CASE CASE Mrs. , 23/ Female, was referred to FH in a state of - PDF document

11/04/2013 CASE CASE • Mrs. ………, 23/ Female, was referred to FH in a state of septic shock due to PROM and ? CHORIOAMNIONITIS …. SEPTIC SHOCK / MODS IN • History : – G1 with married life 1 year, with twin gestation ,irregular PREGNANCY ANC and PROM ANC and PROM – Delivered on 14/3/2013, second twin after a gap of 3 hours , had PPH and hypovolemic shock , resuscitated and received 3 whole blood. Dr. Aanchal Bharuka – Became breathless and was intubated and shifted to ICU Department of Anaesthesia, Pain and Critical care, Fernandez hospital, – As patient was unstable, was shifted to another ICU at Prerna Team Adoni….. before coming here. AT ADMISSION INTERVENTIONS • Unconscious, not responding. • Patient resuscitated with fluids as per sepsis bundle • Had generalized Seizure at admission and required stiff vasopressor support. • ETT 7.0 in situ, on AMBU ventilation • HR 160/min • Connected to ventilator • Pulse – not palpable carotids ‐ feeble • Pulse – not palpable, carotids ‐ feeble • Sepsis profile sent, ABG done. S i fil G d • BP ‐ not recordable • Rt. Femoral artery cannulated under vasopressor • SPO 2 ‐ not sensing boluses and infusion, C.O monitor connected • Peripheries ‐ cold, clammy • Pupils ‐ constricted, RL • Lt. IJV Catheter in situ, Rt. IJV site ‐ Hematoma • APACHE II ‐ 33, SOFA ‐ 18 INITIAL INVESTIGATIONS / POINT OF CARE REPORTS Admission ABG LABS X RAY CHEST HB % 10.7 AFTER WBC 27300 ADMISSION ADMISSION PLATELETS PLATELETS 42000 42000 CREATININE 1.7 PT/ INR/ APTT 24.9/2.2/39.2 ELECTROLYTES N GRBS 33 PROCALCITONINE 35.33 1

11/04/2013 PROBLEMS PROVISIONAL DIAGNOSIS • Septic shock / MODS • AKI • ARDS • Hepatic dysfunction • Hepatic dysfunction • ? Hypoxic / Glucopenic encephalopathy PROM / • Severe metabolic acidosis CHORIOAMNIONITIS/ PPH / • Dyselectrolytemia SEPTIC SHOCK ‐ MODS PLAN SUBSEQUENT PROGRESS • Continue stiff ventilatory support • Patient remained unresponsive. • Continue stiff Inotropic support • Avoid NMBAs • Stabilized hemodynamically and ventilatory parameters became relatively better became relatively better • Minimize sedation • Minimize sedation • Assess CNS status • CXR improved • Continue sepsis bundle aggressively • Empiric antibiotic started ‐ IMIPEMAN in this case • Attenders counseled for radio ‐ imaging brain • MRI/MRV as soon as patient stabilizes • Nutrition support ‐ TPN / EN MRI BRAIN ‐ PND 4 MRI BRAIN ‐ PND 4 2

11/04/2013 CT CHEST MRI VENOGRAM ELECTROLYTES… HYPERNATREMIA SUBSEQUENT DAYS… DAY 6 – Eye opening, recognizing the parents – Weaning from MV stepped up DAY 7 ‐ 11 DAY 7 11 – GCS 15 – ABG: pH 7.35, PaO 2 ‐ 125, PaCO 2 ‐ 38.5 – Trial of extubation planned with anticipated difficult weaning in view of Sepsis indiced myopathy, tachycardia and fever spikes – Attenders counseled for tracheostomy also. CHEST X RAY PND ‐ 7 3

11/04/2013 CONTD… S C VO 2 • Trial of extubation given: Twice • DAY 13: Tracheostomised CHEST XRAY CONTD…… • DAY 14 ‐ 20 ‐ Maintaining on T – Piece on room air with intermittent Oxygen – Shifted to room – Tachycardia and fever persistent Tachycardia and fever persistent – Abdominal distension present – USG Guided Abd paracentesis CONTD…… MICROBIOLOGY & ANTIBIOTICS DAY culture Organism Resistance Antibiotic Remark • Paracentesis: Before NIL TAXIM Changed admission MAGNEX in < 48 hrs – Straw colored fluid ERTAPENEM – 90% Neutrophils 15/3/13 Blood Empirically Imipenam – C/S: E.Coli + Candida 15/3/13 HVS & Urine Enterococcus CRE Ofloxacillin Given for 8 Clindamycin y days y 16/3/13 Endotracheal Nil tip, central line Urine ‐ candida Nil Blood ‐ Fungus Nil 18/3/13 Arterial line tip NIL 20/3/13 Blood – aerobic NIL & anaerobic 4

11/04/2013 MICROBIOLOGY & ANTIBIOTICS CONTD…… Date Culture Organism Resistance Antibiotic Remark • DAY 21 21/3/13 E. T. Tip NIL – CC T Abdomen done – CIAKI Protocol 22/3/13 CENTRAL Line NIL – Despite that pt collapsed in CT Scan 25/3/13 Endotracheal tip Pseudomonas Piperacillin ‐ Given for 8 Aeruginosa Aeruginosa Tazobactum Tazobactum days days Suite, resuscitated, stabilized and Suite resuscitated stabilized and (No VAP) shifted Urine Sterile 2/4/13 Central line tip Non Albicans Fluconazole candida 3/4/13 Blood ‐ Aerobic Nil 4/4/13 Ascitic fluid Candida species, Magnex forte E.Coli CT Abdomen CT Abdomen CONTD.. • DAY 21 Patient was taken up for surgery with high risk consent Ileostomy done, pus removed • DAY 24 Post surgery patient is stable and on weaning protocol . Change of Tracheostomy and Rt. SCV insertion 5

11/04/2013 ~ 3.5L of feculent, bilious Large Cecal perforation with ascitic fluid! necrotic mucosa Large Cecal perforation with necrotic mucosa Ileostomy Stabilized immediate post debridement! DISCUSSION…… SEPSIS……. 6

11/04/2013 Sepsis in pregnancy CAUSES OF SEPSIS NON OBSTETRIC OBSTETRIC CAUSES • Urinary tract Infection • Chorioamnionitis • Pyelonephritis y p • Postpartum Endometritis p • Pneumonia • Septic Abortion • H I V • CS Wound Infection • Malaria • Episiotomy Infection • Appendicitis etc… RISK FACTORS FOR SEPSIS IN OBSTETRICS SPECTRUM OF SEPSIS: DISEASE OF CONTINUUM ! OBSTETRIC FACTORS PATIENT FACTORS • Amniocentesis, and other • Obesity invasive intrauterine • Impaired glucose procedures tolerance/diabetes • Cervical suture • Impaired immunity • PROM • Anaemia • Prolonged labour with • Vaginal discharge multiple (>5) V/E • History of pelvic infection • Vaginal trauma • History of Group B Caesarean section • streptococcal infection • RPOC SYSTEMIC INFLAMMATORY RESPONSE SEPSIS SYNDROME Sepsis is the systemic response to infection. Thus in sepsis, clinical signs of SIRS + definitive evidence of infection • SIRS is a widespread inflammatory response to a variety of severe clinical insults. SEVERE SEPSIS SEPTIC SHOCK • This syndrome is clinically recognized by the presence of two or more of the following: Sepsis is considered Sepsis is considered Septic shock is sepsis S ti h k i i • Temperature >38 0 C or <36 0 C severe when associated with hypotension despite • Heart rate >90 beats/min with organ dysfunction, adequate fluid hypoperfusion or • Respiratory rate >20 breaths/min or PaCO 2 < 32 mmHg resuscitation. hypotension. • White blood cells >12 ∙ 109/dL or <4 ∙ 109/dL or >10% immature (band) forms 7

11/04/2013 SURVIVING SEPSIS CAMPAIGN BUNDLES 2013 UPDATED GUIDELINES Sepsis Clock Sepsis Clock • TO BE COMPLETED WITHIN 3 HOURS: 1) Measure lactate level • SSC was initiated in October 2002 SSC was initiated in October 2002 2) Obtain blood cultures prior to administration of 2) Obtain blood cultures prior to administration of antibiotics • Evidence based Guidelines ( 2004 ) 3) Administer broad spectrum antibiotics • International Guidelines for Management of severe sepsis ‐ 2008 4) Administer 30 mL/kg crystalloid for hypotension or lactate ≥ 4mmol/L • Revised again in 2012 and released in JAN 2013 SURVIVING SEPSIS CAMPAIGN Sepsis Clock Sepsis Clock BUNDLES TO BE COMPLETED WITHIN 6 HOURS TO BE COMPLETED WITHIN 3 HOURS: 5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation)to maintain a MAP 65 mm Hg 1) Measure lactate level 6) In the event of persistent arterial hypotension despite volume resuscitation or initial lactate ≥ 4 mmol/L (36 mg/dL): resuscitation or initial lactate ≥ 4 mmol/L (36 mg/dL): 2) Obtain blood cultures prior to administration of antibiotics ‐ Measure CVP* ‐ Measure ScvO2* 3) Administer broad spectrum antibiotics 7) Remeasure lactate if initial lactate was elevated* 4) Administer 30 mL/kg crystalloid for hypotension or lactate ≥ 4mmol/L *Targets for quantitative resuscitation included in the guidelines are CVP of 8 mm Hg, ScvO2 of 70%, and normalization of lactate MANAGEMENT STRATEGIES TO BE COMPLETED WITHIN 6 HOURS 5) Apply vasopressors (for hypotension that does not respond • Initial Resuscitation to initial fluid resuscitation)to maintain a MAP 65 mm Hg • Screening For Sepsis And Performance Improvement 6) In the event of persistent arterial hypotension despite • Diagnosis volume resuscitation or initial lactate ≥ 4 mmol/L (36 mg/dL): • Antimicrobial Therapy • Antimicrobial Therapy ‐ Measure CVP* • Source Control ‐ Measure ScvO2* • Infection Prevention 7) Remeasure lactate if initial lactate was elevated* *Targets for quantitative resuscitation included in the guidelines are CVP of 8 mm Hg, ScvO2 of 70%, and normalization of lactate 8

11/04/2013 Other Supportive Therapy Of Severe Hemodynamic Support And Adjunctive Sepsis Therapy • Blood Product Administration • Fluid Therapy of Severe Sepsis • Immunoglobulins – No role • Selenium ‐ No role • Recombinant Activated Protein C (Rhapc) – No role • Recombinant Activated Protein C (Rhapc) No role • Inotropic Therapy • Mechanical Ventilation Of Sepsis ‐ induced Acute Respiratory Distress Syndrome (ARDS) • Corticosteroids • Sedation, Analgesia, And Neuromuscular Blockade In Sepsis • Glucose Control • Renal Replacement Therapy THANK YOU • Bicarbonate Therapy Bicarbonate Therapy • Deep Vein Thrombosis Prophylaxis • Stress Ulcer Prophylaxis • Nutrition • Setting Up Goals Of Care 9