BACTERIAL SEPSIS
Slides prepared by - Dr Pragyan Routary
Case Discussion 1
CHIEF COMPLAINTS
A 62 Year old female presenting with
• Increased frequency of micturition for 5 days
• High Grade Fever associated with chills & rigor for 4 days.
• Pain whole abdomen for 3 days.
• Right Flank pain.
HISTORY Fever was high grade intermittent in
nature associated with chills and rigor.
OF Increased frequency of micturition
PRESENT was associated with burning
sensation
ILLNESS .
It was accompanied by flank pain as well
HISTORY .
Underwent Lap cholecystectomy 2 months back after
which she developed secondary abdominal sepsis
OF PAST and was on Foleys catheterization for 3 weeks
ILLNESS
AND
SURGICAL Diabetes mellitus for 4 years- uncontrolled and
HISTORY
.
requires Insulin with OHAs.
Hypertension since 10 years on Telmisartan 40mg
• DRUG HISTORY –
• She is on Oral Hypoglycemic agent - OHA ( GLIMIPERIDE 4MG AND
METFORMIN 1000MG ) AND INSULIN Human Mixtard 30/70 14 unit
BBF, 10unit BD.
• As she had a history of hypoglycemia 7 days back, she had stopped
insulin on her own and at present on OHA only.
• O&G History
• 2 live births from normal delivery. LCB – 20 years back.
• Menopause – 5 Years Back.
IN ED –Examination
• Mild drowsy but oriented to time , place and person
• HR =110/MIN, BP= 80/50 mmHg, RR= 28/min, SpO2=98% room air.
• No Pallor, icterus, pedal edema, cyanosis, clubbing.
• Febrile = 103.8 deg F, dry tongue and skin.
• Bedside HGT= 412 mg/dl
• P/A = mild tenderness all over the abdomen,
• CVS/ RS/ CNS Examination - normal
PROVISIONAL DIAGNOSIS
PROVISIONAL DIAGNOSIS
• UROSEPSIS
PROVISIONAL DIAGNOSIS
• UROSEPSIS
• DIABETIC KETOACIDOSIS
PROVISIONAL DIAGNOSIS
• UROSEPSIS
• DIABETIC KETOACIDOSIS
• ABDOMINAL SEPSIS ( POST OP )
PROVISIONAL DIAGNOSIS
• UROSEPSIS
• DIABETIC KETOACIDOSIS
• ABDOMINAL SEPSIS ( POST OP )
PROVISIONAL DIAGNOSIS
• UROSEPSIS + SEPTIC SHOCK
What next?
What next?
• Balanced crystalloid IV fluid administration in small boluses
What next?
• Balanced crystalloid IV fluid administration in small boluses
• IV Vasopressors – Noradrenaline infusion.
What next?
• Balanced crystalloid IV fluid administration in small boluses
• IV Vasopressors – Noradrenaline infusion.
• Cultures – Blood 2 sets, Urine – 1 set
What next?
• Balanced crystalloid IV fluid administration in small boluses
• IV Vasopressors – Noradrenaline infusion.
• Cultures – Blood 2 sets, Urine – 1 set
• Blood Parameters to be sent - CBC, RFT, LFT.
What next?
• Balanced crystalloid IV fluid administration in small boluses
• IV Vasopressors – Noradrenaline infusion.
• Cultures – Blood 2 sets, Urine – 1 set
• Blood Parameters to be sent - CBC, RFT, LFT.
• Urine Routine & Microscopy.
What next ?
• Balanced crystalloid IV fluid administration in small boluses
• IV Vasopressors – Noradrenaline infusion.
• Cultures – Blood 2 sets, Urine – 1 set
• Blood Parameters to be sent - CBC, RFT, LFT.
• Urine Routine & Microscopy.
• USG Of Abdomen & Pelvis
What next ?
• Balanced crystalloid IV fluid administration in small boluses
• IV Vasopressors – Noradrenaline infusion.
• Cultures – Blood 2 sets, Urine – 1 set
• Blood Parameters to be sent - CBC, RFT, LFT.
• Urine Routine & Microscopy.
• USG Of Abdomen & Pelvis
1 HOUR BUNDLE
• Balanced crystalloid IV fluid administration in small boluses
• IV Vasopressors – Noradrenaline infusion.
• Cultures – Blood 2 sets, Urine – 1 set
1 HOUR BUNDLE
• Balanced crystalloid IV fluid administration in small boluses
• IV Vasopressors – Noradrenaline infusion.
• Cultures – Blood 2 sets, Urine – 1 set
• Measure Lactate
• Appropriate Antibiotics -
1 HOUR BUNDLE
• Balanced crystalloid IV fluid administration in small boluses
• IV Vasopressors – Noradrenaline infusion.
• Cultures – Blood 2 sets, Urine – 1 set
• Measure Lactate
• Appropriate Antibiotics
1 HOUR BUNDLE
• Balanced crystalloid IV fluid administration in small boluses
• IV Vasopressors – Noradrenaline infusion.
• Cultures – Blood 2 sets, Urine – 1 set
• Measure Lactate
• Appropriate Antibiotics – Inj Piperacillin Tazobactam Started.
AFTER 1 HOUR IN ED
After initial management
HR= 104/ min, BP= 100/64 mmHg( with Norad )
Patient shifted to ICU
Still drowsy but oriented.
DAY 1 - ICU
Lab parameters Urine R/M
• TLC=21000 • Pus cells= plenty
• Creat= 1.8 • Mild proteinuria
• Urea= 66 • Nitrites and LSE positive.
• Hb= 10.9
• Serum electrolytes, LFT
was within limits.
BED SIDE USG WHOLE ABDOMEN
• USG shows echogenic dirty
shadows arising from renal
pelvis with focal collection in
upper pole of right kidney.
• Possibly Emphysematous
pyelonephritis
DAY 1/ 3- ICU
• Patient continued to be sick with moderate Noradrenaline
support.
• Urine Culture showed Pseudomonas sensitive to Piperacillin
Tazobactam.
• But patient condition remain critical.
• WHAT NEXT ?
DAY 1/ 3- ICU
• Patient continued to be sick with moderate Noradrenaline
support.
• Urine Culture showed Pseudomonas sensitive to Piperacillin
Tazobactam.
• But patient condition remain critical.
• WHAT NEXT ?
• SOURCE CONTROL
DAY 3- ICU
UROLOGY
PLANNED FOR DJ PROCEDUR
CONSULTATION
STENT PLACED E DONE
TAKEN
DAY 4- ICU
Lab parameters Vitals Management
• TLC-14400 • HR= 88/min • Conservative
• Urea= 48 • BP= 100/70 with continued
• Creat= 1.4 mmHg( Off antimicrobial
• Serum vasopressors) and HGT control.
electrolytes • Chest- B/L NVBS • Sensorium
within normal • P/A = soft with improved and
limits. no tenderness. patient alert.
DAY 4- ICU
Antimicrobial
Patient was shifted
continued as per
to ward
Culture report.
COURSE IN WARD – DAY 5 - 7
Patient was further Patient
Urology review
managed in ward discharged on
was done
for 2 more days Day 7
Thank you
