Category: 3.9

Recognises and manages the septic patient

Invasive Streptococcal A Infections and Intravenous Immunoglobulin

Invasive Streptococcal A Infections and Intravenous Immunoglobulin

Steve MathieuLeave a comment

A middle aged woman presented with a one day history of swollen, painful red thigh after a prodromal sore throat. She had a exquisitely tender left thigh and knee with cellulitis. She was apyrexial, with normal heart rate and blood pressure, but had a respiratory rate of 24. She had a neutrophilia (28), elevated CRP, hyperlactataemia (4.1) an acute kidney injury (creat 170) and a mild coagulopathy. She was given analgesia, broad spectrum antibiotics (including clindamycin) and underwent a CT thigh which showed muscle swelling in the anterior compartment with fluid tracking up to the hip. Knee aspirate showed large number of gram positive cocci, later confirmed as Streptococcus A. Two hours into her admission the inflammation was involving the groin. She underwent exploration and debridement in theatre, and was noradrenaline dependent postoperatively. She was commenced on intravenous immunoglobulin on the same day. She required further debridement of the leg and lower abdomen on day 3. She gradually weaned off support, and underwent several more operations for closure of wounds and reconstructive surgery.

What is the role of IVIG in Invasive Streptococcal Infections

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Dexamethasone in Bacterial Meningitis

Dexamethasone in Bacterial Meningitis

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A previously healthy 25 year old female was admitted with low GCS and a fever. She had a 24 history of viral symptoms including sore throat and a headache. On admission she had a GCS of 3, temperature of 38.9°C and raised inflammatory markers. She was intubated but did not require vasopressor support. A CT brain showed diffuse cerebral swelling, effacement of the sulci, sylvian fissures, basal cisterns and 3rd/4th ventricles, and early cerebellar tonsillar herniation. Lumbar puncture was not performed due to CT appearances. She was commenced on intravenous (IV) ceftriaxone 2g twice daily, IV acyclovir 800mg three times daily, and IV dexamethasone 10mg four times daily. Unfortunately, her pupils remained fixed and dilated on sedation hold 36 hours later, and she was making no respiratory efforts. She subsequently became a DBD organ donor.

What is the evidence for dexamethasone in bacterial meningitis?

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Corticosteroids in Septic Shock

Corticosteroids in Septic Shock

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A week after an elective colectomy, a 70yr old man developed septic shock and multiorgan failure secondary to anastomotic breakdown. He was managed according to surviving sepsis guidelines with source control, early antibiotics, fluids and noradrenaline. The patient remained hypotensive and refractory to noradrenaline therapy, and had vasopressin and low dose hydrocortisone infusion commenced.

What is the evidence for the use of corticosteroids in septic shock?Read More »

Diagnosing Ventilator Acquired Pneumonia

Diagnosing Ventilator Acquired Pneumonia

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A 65 year old woman developed a left lower lobe hospital acquired pneumonia following a elective laparoscopic procedure for which she was ventilated for 4 days. Twenty four hours post extubation, she developed hypoxic respiratory failure with bilateral patchy shadowing on chest X-ray. She was reintubated and subsequently grew Pseudomonas aeruginosa from tracheal aspirate.

How do we diagnose Ventilator Associated Pneumonia (VAP)?Read More »

Transfusion in Sepsis

Transfusion in Sepsis

ICM Case Summaries1 Comment

A 85 year old man presented with acute bowel obstruction. He had a history of hypertension and diverticulitis disease, but was active for his age. He was not known to have coronary or any other vascular pathology. At laparotomy, a large diverticulitis abscess was identified. When this was manipulated, he developed an SVT with a ventricular rate of 210 bpm which progressed to VT. He received 1 mg adrenaline and 2 minutes CPR in total, with no electrical shocks. At this point perfusion and pressure returned. Surgery was expedited and simplified. He remained intubated and ventilated on ITU post-operatively. ECG demonstrated global t-wave inversion. He required noradrenaline and adrenaline to maintain blood pressure. During the initial 48 hours, his haemoglobin (Hb) fell from 11.9 g/dl to 8.1 g/dl, raising the suggestion of packed red cell (PRC) transfusion.

What is the most appropriate threshold to transfuse packed red cells in critically ill patients?Read More »

Necrotising Fasciitis - Advances in diagnosis and management

Necrotising Fasciitis – Advances in diagnosis and management

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A 40 year old man underwent a minor elective day case lower limb soft tissue operation. 72 hrs later he began to feel unwell and developed fevers and rigors. He was seen first thing in the morning with increasing pain and inflammation extending up from the foot to the knee. Intravenous antibiotics were started on admission. He was in theatre having a debridement by late morning, by which time the inflammation had spread to the inner thigh. He was in profound septic shock with disseminated intravascular coagulopathy. During the debridement, it was noted that the inflammation had spread to his pelvis. He had a laparotomy and it was determined that the resection he would require was unsurvivable. Treatment was withdrawn and he died on the operating table.

How is necrotising fasciitis diagnosed and how is it managed?

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Vasopressin in Septic Shock

Vasopressin in Septic Shock

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An elderly man presented with an acute abdomen. At operation, he was found to have four-quadrant peritonitis due to a perforating sigmoid tumour. He underwent a hemicolectomy and had a defunctioning stoma formed. Postoperatively, he required 0.7mcg/kg/min noradrenaline to maintain a MAP 65mmHg. A vasopressin infusion was commenced and his noradrenaline requirements decreased. However, he developed acute kidney injury and subsequent multiorgan failure. Treatment was withdrawn around 48 hours post-operatively.

Is vasopressin safe to use in septic shock? What are the benefits?Read More »

IV Immunoglobulin for Necrotising Fasciitis

IV Immunoglobulin for Necrotising Fasciitis

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A 40 year old woman presented with painful swelling of the right side of the neck. She had previously suffered a haematological malignancy and received a bone marrow transplant. A presumptive diagnosis of necrotising fasciitis was made and the neck, shoulder and chest underwent surgical debridement. Postoperatively, the patient remained ventilated in septic shock. Further debridement was required at 24 hours. Group A streptococcus was grown from the debrided tissue and IV immunoglobulins was commenced. The patient gradually weaned from support and was discharged from ICU several days later.

Does IV immunoglobulin have a role to play in the treatment of necrotising fasciitis?Read More »

Early Goal Directed Therapy for Severe Sepsis

Early Goal Directed Therapy for Severe Sepsis

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An elderly man presented with urosepsis. He was in septic shock with a lactate of 8.2 on presentation. He was commenced on antibiotics and fluid resuscitated in the Emergency Department and his lactate was remeasured as 6.1. His ScvO2 was measured as 54%, rising to 63% after further fluid challenge. He was fluid resuscitated and commenced on noradrenaline to maintain a MAP of 65. He recovered from his urosepsis and was discharged from hospital 5 days later.

What is the evidence for and against Early Goal Directed Therapy for the management of severe sepsis?Read More »

Management of the Open Abdomen

Management of the Open Abdomen after Severe Abdominal Sepsis

ICM Case Summaries1 Comment

A middle aged man presented with a week long history of severe abdominal pain and distension. CT scans confirmed free air, fluid and probable large bowel perforation. Laparotomy revealed multiple large bowel perforations and four quadrant peritonitis. He had an extensive washout, a colectomy and a laparostomy with negative pressure dressing applied. He returned to theatre at 24 hrs for further washout, and at 48hrs for stoma formation. He had several further relook laparotomies, and abdominal wall closure was achieved on day 10. During this time he had been treated for septic shock and acute kidney injury and had been commenced on parenteral nutrition. His recovery was further complicated by healthcare associated infections but he left hospital nearly a month later.

How is an open abdomen managed after severe abdominal sepsis?Read More »