PCT-1 CASE
PRESENTATION
Presented by: XYZ
(P17091029)
(M. Pharm Clinical Pharmacy)
http
A CASE STUDY OF 67 YEAR OLD
FEMALE ADMITTED IN
HOSPITAL WITH CHIEF
COMPALINT OF SOB AND
DIAGNOSED WITH UROSEPSIS
AND SEPTICAEMIC SHOCK
Urosepsis and Septic shock
• Sepsis is a clinical syndrome of life-threatening organ dysfunction
caused by a dysregulated response to infection.
• Sometimes,the bacteria that caused the UTI can infect bloodstream.
This condition is called Urosepsis.
• Septic shock is a critical reduction in tissue perfusion; acute failure
of multiple organs, including the lungs, kidneys, and liver.
• Septic shock is a subset of sepsis with significantly increased
mortality due to severe abnormalities of circulation and/or cellular
metabolism.
SITE OF INFECTION
Signs and symptoms of urosepsis
• Fever
• Pain on the lower sides of back
• Nausea and vomiting
• Extreme tiredness
• Decreased urine output
• Inability to think clearly
• Difficulty breathing
• Abnormal heart function
• Abdominal pain
• Rapid heart rate
• High or low body temperature
• Fast breathing
Case: SP00XXXX
• 67 years old Woman
• Chief Complaint (s)
Sudden onset of SOB today.
• Patient Demographics
Reg. Number SP001XXXX
Gender Female
Age 67 years
Ethnicity Malay
DOA 05/10/2019
DOD 08/10/2019
Patient transferred from Hospital X and admitted into (Y).
Presented to ICU on Saturday (05/10/2019), with the followings:
• Progressively worsening SOB
• Tiredness
• Back pain
• Mental confusion
• Oliguria
• No fever
• No chest pain
• No cough
• No runny nose
• No vomiting
• No diarrhea
• Progressively worsening SOB
• Tiredness
• Back pain
• Mental confusion
• Oliguria
• No fever
• No chest pain
• No cough
• No runny nose
• No vomiting
• No diarrhea
Past Medical History
– Heart failure
– PE
– CKD (Fluid restriction < 500 cc /day)
– DM
– HPT
Past Medical History
She was admitted in Hospital Pantai (2/10/2019)
Severe back pain
Difficulty in breathing and subsequently collapsed
Given CPR for 20 minutes
Past Medical History
ICU Hospital SAH (20/08/2018 till 27/08/2018)
Klebsiella pneumonia bactremia with PE
Intubated for 3 days
Past Medication History
– T Bisoprolol 5 mg OD
– T Furosemide 40 mg OD
– T Clopidogrel 75 mg OD
– T Atorvastatin 40 mg ON
– T Aspirin 150 mg OD
– T Loratadine 10 mg OD
– T Amlodipine 10 mg OD
– T Gliclazide MR 30 mg OD
– T Warfarin 3 mg
Review of system
General Unstable, Ill condition, Intubated, Sedated
Vital signs BP:148/74, PR:90, T: 370C, RR: 30, SPO2: 97
NEURO/MENTAL Disturbed, Confused
CVS sinus rhythm, no murmur
CHEST Equal air entry, Lungs clear
Pale eyes, no edema, pupil 3x3 reactive, bilateral tympanic membrane normal, no
HEENT
ear discharge, no tonsils.
ABDOMEN soft, non-tender
HEPATIC no hepatomegaly, no organomegaly
SKIN/MUSCLE moist, no rash
LYMPH NODE not palpable
Lab Investigations
• Arterial Blood Gases (ABG)
pH (Arterial) 7.35 ( 7.300- 7.450)
Partial CO2 (Arterial) 24.0 mmHg ( 35.0- 48.0)
Partial O2 (Arterial) 60.5 mmHg ( 83.0- 108.0)
Bicarbonate (Arterial) 15.2 mmol/L ( 22.2- 28.3)
Base Excess (Arterial) -12.6 mmol/L ( -3.2- 1.8)
Oxygen Saturation (Arterial) 88.7 % ( 94.0- 98.0)
Blood Pressure Chart SBP DBP
160
150
SBP
140
130
Blood Pressure
120
110
100
90
80
DBP
70
60
05/10/19 06/10/19 07/10/19 08/10/19
Vital Signs 05/10/19 06/10/19 07/10/19 08/10/19
Temperature 37 37 37.5 37
Respiratory rate 30 33 32 34
Heart rate 102 100 97 90
SPO2 97% 97% 100% 95%
LAB INVESTIGATIONS – FBC, BUSE & Creatinine
Test Normal Range 05/10 06/10 07/10 08/10
Full Blood Count
TWBC 5.2-12.4 x 103/uL 8.6
RBC 4.5-6.3 x10 4.5
Hemoglobin 12 -16 g/dL 10.4
Hematocrit 37 – 47 % 38.4
Platelet 200 – 400 103/uL 300
BUSE & Renal Function Tests
Na+ 135-145 mmol/L 132 134 135
Ca2+ 2.2-2.7 mmol/L 2.07
K+ 3.5-5.0 mmol/L 7.5 4.9 4.9
Mg 2+ 0.7-1.0mmol/L 0.8
PO43- 1.0-1.95 mmol/L 3.4
Urea 2.76-8.07 mmol/L 81.9 80.9
Creatinine 27-42 umol/L 1022 1098
LAB INVESTIGATIONS – LIVER PROFILE
Test Normal Range Test values (05/10/2018)
INR 02 – 03 (Targeted) 13 (Upon admission)
PT/aPTT 10- 13.5 sec 13.5 sec
Total Protein (g/L) 66-87 g/L -
Albumin (g/L) 35-50 g/L 28
Total Bili (mmol/L) <20 11
ALP (U/L) 53-141 174
Microbiological findings
Date of Date of Results Sample Culture & Sensitivity Test
Sample Taken Reported (taken in Hosp
Pantai)
01/10/19 04/10/2019 Blood Klebsiella Pneumonia sensitive
Diagnosis/ Impression
Urosepsis with septicemic shock
Date
Progress
Objective/Assessment
Note Plan
05/10/2 sedatedon IV Midamorphine 2cc/hr
019
septic parameters in ICU
haemodynamically supported on IV urgent HD
Noradrenaline 15cc/hr and IV Dopamine IV Pantoprazole 40mg BD
10cc/hr continue IV tazosin 2.25g QID
CBD ongoing bladder irrgation - clearing, no
pyuria seen. BP 150/68. PR 104. SPo2 98%
keep UO > 0.5cc/kg/hr
mechanical DVT prophylaxis
IV Human Albumin 20% 50cc
IV Hydrocortisone 50mg QID
Date
Progress
Objective/Assessment
Note Plan
06/10/ sedated via IV Propofol 10mg/ml Tazocin 2.25g QID - Day 2
2019
hemodynamically supported via quadruple IV Human Albumin 20% 50cc - Day 2
inotropes IV Hydrocortisone 50mg QID - Day 2
IV Noradrenaline 35ml/hr IV Pantoprazole 40mg BD
IV Adrenaline 15ml/hr
IV Vasopressin 8 ml/hr
Miconazole cream LA BD
IV Dobutamine 2.5ml/hr IV Amiodarone 600mg over 23 hours
BP 106/50, PR 116, SPO2 99%, T 38.5, CVP 8 started due fast AF last night – withhold
DXT 5.4 in view of HR less than 80.
I/O 2586.1 / 790
Bal + 1796.1
U/O 0 - 120cc/hr
Lungs equal air entry, CVS DRNM, p/a soft
Date
Progress
Objective/Assessment
Note Plan
07/10/2 ISSUES :
019-
start IV Digoxin 0.25mg OD
08/10/2 1) severe urosepsis in severe septicaemic increase IV Noradrenaline to 40cc/hr
019 shock requiring multiple vasopressors
Cont. IV human albumin 20% 50cc OD
2) pt came in with severe acute on CKD (urea start oral kalimate 15g TDS
80, creat 1000)
- yesterday sustained SLED on inotropic
3rd cycle of lytic cocktail
support if persistent hyperkalaemia, to serve IV
- urea 81 --> post HD 63, creat 1090 --> post salbutamol 0.5mg stat
HD 768 off IV Fentanyl
3) refractory hyperkalaemia (K 6.6 this start IV calcium gluconate 1g TDS X 3
morning) causing haemodynamic crash days
4) cardiac monitor showing on off asystole but start calcium infusion 1g/hr
pulse still palpable start bicarbonate infusion 10cc/hr
- responding to boluses of IV Adrenaline (total
stanby IV Adrenaline 1 in 10,000 bedside
0.6mg)
5) ABG shows metabolic acidosis off IV vitamin K
6) severe lactic acidosis (lactate 7)
7) coffee ground on RT
Date
Progress
Objective/Assessment
Note Plan
Patient deceased
Initial Management
• Ventilate, Intubate, Sedate
• Start Inotropes
– Taper down accordingly
• Start IV piperacillin and tazobactam 4.5g STAT and
2.25g QID
Send blood culture, urine culture, UFEME, CRP, FBP,
iron studies, Hep B, C, HIV
• To insert femoral catheter and HD today
• To repeat RP and VBG 4hrs post HD
• Withhold all old medications
Drugs Dose/ Start & Potential Monitoring Rationale of
Prescribed Frequency Stop date ADRs/SE parameters Use / Drug
Response
I.V Hydrocortisone Qid 50 mg 06/10/2019- Hypokalemic Blood glucose inflammation, status
08/10/2019 alkalosis, levels asthmaticus, acute
Myocardial and chronic adrenal
rupture insufficiency
BD 40 mg 05/10/2019- Atrophic Gastritis Magnessium levels Reduce stomach acid
I.V Pantoprazole 08/10/2019 secretions
I.V Tazocin TDS 4.5 g 05/10/2019- Trouble in sleeping, Sodium levels Bacterial infections
08/10/2019 abdominal cramps speciafically (All
electrolytes)
I.V Human Albumin 06/10/2019 Blood volume loss in Electrolytes, Blood Severe skin reactions,
sepsis pressure monitoring fever and chills
I.V Digoxin OD 0.25 08/10/2019- Endocardititis, Electrolytes balance, Herat failure, Atrial
08/10/2019 Hypertension, Throid Heart rate, fibrillation
disorders, Mental behaviour changes
confusion
Oral Kalimate TDS 15g 06/10/2019- constipation, loss of Magnessium levels hyperkalemia
08/10/2019 appetite,
I.V Calcium gluconate TDS 1 gm 07/10/2019- Increased thirst and Electrolytes balance Off label use in
08/10/2019 tigling sensation cardiac arrest
Miconazole cream LA 05/10/2019- Anti fungal cream
08/10/2019
Rational of Therapy
Pharmaceutical care issues
• PCI 1 : Need for Digoxin
• PCI 2: Failure to provide treatment for AF
• PCI 3: Contraindication of Inotropes
• PCI 4: Monotherapy with Calcium
• PCI 5: Drug – Drug Interactions
PCI 1 : Need for Digoxin
Goal of therapy:
• Patient required treatment with digoxin
– Electrolyte imbalance
– Sensitive to toxic effects
Cardiac glycosides have important positive inotropic,
neurohormonal, and electrophysiologic actions.
The ability of digoxin to reduce sympathetic activation has also
been recognized. For maximal early benefits, digoxin requires
loading doses, which can be administered intravenously or
orally.
DrugPoint. 2007. "Digoxin toxicity caused by a decline in renal function." Prescriber 18 (14):41-43. doi: 10.1002/psb.110.
PCI # 1: Need for digoxin..
Digoxin Dose
• Patient required treatment with digoxin
– Electrolyte imbalance
– Sensitive to toxic effects
PCI 2: Failure to provide treatment for AF
Treatment for AF
• Goal of therapy
– Patient required amiodarone for fast atrial fibrillation.
• Amiodarone can directly cause both sinus
bradycardia and AV nodal block, due primarily to its
calcium channel blocking activity.
PCI 3: Contraindication of Inotropes
• Adrenaline may worsen acidosis and
increase lactate
• Dopamine causes cardiac arrhythmias and
should be considered in patients with low
risk of dysrhythmia.
• Vasopressin may further decrease cardiac
output
• IV Dobutamine may decrease blood
pressure
PCI 4: Monotherapy with Calcium
• Intravenous calcium
– Short-lived 30 – 60 minutes
• Combination therapies
– Drive potassium into cells
– Insulin and Glucose
• Recommended
– Bicarbonate
• Not recommended – limited efficacy
Mount, David B. "Treatment and Prevention of Hyperkalemia in Adults." Uptodate. Ed. Post, Ted. W.2017. Print.
PCI 5: Drug – Drug Interactions
• Hydrocortisone can cause hypokalaemia, increasing the risk of torsade de
pointes, which might be additive with the effects of amiodarone.
Recommendation: The combined use of drugs that can cause hypokalaemia
(e.g. amphotericin B, beta-agonist bronchodilators, corticosteroids, thiazide
and loop diuretics, stimulant laxatives, and theophylline) and drugs that
prolong the QT interval (e.g. class Ia and class III antiarrhythmics) should be
well monitored because hypokalaemia increases the risk of torsade de
pointes(Baxter 2010).
Mount, David B. "Treatment and Prevention of Hyperkalemia in Adults." Uptodate. Ed. Post, Ted. W.2017. Print.
PCI 5: Drug – Drug Interactions…
In patients with AF, all combinations of warfarin, aspirin,
and clopidogrel are associated with increased risk of
nonfatal and fatal bleeding. Dual warfarin and clopidogrel
therapy and triple therapy carried a more than 3-fold higher
risk than did warfarin monotherapy.
Mount, David B. "Treatment and Prevention of Hyperkalemia in Adults." Uptodate. Ed. Post, Ted. W.2017. Print.
Summary
• 67 years old woman
• Presented with worsening SOB
– CKD, DM, HTN, IHD
• Diagnosed with Urosepsis with septicemic
shock.
• Provided with ICU care (ventilatory, sedation,
analgesia)
• Patient could not survive.
References
1. Howard R. Digoxin toxicity caused by a decline in renal function.
PRESCRIBER-LONDON THEN GUILDFORD-. 2007;18(14):41.
2. Malaysia, Ministry of Health. "National Antibiotic Guideline." 2014. Print.
3. Balakrishnan, S.D., Shahid, N.J., Fairuz, T.M. and Ramdhan, I.M.A., 2014.
‘Does the National Antibiotic Guideline-2008 remain applicable for treating
diabetic foot infection?’A new evidence-based regional study on culture and
sensitivity patterns in Terengganu population. Malaysian orthopaedic
journal, 8(1), p.42.
4. Mount DB. Treatment and prevention of hyperkalemia in adults. UpToDate.
Waltham (MA): Wolters Kluwer. 2013.
5. Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, Kumar
A, Sevransky JE, Sprung CL, Nunnally ME, Rochwerg B. Surviving sepsis
campaign: international guidelines for management of sepsis and septic
shock: 2016. Intensive care medicine. 2017 Mar;43:304-77.
Thank you!
