Patient Case CH...1. Patient status is improving. Skin looks better, patient is less angr y looking. 2. Sepsis Cellulitis - improving 10/18/19: 3. Sepsis Pneumonia: improving. On 40%

Patient Case CHGregory Butler

PharmD Candidate 2020MCPHS University

Objectives

▪ Discuss the course of treatment for a case of sepsis

▪ Describe changes in therapy and how they relate to the presenting conditions

▪ Consider medication choices and identify any drug related issues

1. Source control: AMS - empiric with 2 agents2. Hypoperfusion: Pressors3. Fluid therapy: lactic acid - to assess perfusion4. Glucose control & EN nutrition 2

Background

CC: I’m feeling dizzy and feverish. I may have gotten a tick bite.HPI: ▪ CH is a 39 year old male who presented to ED with

complaints of pounding in the head, cough, SOB, total body aches and pains.

▪ He also complains of diarrhea and constipation at the same time.

▪ O2 sat noted to be 88% when arrived. Patient is a smoker.

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Background

PMH: ▪ ADD▪ ALCOHOL WITHDRAWAL SEIZURES▪ ANXIETY/DEPRESSION/PTSD▪ INSOMNIA▪ HTN▪ HLD▪ DM2▪ TOBACCO ABUSE▪ Morbid obesity: BMI = 55.4

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Background

Home Medication List: ▪ Albuterol HFA▪ Insulin aspart, glargine▪ Lisinopril 10 mg▪ Lovastatin 40 mg▪ Metformin 1000 mg BID▪ Metoprolol tartrate 150 mg BID▪ Olanzapine 30 mg▪ Pantoprazole 40 mg▪ Pregabalin 100 mg TID▪ Venlafaxine 300 mg▪ Zolpidem 10 mg QHS▪ Amlodipine 10 mg

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Course

Allergies: Haldol, chlorpromazine

FHx/SHx: Daily tobacco use. Patient is unemployed, yesterday was chopping down trees in the woods. (May have received a tick bite).Abuses alcohol: “12 pack daily for the last 2 days + liquor”

Vitals 10/13: T:100.7 F, HR: 114, RR:28, BP: 121/40mmHg, O2 Sat: 88%

ROS: ▪ Musculoskeletal: Pounding in head, total body aches and pains▪ Gastrointestinal: diarrhea and constipation▪ All other: reviewed and normal

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Background

Labs on Admisison: ▪ WBC = 12.9 H (4.5-11) x10^3/uL▪ Hgb = 12.0 L (13-17)▪ D-dimer = 0.81 H (<0.50) ug/mL▪ BUN/SCr ratio = 26.7 H (10-20)▪ Albumin = 3.9 L (4-5)▪ Urine RBC = 4 H (0-2)▪ Urine bacteria = few H (none)

▪ All other labs WNL

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Course

Day of admission - 10/13/19: Patient received 4L O2, increasing O2 say from 88% to 92% on room air. Patient has elevated lactic acid of 2.4 (0.5-2.2)▪ 4 mg IV zofran▪ 10 mg IV toradol

CXR and physical exam: Consistent with pneumonia▪ 1g IV ceftriaxone▪ 200 mg PO doxycycline - potential Lyme, ehrlichiosis▪ Tested for EEE

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Course

Problem List 10/13/19:1. Sepsis

a. Sepsis identified w/o evidence of end organ damage/shock. Presents with fever, tachycardia, elevated WBC. Source unclear. Covered for CA-P with Ceftriaxone and Doxycycline. UA negative

i. Check for tick-borne illnesses2. Diabetes: Continue outpatient regimen. If BG changes, add SQ insulin

a. Metformin 1000 mg BID

3. HTN: Patient is normotensive, resume outpatient regimen tomorrow

4. Alcohol abuse: Place on CIWA and monitor carefully a. (Lorazepam 1-2 mg)

5. PTSD: Continue outpatient psych regimena. Olanzapine 15 mg BID

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Course

Problem List 10/14/19:

*Encephalopathy: Solely due to sepsisa. Librium 50 mg given per CIWA. Hold nighttime seroquel and

lyrica.b. Urine drug screen ordered

1. Sepsis: Hemodynamically stable due to aggressive IV fluids - stopped fluids because of pedal edema. Added vancomycin for cellulitis of right lower leg (DM). Keep leg elevated.

2. Diabetes: Hold metformin and begin insulin sliding scale

3. Alcohol abuse: Continue on CIWA10

Course

After short stay in ACU, retransfered to ICU 10/15/19:

1. ID CONSULT: Likely due to bacteremia with group G strep in the setting of right leg cellulitis.a. DSC vancomycin, continue ceftriaxoneb. Add clindamycin 900 mg q8 x 48h

2. Diabetes and obesity: Plan to speak with dietitian

3. Alcohol abuse: Continue on CIWA

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Course

Limited Brief Communication 10/15/19:

1. Patient threatens to leave against medical advice. Pt found lying in bed without oxygen, with mild subacromial cyanosis, evidence of hypoxia and saturating in low 80%s. Lungs diminished with bibasilar fine crackles.a. Nebulizer treatments administered. Precedex ordered for eICU

physician’s discretion 2. Delirious, agitated, threatening staff, hitting staff, and attempts to

pull out tube. 3. COPD in presence of cigarette smoking status, given nicotine patch. 4. Protein malnutrition: Speak to dietitian, monitor.5. Diabetes: A1c >10%. Patient now NPO, continue sliding scale.

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Course

10/16/19:1. Sepsis Patient required intubation. Clinically there is worsening. ID

consult ordered. Mechanical ventilation to be continued.a. Continue clindamycin and ceftriaxone. b. Underwent spontaneous breathing trial, FiO2 80%.c. Aspiration pneumonia noted to be due to gastric secretions.

2. Diabetes and obesity: Will be addressed in the futurea. DM detail: peripheral angiopathy without gangrene.

3. HTN: Patient is normotensive, resume outpatient regimen tomorrow

4. Alcohol abuse: Place on CIWA, pt is on propofol infusion.a. Pt is given folic acid, thiamine, and multivitamins.

5. Anticoagulation: Enoxaparin 40 mg SQ6. Care: Continuing indwelling catheter, OG tube inserted. May need

fentanyl.13

Course

10/17/19:1. Patient status is improving. Skin looks better, patient is less angry

looking. 2. Sepsis Cellulitis - improving

10/18/19:3. Sepsis Pneumonia: improving. On 40% FiO2. Not able to come off

ventilator yet. 4. Diabetes and obesity: Unchanged BG. Monitor closely.5. Alcohol abuse: Withdrawal symptoms improving.

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Course

10/18/19:1. Sepsis: Pneumonia: improving. Cellulitis: improving. Unable to

extubate.a. Sepsis: resolved.

2. Diabetes and obesity: Unchanged BG. Monitor closely.

3. HTN: Patient is normotensive.

4. Alcohol abuse: Withdrawal symptoms improving. Continue IV sedatives fentanyl and propofol.

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Course

10/20/19:*Hypoxemia Overnight. Respiratory status declineda. 40 mg IV lasix given

1. Sepsis Pneumonia: CXR shows bilateral infiltratesa. Continue ceftriaxone & ventilation.

2. Other conditions: Unchanged.

10/21/19:*Hypoxemia Overnight. Respiratory declinedb. 40 mg IV lasix given

3. Bacteremia: Repeat blood cultures shown to be negative4. Pneumonia: Improving.

a. Continue ceftriaxone & ventilation.5. Other conditions: Unchanged. No complaints, but wants ice cream. 16

Course

10/22/19:1. Pneumonia: Improving, cut back on FiO2 to 45L nasal cannula, OFF

VENTILATOR for almost 24h.2. Cellulitis: Final day of ceftriaxone.3. Diabetes: Add lantus 20 units daily to his regimen. (Sepsis resolved)4. Continue ceftriaxone & ventilation.5. Other conditions: Unchanged.

Discharge summary 10/23-6/19:Patient discussed in rounds, will go to head CT to rule out abnormal findings. Patient was unsuccessful with PT 10/23, but was able to cooperate and get out of bed today (10/25). He is still resolving from delirium caused by propofol and fentanyl, which will take some time to clear as it is held in his tissues. CXR shows much better aeration, no ABx needed.

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Questions?