The ER calls with an ICU admission as follows: 60 year old presenting with complaints of cough and shortness of breath. Vitals include a temp of 101, pulse of 130, bp 90/60, and pulse ox of 65%. The patient has significant increased work of breathing . CXR reveals a RUL infiltrate.
What do you want to do for this patient? Give evidence to support your plan.
This patient is septic given that they are febrile, tachycardic and have a source of pneumonia. Uptodate 1.
ReplyDeletePatient will need a 30ml/kg fluid bolus and if she does not respond appropriately could potentially need vasopressor support. Antibiotic therapy would need to be started. Uptodate 2.
Patient could be started on an empiric therapy of azithromycin and zosyn for community acquired pneumonia Uptodae 3.
With the patient having tachycardia, hypotension and hypoxia you could also entertain the idea of pulmonary embolism but the patient's well's score is -2 based on the information provided. Therefore unlikely.
If needed the vasopressor of choice is levophed followed by vasopressin.
1.http://www.uptodate.com/contents/systemic-inflammatory-response-syndrome-sirs-and-sepsis-in-children-definitions-epidemiology-clinical-manifestations-and-diagnosis?search=sirs+criteria&source=search_result&selectedTitle=2%7E150
2. http://www.uptodate.com/contents/systemic-inflammatory-response-syndrome-sirs-and-sepsis-in-children-definitions-epidemiology-clinical-manifestations-and-diagnosis?search=sirs+criteria&source=search_result&selectedTitle=2%7E150
3. http://www.uptodate.com/contents/treatment-of-community-acquired-pneumonia-in-adults-who-require-hospitalization?search=treatment+of+community+acquired+pneumonia&source=search_result&selectedTitle=1%7E150
This patient meets the sepsis criteria with an elevated temperature and tachycardia with an apparent pneumonia. She does not meet criteria for severe sepsis. She is also hypotensive and hypoxic.
ReplyDeletePer the surviving sepsis guidelines the patient should be treated with crystalloid IV fluids at 30 mL/kg. A lactic acid level should be obtained, check blood and sputum cultures and then start patient on IV antibiotics. A repeat lactic acid should be check in 3 hours if elevated. At this time patient does not meet septic shock criteria, MAP is 70 and there is no need for vasopressor support.
Surviving sepsis guidelines
An ABG should be obtained to further quantify patient’s respiratory state and she should be placed on supplemental oxygen. If patient’s respiratory state improves regarding both oxygen saturation and effort on nasal cannula she can be admitted with telemetry. If she requires non-invasive ventilation patient should be admitted to progressive care. If she is still unable to maintain her airway or if her MAP deteriorates from admission to the point where she requires intubation or vasopressors patient may be admitted to the ICU.
"ICU Admission, Discharge and Triage Guidelines: A Framework to Enhancve Clinical Operations, Development of Institutional Policies, and Further Research" Nates et al, CCMjournal.org 8:2016, 44:8, 1553-1602
Initial treatment for community acquired pneumonia in the non-ICU setting should be either a flouroquinolone such as levaquin monotherapy or a b-lactam such as ceftriaxone + a macrolide such as azithromycin as per the ID society guidelines. Given the fact that the patient is septic, dual therapy is recommended per the surviving sepsis guideline.
"Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults" IDSA/ATS Guidelines for CAP in Adults • CID 2007:44 (Suppl 2) • S27
Other considerations in this patient: For her cough she can be treated with duonebs, accapella, guafenison or other treatments. A 12 lead EKG should be obtained given her tachyarrhythmia. There is a broad differential and treatment will be based on further workup. Given her shortness of breath and tachycardia PE must be considered. Her Wells score is low risk so that does not require further workup.
This patient meets criteria for sepsis. I would first want to get some information including how much IVF the patient has received, if an ABG was done, if the patient is currently on any supplemental oxygen or NIPPV, and brief HPI/PMH. Within the first 3 hours, I would want to make sure he received 30 cc/kg crystalloid IVF (NS or LR), obtain lactic acid, obtain stat blood/urine/sputum cultures, and first start off with administering broad spectrum antibiotics (Vancomycin to cover for MRSA pneumonia and Zosyn to cover for any gram negative/aneorobic organisms). If there was any concern that the patient can’t protect his airway or becomes encephalopathic or hemodynamically unstable on Bipap with worsening PCo2 of 50 or greater, the patient should be immediately intubated. His Map is currently > 65, but if after fluid resuscitation Map is < 65, he should be started on vasopressors because he meets the criteria for septic shock. Levophed would be the first choice in septic shock with vasopressin added after levophed if necessary because both increase vascular resistance and vasopressin potentiates the effect of levophed. If there is concern that these vasopressors will need to be infused for a prolonged period of time, central venous access will need to be obtained to reduce the risk of extravasation and tissue ischemia.
ReplyDeleteSources:
http://www.survivingsepsis.org/Bundles/Pages/default.aspx
https://www.openanesthesia.org/indications_for_mechanical_ventilation/
http://www.surgicalcriticalcare.net/Guidelines/vasopressin.pdf
https://pulmccm.org/critical-care-review/vasopressors-inotropes-shock-syndromes-review/
The patient clearly meets the severe sepsis criteria because of her temperature , tachycardia ,pneumonia and hypotension but doesn’t meet the septic shock criteria because MAP is 70 . I will start the patient on IV fluids and start the oxygen supplementation through NC . Then I will give him breathing treatment with Duonebs and will draw blood cultures and also take sputum cultures. After the cultures I will administer broad spectrum antibiotics with IV Vancomycin and IV Zosyn. In the meantime I will access his respiratory status and also administer a dose of IV solumedrol and 625 mg Tylenol . Patient will be placed on continuous telemetry monitoring to monitor. I will also order chest PT and Robitussin syrup for chest congestion. Further management depends upon patient condition.
ReplyDeleteWould request that the patient be put on BIPAP right away and order stat ABG and lactic acid. Would want to get BMP too in the event we have a mixed acidosis. Next I would get cultures (sputum, urine, and blood x2) as the patient is sepsis with RUL PNA as source of infection after meeting SIRS criteria (fever 101 and HR 130). Then would start her on IV ceftriaxone and IV azithromycin (after checking allergy history and EKG for QT prolongation) for community acquired PNA Then give IV fluid preferably a cristalloid solution like NS or LR within 3 hours (30cc/kg ) in the form of boluses until BP and tissue perfusion are improved (targeted MAP>65). I would also repeat lactic acid q6H x3 and closely monitor vital signs and O2 saturation. Will plan to deescalate antibiotics once we have the results of cultures and sensitivities. Other labs would be ordered as well.
ReplyDeleteAccording to Up To Date,< for patients with sepsis and septic shock, therapeutic priorities include securing the airway, correcting hypoxemia, and establishing vascular access for the early administration of fluids and antibiotics.>