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

11/04/2013 1 SEPTIC SHOCK / MODS IN PREGNANCY

• Dr. Aanchal Bharuka

Department of Anaesthesia, Pain and Critical care, Fernandez hospital, Prerna Team

CASE CASE

• Mrs. ………, 23/ Female, was referred to FH in a state of septic

shock due to PROM and ? CHORIOAMNIONITIS ….

• History:

– G1 with married life 1 year, with twin gestation ,irregular 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. – Became breathless and was intubated and shifted to ICU – As patient was unstable, was shifted to another ICU at Adoni….. before coming here.

AT ADMISSION

• Unconscious, not responding.
• Had generalized Seizure at admission
• ETT 7.0 in situ, on AMBU ventilation
• HR 160/min
• Pulse – not palpable carotids‐ feeble
• Pulse – not palpable, carotids‐ feeble
• BP‐ not recordable
• SPO2‐ not sensing
• Peripheries‐ cold, clammy
• Pupils‐ constricted, RL
• Lt. IJV Catheter in situ, Rt. IJV site ‐ Hematoma
• APACHE II‐ 33, SOFA‐ 18

INTERVENTIONS

• Patient resuscitated with fluids as per sepsis bundle

and required stiff vasopressor support.

• Connected to ventilator

S i fil G d

• Sepsis profile sent, ABG done.
• Rt. Femoral artery cannulated under vasopressor

boluses and infusion, C.O monitor connected

INITIAL INVESTIGATIONS / POINT OF CARE REPORTS

Admission ABG LABS

HB % 10.7 WBC 27300 PLATELETS 42000 PLATELETS 42000 CREATININE 1.7 PT/ INR/ APTT 24.9/2.2/39.2 ELECTROLYTES N GRBS 33 PROCALCITONINE 35.33

X RAY CHEST AFTER ADMISSION ADMISSION

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PROVISIONAL DIAGNOSIS

PROM / CHORIOAMNIONITIS/ PPH / SEPTIC SHOCK ‐ MODS

PROBLEMS

• Septic shock / MODS
• AKI
• ARDS
• Hepatic dysfunction
• Hepatic dysfunction
• ? Hypoxic / Glucopenic encephalopathy
• Severe metabolic acidosis
• Dyselectrolytemia

PLAN

• Continue stiff ventilatory support
• Continue stiff Inotropic support
• Avoid NMBAs
• Minimize sedation
• Minimize sedation
• Assess CNS status
• Continue sepsis bundle aggressively
• Empiric antibiotic started ‐ IMIPEMAN in this case
• MRI/MRV as soon as patient stabilizes
• Nutrition support‐ TPN / EN

SUBSEQUENT PROGRESS

• Patient remained unresponsive.
• Stabilized hemodynamically and ventilatory parameters

became relatively better became relatively better

• CXR improved
• Attenders counseled for radio‐imaging brain

MRI BRAIN‐ PND 4 MRI BRAIN‐ PND 4

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MRI VENOGRAM CT CHEST 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, PaO2‐ 125, PaCO2‐ 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.

ELECTROLYTES… HYPERNATREMIA CHEST X RAY PND ‐7

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SCVO2

CONTD…

• 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……

• Paracentesis:

– Straw colored fluid – 90% Neutrophils – C/S: E.Coli + Candida

DAY culture Organism Resistance Antibiotic Remark Before admission NIL TAXIM MAGNEX ERTAPENEM Changed in < 48 hrs 15/3/13 Blood Empirically Imipenam 15/3/13 HVS & Urine Enterococcus CRE Ofloxacillin Clindamycin Given for 8 days

MICROBIOLOGY & ANTIBIOTICS

y y 16/3/13 Endotracheal tip, central line Nil Urine‐candida Nil Blood‐Fungus Nil 18/3/13 Arterial line tip NIL 20/3/13 Blood – aerobic & anaerobic NIL

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MICROBIOLOGY & ANTIBIOTICS

Date Culture Organism Resistance Antibiotic Remark 21/3/13

• E. T. Tip

NIL 22/3/13 CENTRAL Line NIL 25/3/13 Endotracheal tip Pseudomonas Aeruginosa Piperacillin‐ Tazobactum Given for 8 days Aeruginosa (No VAP) Tazobactum days Urine Sterile 2/4/13 Central line tip Non Albicans candida Fluconazole 3/4/13 Blood‐ Aerobic Nil 4/4/13 Ascitic fluid Candida species, E.Coli Magnex forte

CONTD……

• DAY 21

– CC T Abdomen done – CIAKI Protocol – Despite that pt collapsed in CT Scan Suite resuscitated stabilized and Suite, resuscitated, stabilized and shifted

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

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~ 3.5L of feculent, bilious ascitic fluid! Large Cecal perforation with necrotic mucosa Large Cecal perforation with necrotic mucosa

Ileostomy

Stabilized immediate post debridement!

DISCUSSION…… SEPSIS…….

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Sepsis in pregnancy

CAUSES OF SEPSIS

NON OBSTETRIC

• Urinary tract Infection
• Pyelonephritis

OBSTETRIC CAUSES

• Chorioamnionitis
• Postpartum Endometritis

y p

• Pneumonia
• H I V
• Malaria
• Appendicitis etc…

p

• Septic Abortion
• CS Wound Infection
• Episiotomy Infection

RISK FACTORS FOR SEPSIS IN OBSTETRICS

OBSTETRIC FACTORS

• Amniocentesis, and other

invasive intrauterine procedures PATIENT FACTORS

• Obesity
• Impaired glucose

tolerance/diabetes

• Cervical suture
• PROM
• Prolonged labour with

multiple (>5) V/E

• Vaginal trauma
• Caesarean section
• RPOC
• Impaired immunity
• Anaemia
• Vaginal discharge
• History of pelvic infection
• History of Group B

streptococcal infection SPECTRUM OF SEPSIS: DISEASE OF CONTINUUM !

SYSTEMIC INFLAMMATORY RESPONSE SYNDROME

• SIRS is a widespread inflammatory response to a variety of

severe clinical insults.

• This syndrome is clinically recognized by the presence of

two or more of the following:

• Temperature >380C or <360C
• Heart rate >90 beats/min
• Respiratory rate >20 breaths/min or PaCO2 < 32 mmHg
• White blood cells >12 ∙ 109/dL or <4 ∙ 109/dL or >10%

immature (band) forms SEPSIS Sepsis is the systemic response to infection. Thus in sepsis, clinical signs of SIRS + definitive evidence of infection SEVERE SEPSIS Sepsis is considered SEPTIC SHOCK S ti h k i i Sepsis is considered severe when associated with organ dysfunction, hypoperfusion or hypotension. Septic shock is sepsis with hypotension despite adequate fluid resuscitation.

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• SSC was initiated in October 2002

SSC was initiated in October 2002

• Evidence based Guidelines ( 2004 )
• International Guidelines for Management of severe sepsis‐

2008

• Revised again in 2012 and released in JAN 2013

SURVIVING SEPSIS CAMPAIGN BUNDLES 2013 UPDATED GUIDELINES

• TO BE COMPLETED WITHIN 3 HOURS:

1) Measure lactate level 2) Obtain blood cultures prior to administration of

Sepsis Clock Sepsis Clock

2) Obtain blood cultures prior to administration of antibiotics 3) Administer broad spectrum antibiotics 4) Administer 30 mL/kg crystalloid for hypotension or lactate ≥4mmol/L

TO BE COMPLETED WITHIN 6 HOURS 5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation)to maintain a MAP 65 mm Hg 6) In the event of persistent arterial hypotension despite volume resuscitation or initial lactate ≥4 mmol/L (36 mg/dL): Sepsis Clock Sepsis Clock resuscitation or initial lactate ≥4 mmol/L (36 mg/dL): ‐ Measure CVP* ‐ Measure ScvO2* 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

SURVIVING SEPSIS CAMPAIGN BUNDLES

TO BE COMPLETED WITHIN 3 HOURS: 1) Measure lactate level 2) Obtain blood cultures prior to administration of antibiotics 3) Administer broad spectrum antibiotics 4) Administer 30 mL/kg crystalloid for hypotension

• r lactate ≥4mmol/L

TO BE COMPLETED WITHIN 6 HOURS 5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation)to maintain a MAP 65 mm Hg 6) In the event of persistent arterial hypotension despite volume resuscitation or initial lactate ≥4 mmol/L (36 mg/dL): ‐ Measure CVP* ‐ Measure ScvO2* 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

MANAGEMENT STRATEGIES

• Initial Resuscitation
• Screening For Sepsis And Performance Improvement
• Diagnosis
• Antimicrobial Therapy
• Antimicrobial Therapy
• Source Control
• Infection Prevention

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Hemodynamic Support And Adjunctive Therapy

• Fluid Therapy of Severe Sepsis
• Inotropic Therapy
• Corticosteroids

Other Supportive Therapy Of Severe Sepsis

• Blood Product Administration
• Immunoglobulins – No role
• Selenium‐ No role
• Recombinant Activated Protein C (Rhapc)

No role

• Recombinant Activated Protein C (Rhapc) – No role
• Mechanical Ventilation Of Sepsis‐induced Acute Respiratory

Distress Syndrome (ARDS)

• Sedation, Analgesia, And Neuromuscular Blockade In Sepsis
• Glucose Control
• Renal Replacement Therapy
• Bicarbonate Therapy

Bicarbonate Therapy

• Deep Vein Thrombosis Prophylaxis
• Stress Ulcer Prophylaxis
• Nutrition
• Setting Up Goals Of Care

THANK YOU