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***Details changed to protect patient anonymity***

67 year old female with a hx of HTN, uncontrolled T2DM and recurrent cystitis presented with a week's worth of abdominal and left flank pain with 3 days of worsening dyspnea. On presentation had a MAP in the 40s, HR in the 110s and a RR of 30.

Initial labs had a WBC of 24k, lactate of 5, procal of 14 and bicarb of 14. Imaging had a clean CXR, CT A/P with some air in the left ureter as well as the renal parenchyma. Empiric ceftriaxone and vanc were started.

Received 30mL/kg bolus and was started on NE.  Once they added in vaso they gave me a call as that is the trigger for a critical care consult in our system (either 2 pressors or intubated). On my exam she had some light mottling to bilateral lower extremities, reaching to about the knees, was mildly encephalopathic, moaning but answering questions.  HR had crept up to 120 or so with a pressure around 100/60 on 24 of NE and 0.04 of vasopressin. She was broadened to meropenem and I went upstairs after giving recs to the hospitalist.

Around two hours later the hospitalist let me know that the patient now had a HR in the 150S-160s, I asked her to go down and see her as we had a COVID patient which needed an airway.  When I made my way downstairs the patient was now completely obtunded, mottled up to her abdomen with a sinus tach of 160, BP 104/58(ish), RR 24 on 28mcg/min of NE and 0.04 of vaso.

Next step from anyone? Curious regarding other folks' approach.

@LT_Oneal_PAC and @EMEDPA we're still downstairs so you're totally allowed to play 😉

 

 

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Also from the "downstairs":

  • Progressive mottling is extremely concerning.
  • Air in the ureter and renal parenchyma is concerning for either gas from the infectious process or a fistula to the bowels - did anything like that show on the C/T
  • Any coagulapathy?  Platelet count?  Coag labs?  Patient's temp?
  • Anything that looked like ischemic gut?
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4 minutes ago, ohiovolffemtp said:

Also from the "downstairs":

  • Progressive mottling is extremely concerning.
  • Air in the ureter and renal parenchyma is concerning for either gas from the infectious process or a fistula to the bowels - did anything like that show on the C/T
  • Any coagulapathy?  Platelet count?  Coag labs?  Patient's temp?
  • Anything that looked like ischemic gut?

@ohiovolffemtp you are 100% correct and I will never forgive myself for forgetting to add you in on the case 😄

It looked like emphysematous pyelonephritis, I've only seen one other case to be honest.  INR was 1.5, platelets 120k or so.  Temp was 38.1.  Gut looked good on the scan.

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Well, just remember I'm depending on younger folks like you to pay for my social security in under 7 years. 😁

Did this patient survive?  From the progression I'm very concerned that her discharge might be to her eternal home.

Oh, but don't ever ask me to start a patient on precedex - it would be faster for me to fly the patient to a hospital that has it vs getting it couriered to me.

Edited by ohiovolffemtp
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3 minutes ago, ohiovolffemtp said:

Well, just remember I'm depending on younger folks like you to pay for my social security in under 7 years. 😁

Did this patient survive?  From the progression I'm very concerned that her discharge might be to her eternal home.

Unfortunately she did not survive, made it about 24 hours. Outside of some of our COVID folks I haven't seen sick escalate this quickly.  Walking and talking to dead in <36 hours.

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12 hours ago, MediMike said:

***Details changed to protect patient anonymity***

67 year old female with a hx of HTN, uncontrolled T2DM and recurrent cystitis presented with a week's worth of abdominal and left flank pain with 3 days of worsening dyspnea. On presentation had a MAP in the 40s, HR in the 110s and a RR of 30.

Initial labs had a WBC of 24k, lactate of 5, procal of 14 and bicarb of 14. Imaging had a clean CXR, CT A/P with some air in the left ureter as well as the renal parenchyma. Empiric ceftriaxone and vanc were started.

Received 30mL/kg bolus and was started on NE.  Once they added in vaso they gave me a call as that is the trigger for a critical care consult in our system (either 2 pressors or intubated). On my exam she had some light mottling to bilateral lower extremities, reaching to about the knees, was mildly encephalopathic, moaning but answering questions.  HR had crept up to 120 or so with a pressure around 100/60 on 24 of NE and 0.04 of vasopressin. She was broadened to meropenem and I went upstairs after giving recs to the hospitalist.

Around two hours later the hospitalist let me know that the patient now had a HR in the 150S-160s, I asked her to go down and see her as we had a COVID patient which needed an airway.  When I made my way downstairs the patient was now completely obtunded, mottled up to her abdomen with a sinus tach of 160, BP 104/58(ish), RR 24 on 28mcg/min of NE and 0.04 of vaso.

Next step from anyone? Curious regarding other folks' approach.

@LT_Oneal_PAC and @EMEDPA we're still downstairs so you're totally allowed to play 😉

 

 

 

I would have started meropenem (push dose) and linezolid on someone looking this sick as soon as the I had urine and blood cultures drawn. There is a EM infectious disease guru out of Cali that has really pushed that this should be the new vanc/zosyn. I'm not quite there yet, but I'm quicker on the meropenem  these days in people who have recurrent UTIs and septic. 

The questions below are what I would be asking myself at some point:

ECG? Troponin ? POC cardiac US show any depressed LV function? are we flogging a dying heart as well as fighting distributive shocK?

Glucose? Beta hydroxybutyrate? Did infection lead to DKA or HHS?

IVC indicating fluid tolerant? Do I need to give more fluids?

Metabolic panel? Making urine? Does this lady need dialysis?

ABG? Is she tuckering out with her rapid breathing? Does she need Bipap or intubation?

Is the sepsis causing the tachyarrhythmia or is the high dose NE causing it? Should I be using phenylephrine now?

ScVO2?

Could consider steroids if failing 2 pressors as they may have their adrenals in the crapper, but I haven't thought much about that since I was in the SNICU. 

Call the ICU PA and ask them to take this patient off my hands. Ask them family if they would like the Chaplain. 

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Excellent thoughts above.  Thank you for sharing this excellent case.

Agree, when patients are not responding or crashing will do a quick POCUS (with the CVSpO2) to assess for sepsis induced cardiomyopathy or Takutsubo and consider dobutamine.  

Often, will consider stress dose steroids when patients are crashing (rapidly escalating vasopressor dose). 
 

My institution recently moved to Epic   I always try to look at micro data to see if they have any resistant MDROs in their history (looks bad if they are a frequent flier and you have them on zosyn and their E. Coli has been resistant to it). Meropenem is usually broad enough.

I question the initial use of ceftriaxone (not covering Pseudomonas) but yet are covering MRSA with vanc?  Why cover one resistant organism and not another (no Pseudomonas in your patient population)?  At my institution any patient on life support (vasopressor) gets at least vanc/zosyn. This delay in broad spectrum could have increased her mortality.

If there is a strong suspicion of urinary source highly likely it is gram negative and when the patients are crashing or confirmed gram negative bacteremia I will strongly consider a dose of gent for double gram negative coverage.  It’s the gram negatives that cause this profound vasodilators effect/vasoplegia.  
 

I don’t recall seeing a TSH.  Fast or slow, hot or cold, AMS get TFTs.  

Lastly, this patient wouldn’t have been a candidate but if a younger person with few comorbidities was maxed on 3-4 vasopressors and had considered/attempted inotrope would consider calling the shock team (if available at your academic healthcare system).  Never seen them come and cannulate a patient for V/A ECMO but we have called for a few consults.

 

Edited by polarbebe
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7 hours ago, LT_Oneal_PAC said:

 

I would have started meropenem (push dose) and linezolid on someone looking this sick as soon as the I had urine and blood cultures drawn. There is a EM infectious disease guru out of Cali that has really pushed that this should be the new vanc/zosyn. I'm not quite there yet, but I'm quicker on the meropenem  these days in people who have recurrent UTIs and septic. 

The questions below are what I would be asking myself at some point:

ECG? Troponin ? POC cardiac US show any depressed LV function? are we flogging a dying heart as well as fighting distributive shocK?

Glucose? Beta hydroxybutyrate? Did infection lead to DKA or HHS?

IVC indicating fluid tolerant? Do I need to give more fluids?

Metabolic panel? Making urine? Does this lady need dialysis?

ABG? Is she tuckering out with her rapid breathing? Does she need Bipap or intubation?

Is the sepsis causing the tachyarrhythmia or is the high dose NE causing it? Should I be using phenylephrine now?

ScVO2?

Could consider steroids if failing 2 pressors as they may have their adrenals in the crapper, but I haven't thought much about that since I was in the SNICU. 

Call the ICU PA and ask them to take this patient off my hands. Ask them family if they would like the Chaplain. 

Depending on the facility Mero is totally on lockdown, once shop required an ID consult to start it, another if used for more than 24 hours... luckily no one cares here. I've avoided linezolid in any situation where I'm concerned about bacteremia due to its bacteriostatic nature, although I'm not sure how founded in science that approach is.

ECG sinus tach, troponin is 0.9 from 0.01. She was making urine but it was falling off.

Ended up deciding to intubate her with 0.15mg/kg etomidate and 1.5mg/kg of roc. Cranked up the NE prior to induction, passed a 7.5 tube with VL after taking a second to poke at a much smaller glottic opening than I was anticipating. Immediate post intubation pressure was in the 60s despite the half dose induction agent but popped back up after a minute or two.

Threw in an art line, HR seemed to be coming down a bit, asked them to call me if it didn't carry on that trajectory. About 2 hours later they called me and said she had been sitting at 160 ever since I walked out of the room. They brought her upstairs and she looked worse (if that was possible). Threw a probe on her chest @LT_Oneal_PAC and @polarbebe nailed it, picture below. Had a conversation with son who agreed with a DNR status.

Called urology who shrugged their shoulders, IR agreed to throw in a nephrostomy tube despite only mild-mod hydro without obstruction (after getting 2 provider sign off that they weren't responsible for her dying when they proned her). 

Unfortunately her pressor requirements continued to increase, ended up maxed on everything outside of AT2. Transitioned to comfort care the following morning.

The progression was incredibly rapid, to be honest it really caught me off guard. Little research showed that depending on severity mortality ranges between 18% and 69%, major recs are antibiotics (dur) and perc drain if there's anything there.

PXL_20210929_025853038.MP.jpg

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The shape of that heart looks like an “octopus pot” did they call it Takotsubo?


Every several months I will come across someone in mixed shock, both septic and cardiogenic shock.  Needless to say patients with two concurrent shock types don’t do well (though I am surprised once in a while when they make it out of the unit). 
 

Usually we trial dobutamine and gentle diuresis.  We very rarely ever place a Swan Ganz anymore.  The CVP and the CVSpO2 although poor surrogates usually substitute (in addition to other measures of hemodynamics and end organ perfusion). 
 

 

 


 

 

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