, leukositosis,
neutrofilia, hypoalbuminemia,↑ hsCRP & Procalcitonin.
SOFA score 5  10. Chest X-ray : pneumonia. Sputum ETT
culture: Pseudomonas aeruginosa. Blood culture negative.
Some probable conditions :
• Pneumonia was caused by virus or fungi.
• Colonisation S.aureus locally  non systemic
• Contamination sputum culture with no systemic infection
• Sepsis may caused by nonaerobic bacteria
• Sepsis may be from another site of infection (not
pneumonia)
Suggestion : reexamine sputum & blood culture, urinalisis
43
 Conclusion
o It has been discussed patient male, 56 yo with
CHF NYHA stage IV, shock condition dt.
cardiogenik DD/ sepsis, and renal insufficiency.
o Hyperglycemia in this patient due to reactive
hyperglycemia DD/ susp. DM type 2.
• S.aureus sputum ETT culture but sterile blood
culture may caused by some conditions : virus,
fungi, or nonaerobic bacteria as sepsis etiology,
no systemic infection, contamination of sputum
ETT culture, and another site of infection.
o
• Suggestion : peripheral blood smear, reticulosite, SI,
TIBC, 2hPPBG, urinalisis, GGT, ALP, total protein,
globulin, echocardiography, kidney USG, reexamine
blood culture.

- Monitoring : CBC, Ur, Cr, Uric acid, Troponin I,

CKMB, NT-ProBNP, SOFA Score, SGOT/PT, Bil T/D/I,
Albumin, Lactic acid, FBG, procalcitonin, BGA, SE,
ECG, Thorax X-ray, Vital Sign, urine output

45
Thank you

46
PCCL PL IDx PDx
1. ♂ 56 th Acute • Unstable Monitoring:
Complaint : SOB + chest pain Coronary Angina - Vital Sign
Past history :HT +, PCI a month Syndrome + Pectoris - ECG
ago, High Cretinine since 2019 Congestive • CHF NYHA - Troponin I
Laboratory Heart class IV dt. - BGA
• Anemia NN Failure HHD + ACS - SE
• Leukositosis, Neutrofilia - Lactic Acid
• Normal FH - CBC
• Normal CKMB & Troponin I - FH
• ↑ NT-pro BNP - Urine output
• ↑ SGOT
• ↑ RBS, FBG
• ↑ hsCRP
• ↑ Lactic acid
• BGA : Metabolic acidosis
Physical Examination
• GCS : 14 gelisah on sedasi
• TD 100/70 (NE + Dobu)
• Tachycardia, tachypnoe
• Rh+/+
• Cold acral
ECG
Total RBBB 47
PCCL PL IDx PDx
Acute • Unstable Monitoring:
ECG Coronary Angina - Vital Sign
Total RBBB Syndrome + Pectoris - ECG
Congestive • CHF NYHA - Troponin I
Radiology Heart class IV dt. - BGA
• Pneumonia Failure HHD + ACS - SE
• Cardiiomegali - Lactic Acid
• Pulmonary Oedem - CBC
- FH
- Urine output

48
PCCL PL IDx PDx
2. ♂ 56 th Sepsis Sepsis ec • reexamine blood
Complaint : SOB + chest pain pneumonia culture
Past history :HT +, PCI a month ago, non-bacterial • Urinalisis
High Creatinine since 2019 • γGT, ALP, total
Laboratory protein, globulin
Anemia NN, Leukositosis, Neutrofilia • pheriperal blood
Hipoalbuminemia smear, reticulosite
↑ Ur ≥ 0,3mg/dL in 2 days
↑ Cr & Uric Acid Monitoring:
↑ hsCRP - Vital Sign
↑ procalcitonin - CBC
↑ Lactic acid. BGA : metabolic - AST, ALT, Bilirubin
acidosis T/D/I, Albumin
SOFA score : 5  10 - Ur, Cr
Culture Sputum ETT : Pseudomonas - BGA, lactic acid, SE
aeruginosa. Blood culture negative - urine output
Physical Examination: GCS - Procalcitonin
14(agitated), BP 100/70 (Dobu+NE), - SOFA score
Tachycardia, Tachypnoe, Rh +/+, - thorax X-ray
cold extremities
Chest X-ray : pneumonia

49
PCCL PL IDx PDx
3. ♂ 56 th Shock Shock Monitoring:
Complaint : SOB + chest pain cardiogenic DD/ - Vital Sign
Past history :HT +, PCI a month ago, shock septic - ECG
High Creatinine since 2019 - Urine output
- CBC
Laboratory - BGA, lactic acid, SE
• Anemia NN, Leukositosis,
Neutrofilia
• Normal FH
• Normal CKMB & Troponin I
• ↑ NT-pro BNP
• ↑ SGOT
• Hipoalbuminemia
• ↑ Ur ≥ 0,3mg/dL in 2 days
• ↑ Cr & Uric Acid
• ↑ hsCRP
• ↑ procalcitonin
• ↑ Lactic acid. BGA : metabolic
acidosis
SOFA score : 5  10
Culture Sputum ETT : Pseudomonas
aeruginosa. Blood culture negative
Physical Examination: GCS
14(agitated), BP 100/70 (Dobu+NE), 50
PCCL PL IDx PDx
3. ♂ 56 th Shock Shock Monitoring:
Complaint : SOB + chest pain cardiogenic DD/ - Vital Sign
Past history :HT +, PCI a month ago, shock septic - ECG
High Creatinine since 2019 - Urine output
- CBC
SOFA score : 5  10 - BGA, lactic acid, SE
Culture Sputum ETT : Pseudomonas
aeruginosa. Blood culture negative
Physical Examination: GCS
14(agitated), BP 100/70 (Dobu+NE),
Tachycardia, Tachypnoe, Rh +/+,
cold extremities
Chest X-ray : pneumonia,
cardiomegaly, pulmonary oedema

51
PCCL PL IDx PDx
4. ♂ 56 th Renal • Acute on - Urinalisis
Complaint : SOB + chest pain Insufficiency CKD ec ACS - Pheriperal Blood
Past history :HT +, PCI a DD/ sepsis Smear
month ago, High Creatinine • CKD dt. - Reticulosite
since 2019 Hipertensive
nephropath Monitoring:
Laboratory y DD/ • CBC
• Anemia NN, Leukositosis, cardiorenal • Ureum, Creatinin
Neutrofilia syndrome • BGA, lactic acid, SE
• Hipoalbuminemia • Albumin
• ↑ Ur ≥ 0,3mg/dL in 2 days • urine output
• ↑ Cr & Uric Acid
• ↑ hsCRP
• ↑ procalcitonin
• ↑ Lactic acid. BGA :
metabolic acidosis

SOFA score : 5  10

52
PCCL PL IDx PDx
4. ♂ 56 th Renal • Acute on - Urinalisis
Complaint : SOB + chest pain Insufficiency CKD ec ACS - Pheriperal Blood
Past history :HT +, PCI a DD/ sepsis Smear
month ago, High Creatinine • CKD dt. - Reticulosite
since 2019 Hipertensive
nephropath Monitoring:
Culture y DD/ • CBC
Sputum ETT culture: cardiorenal • Ureum, Creatinin
Pseudomonas aeruginosa. syndrome • BGA, lactic acid, SE
Blood culture negative • Albumin
• urine output
Physical Examination: GCS
14(agitated), BP 100/70
(Dobu+NE), Tachycardia,
Tachypnoe, Rh +/+, cold
extremities

Chest X-ray : pneumonia,

cardiomegaly, pulmonary
edema

53
PCCL PL IDx PDx
5. ♂ 56 th Hyper Reactive FBG
Complaint : SOB + chest pain glyce hyperglycemia 2hPPBG
Past history :HT +, PCI a month ago, mia DD/ susp. DM Ratio GA : HbA1c
High Creatinine since 2019 tipe 2 Urinalisis
Laboratory
Anemia NN, Leukositosis, Neutrofilia
Hipoalbuminemia
↑ Ur ≥ 0,3mg/dL in 2 days
↑ Cr & Uric Acid
↑ hsCRP
↑ procalcitonin
↑ Lactic acid. BGA : metabolic
acidosis
SOFA score : 5  10
Culture Sputum ETT : Pseudomonas
aeruginosa. Blood culture negative
Physical Examination: GCS
14(agitated), BP 100/70 (Dobu+NE),
Tachycardia, Tachypnoe, Rh +/+, cold
extremities
Chest X-ray : pneumonia

54
• HT kronis  HHD  Cardiorenal Syndrome
• HT kronis  hypertensive nephropathy
Cardiorenal Syndrome
• + atherosclerosis  CAD
• CAD + HHD  Acute HF  shock cardiogenic
 DOC
• Pneumonia  sepsis  shock sepsis?  DOC

55
This patient SOFA SCORE : 15
56
57
Normogram Davenport

58