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Course # 94342 • Sepsis: Diagnosis and Management

CASE STUDY

Patient A is a woman, 50 years of age, who was admitted to the emergency department after a motor vehicle accident. She incurred massive abdominal injuries and was transported to the emergency department unconscious and hypotensive upon arrival. She was receiving 35% O2 via oxygen mask. Her respiratory rate was 28 breaths per minute, and lung sounds were clear bilaterally. She had a sinus tachycardia with a heart rate of 150 beats per minute. Her blood pressure was 80/45 mm Hg. The patient had a 40 pack-year history of cigarette smoking and had been taking medications to control hypertension.

She was transported via stretcher to radiology for a computed tomography scan, which revealed bleeding in the peritoneum. She was taken immediately to surgery. Following surgery, she was taken to the ICU. Three liters of Ringer's lactate had been infused in surgery. Estimated blood loss was 2500 cc, and she received 6 units of whole blood in surgery. Despite fluid resuscitation, the patient was hypotensive during much of the surgical procedure. To assess fluid management, a pulmonary artery catheter was placed while in surgery. A variety of data was obtained upon arrival to the surgical ICU.

Vital SignsHemodynamic ParametersArterial Blood Gases (ABGs)Laboratory ValuesVentilator Settings
BP: 100/50 mm Hg
Pulse: 120 beats per minute
Respirations: 14 breaths per minute on respirator
Temperature: 96.5°F
CVP: 5 mm Hg
PAP: 25/15 mm Hg
PAWP: 13 mm Hg
CO: 3.2
SVR: 1,100
SvO2: 72%
pH: 7.45
PaCO2: 36
PO2: 80
HCO3: 28
SaO2: 95%
Sodium: 130
Potassium: 4.5
Chloride: 95
Glucose: 140
Hemoglobin: 11.5
Hemocrit: 35
WBC: 11,000
Rate: 14 on assist control
FiO2: 40%
Tidal Volume: 800
BP: blood pressure; CI: cardiac index; CO: cardiac output; CVP: central venous pressure; HCO3: bicarbonate; FiO2: fraction of inspired oxygen; PAP: pulmonary artery pressure; PAWP: pulmonary artery wedge pressure; PO2: partial pressure of oxygen; SaO2: oxygen saturation; SvO2: venous oxygen saturation; SVR: systemic vascular resistance; WBC: white blood cells.

Patient A was hemodynamically stable following surgery. She awakened slowly and was able to be extubated and put on a 40% O2 mask.

POST-OPERATIVE DAY 3

Three days after surgery, the patient's level of consciousness began to deteriorate. She was obtunded and only awoke when her name was called. Her skin was warm to touch and appeared flushed, and she had 4+ bounding pulses.

Vital SignsHemodynamic ParametersABGs on 40% O2 MaskLaboratory Values
BP: 110/72 mm Hg
Pulse: 118 beats per minute
Respirations: 28 breaths per minute
Temperature: 104°F
CVP: 6 mm Hg
PAP: 20/12 mm Hg
PAWP: 10 mm Hg
CO: 6.0
CI: 4.2
SVR: 850
SvO2: 85%
pH: 7.48
PaCO2: 30
PO2: 85
SvO2: 85%
Hemoglobin: 9.8
Hemocrit: 28.8
WBC: 25,000
Platelets: 168,000

Urine output was 15 cc per hour for the last three hours. Cultures of sputum, urine, and blood were obtained. Antibiotic therapy was initiated.

Analysis

Identify the term that best describes Patient A's condition at the present moment.

Sepsis is caused by bacteria, viruses, or fungi in the blood. It is a clinical continuum ranging from bacteremia through septicemia to septic shock. Patient A is presently displaying signs of septicemia. Her blood pressure and cardiac output are within an acceptable range. Chemical mediators are being released and causing the physiologic changes.

POST-OPERATIVE DAY 5

On the 5th post-operative day, Patient A's blood pressure dropped to 84/58 mm Hg; her respirations were 32 breaths per minute, heart rate was 130 beats per minute, and temperature was 97°F. Despite 3000 cc fluid resuscitation, Patient A's condition continued to deteriorate. She was re-intubated and connected to a respirator.

Hemodynamic Parameters
CVP: 3 mm Hg
PAP: 15/7 mm Hg
PAWP: 5 mm Hg
CO: 3.0
CI: 1.6
SVR: 1,597
SvO2: 68%

Analysis

List the risk factors applicable to Patient A's case.

Trauma
Cigarette smoking
Hypertension
Abdominal injuries
Multiple invasive lines
Surgery

Patient A is in what stage of septic shock? Describe the symptoms to support your answer.

Patient A is in the hypodynamic (cold) phase of septic shock. This phase is characterized by decreased cardiac output, increased SVR, hypotension, and inadequate tissue perfusion.

What are some of the causative organisms associated with sepsis in a post-operative, hospitalized patient?

Escherichia coli
Klebsiella
Enterobacter
Pseudomonas aeruginosa
Staphylococcus aureus

POST-OPERATIVE DAY 8

On post-operative day 8, Patient A's skin was cool and cyanotic, and mottling was noted in the extremities. She responded only to painful stimuli.

Vital SignsHemodynamic ParametersABGsLaboratory Values
BP: 38/40 mm Hg
Pulse: 170 beats per minute
Respirations: 14 breaths per minute on respirator. She is not assisting.
Temperature: 95.6°F
CVP: 6 mm Hg
PAP: 38/20 mm Hg
PAWP: 18 mm Hg
CO: 2.0
SVR: 1746
SvO2: 48%
pH: 7.28
PaCO2: 48
PO2: 40
SvO2: 52%
SaO2: 80%
Sodium: 160
Potassium: 6.8
BUN: 48
Creatinine: 3.0
Platelets: 72,000
PT: 21
PTT: 100.5
BUN: blood urea nitrogen; PT: prothrombin time; PTT: partial thromboplastin time.

Analysis

Patient A's temperature is 95.6°F. Is this to be expected in the hypodynamic phase and why?

Yes. Hypothermia is common during the hypodynamic phase. Metabolic and myocardial activity are greatly reduced.

What is the physiologic cause of increased SVR in the hypodynamic phase?

In the hypodynamic phase, SVR is caused by decreased cardiac output and elevated serum lactate levels.

What management would be appropriate in this phase?

Afterload reduction and myocardial support are of great importance at this point. Before the use of vasodilators, cautious fluid administration with hemodynamic monitoring is essential to provide normovolemia as the vascular capacitance increases. If fluid resuscitation proves unsuccessful, the use of vasodilators in combination with a positive inotrope may be attempted.

POST-OPERATIVE DAY 10

Patient A died on the 10th post-operative day due to the complications of septic shock: renal failure and hepatic failure complicated by DIC and ARDS.

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