Tuesday, April 10, 2012

Sepsis - Tuesday April 10, 2012

Thank you to Dr. A. Page for hosting morning report and to team 7 for bringing the case.

We discussed a patient referred to internal medicine for sepsis.  She had a history of cholangiocarcinoma (with biliary stenting) and recently had chemotherapy (about 14 days ago).  She presented with chills at home, temperature 37.4 in hospital, tachypnea, tachycardia, some diarrhea, nausea/vomiting.  She did have an indwelling line, bilateral decreased breath sounds at bases, and tender/enlarged liver.  She also had anemia, neutropenia, thrombocytopenia, acute kidney injury (Cr 600), and a low bicarb.

We discussed the definition of sepsis (systemic inflammatory response syndrome caused by infection [or suspected to be caused by infection]).  SIRS requires meeting >= 2 of the following 4 criteria:  fever or hypothermia, HR > 90, RR > 20 or PaCO2 < 32, WBC > 12 or < 4 or > 10% bands.  Our patient met the criteria for SIRS.  The team appropriately looked for/monitor for infection by sending off appropriate cultures (urine, NP swab, blood cultures, hepatitis serologies, stool for C+S, C. diff), CXR, and ordering abdominal imaging (pending).

For her pan-cytopenia, we discussed the need to look for bleeding (given anemia and low platelet count).  Supportive therapy includes transfusion of RBC (threshold of 70).  For platelet of < 10, platelet transfusion to prevent spontaneous intracranial hemorrhage.  Whether to support WBC with GCSF is controversial.  The evidence is that it decreases duration of neutropenia by a small amount.  Some people will give it.  Dr. Page also pointed out that prophylaxis against infection has the unfortunate effect of patients being infected with infections that are not prophylaxed against, or drug resistant organisms.  Given this presentation, it is also important to look at her blood film over night to rule out fragments (TTP, DIC).  Fibrinogen should also be measured.

The patient did grow gram-negative organisms in the blood.  She was on Piptazo and Vancomycin (for the line).  We are reminded that Piptazo has a broad coverage, but does not cover ESBL organisms or atypical organisms (if we think she has community acquired pneumonia).  We also discussed the hypothetical situation of someone with known gram-negative bacteremia (sensitivity unknown yet) who is already on broad-spectrum coverage (Piptazo or meropenem), but continues to deteriorate.  In this situation, it is important to ensure source control (e.g. rule out abdominal abscesses), and that antibiotics coverage may be broadened by adding aminoglycoside (if renal function allows).

As a side note, we also discussed re-activation of hepatitis B when someone is being immunosuppressed (from chemotherapy, organ transplant, etc…).  Lamivudine is usually indicated in these situations.  We discussed that this risk is highest with Hep B S Ag positivity, but is possible with Hep B S Ab positivity as well if someone is immunosuppressed enough.

Although we did not focus on this aspect of management, you can find the Surviving Sepsis Campaign here.  Also, today’s Amuse Bouche was based on a new Rational Clinical Exam Series:  “Does this patient with liver disease have cirrhosis?”  You can find the article here.

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