MBBS YEAR 5 – 2017/2018

EMERGENCY MEDICINE POSTING

MED 5064

CASE REPORT
WITH
EVIDENCE-BASED MEDICINE

SEVERE SEPSIS

NAME : VAISHNEVI A/P NAHENTHARA RAJ

MATRIC NO. : MBBS 1411-6057
GROUP : 3 A1
ROTATION : 4
SUPERVISOR : PROF. RADHI
 1. AIM

The aim of this case report is to evaluate the use of antibiotics in severe sepsis in early
goal directed therapy to prevent septic shock.

2. CLINICAL CASE SUMMARY

HISTORY

Mrs. SZ, a 68 year old Malay lady was brought to the ED Hospital Putrajaya by
ambulance from KLIA for loss of consciousness. Her Glascow Coma Scale score was
E1V2M5 upon arrival. She had just returned from Saudi from Umrah, and had 1 episode of
vomiting and history of fall in Saudi. Her past medical history was unobtainable. She was
febrile, blood pressure was 162/100 mmHg, tachycardic with pulse rate of 103 bpm, with
oxygen saturation of 100% in room air. She was triaged to Resuscitation Red Zone.

She was pink, had good pulse volume, capillary refill time was less than 2 seconds,
warm peripheries felt. Her dextrose stick was high. She had bilateral coarse crepitations upon
lung auscultation, cardiovascular findings were normal. Upon abdomen palpation, she had a
lower abdomen mass palpable, unable to get to the lower border. Pupils were 3mm diameter
and reactive. Her right lower limb was swollen and she had a deformed ankle. Pain score was
unable to be assessed due to low GCS score.

Bedside scan was done, no free fluid found. She was slightly anemic with Hb 11, and
her white cell count was 12.3 which is high. Her VBG showed pH 7.24, HCO2 18, Lactate
5.2, Potassium 5.6 and Sodium 130.

She was managed with fluids IV drip 1 pint Normal Saline over 1 hour, IV drip 1 pint
Normal Saline ran fast. She was given IVI insulin fixed scale run on 6iu/hour and IV
Cefuroxime 1.5mg stat. Investigations taken from her were renal profile, fasting blood sugar,
liver function test, coagulation profile, blood culture & sensitivity, urine FEME, chest X-ray,
X-ray tibia and fibula, X-ray ankle join, ECG and CT brain. She was to be on strict IO
charting. Further history was to be obtained from family when they were to arrive.

WORKING DIAGNOSES :
1. Severe sepsis secondary to Upper Respiratory Tract Infection
2. Diabetic Ketoacidosis secondary to severe sepsis
 3. DISCUSSION

3.1 Evaluate the use of antibiotics in case of severe sepsis in early goal directed
therapy to prevent septic shock.

Sepsis is associated with an in-hospital mortality rate of 30%–40%. The

influence of factors such as causative organism, portal of entry, age, or the occurrence of
septic shock on the outcome of septicemia has been investigated. Early empiric antibiotic
treatment of patients suspected of having sepsis is standard practice. Though adequate
antibiotic therapy has been shown to reduce mortality rates, this issue has not been studied in
detail. By necessity, the association of early empiric antibiotic treatment with mortality in
patients with sepsis must be investigated in an observational manner. The systemic
inflammatory response syndrome can be self-limited or can progress to severe sepsis and
septic shock. Along this continuum, circulatory abnormalities (intravascular volume
depletion, peripheral vasodilatation, myocardial depression, and increased metabolism) lead
to an imbalance between systemic oxygen delivery and oxygen demand, resulting in global
tissue hypoxia or shock. An indicator of serious illness, global tissue hypoxia is a key
development preceding multiorgan failure and death. The transition to serious illness occurs
during the critical “golden hours,” when definitive recognition and treatment provide
maximal benefit in terms of outcome. These golden hours may elapse in the emergency
department, hospital ward, or the intensive care unit. Early hemodynamic assessment on the
basis of physical findings, vital signs, central venous pressure, and urinary output fails to
detect persistent global tissue hypoxia. A more definitive resuscitation strategy involves goal-
oriented manipulation of cardiac preload, afterload, and contractility to achieve a balance
between systemic oxygen delivery and oxygen demand. End points used to confirm the
achievement of such a balance (hereafter called resuscitation end points) include normalized
values for mixed venous oxygen saturation, arterial lactate concentration, base deficit, and
pH. Mixed venous oxygen saturation has been shown to be a surrogate for the cardiac index
as a target for hemodynamic therapy. In cases in which the insertion of a pulmonary-artery
catheter is impractical, venous oxygen saturation can be measured in the central circulation.
Whereas the incidence of septic shock has steadily increased during the past several decades,
the associated mortality rates have remained constant or have decreased only slightly. Studies
of interventions such as immunotherapy, hemodynamic optimization or pulmonary-artery
catheterization enrolled patients up to 72 hours after admission to the intensive care unit. The
negative results of studies of the use of hemodynamic variables as end points (“hemodynamic
optimization”), in particular, prompted suggestions that future studies involve patients with
similar causes of disease or with global tissue hypoxia (as reflected by elevated lactate
concentrations) and that they examine interventions begun at an earlier stage of disease.

Compelling evidence has shown that aggressive resuscitation bundles, adequate

source control, appropriate antibiotic therapy, and organ support are cornerstone for the
success in the treatment of patients with sepsis. Delay in the initiation of appropriate
antibiotic therapy has been recognized as a risk factor for mortality. To perform a
retrospective analysis on the Surviving Sepsis Campaign database to evaluate the relationship
between timing of antibiotic administration and mortality. A total of 17,990 patients received
antibiotics after sepsis identification and were included in the analysis. In-hospital mortality
was 29.7% for the cohort as a whole. There was a statically significant increase in the
probability of death associated with the number of hours of delay for first antibiotic
administration. Hospital mortality adjusted for severity (sepsis severity score), ICU admission
source (emergency department, ward, vs ICU), and geographic region increased steadily after
1 hour of time to antibiotic administration. Results were similar in patients with severe sepsis
and septic shock, regardless of the number of organ failure. The results of the analysis of this
large population of patients with severe sepsis and septic shock demonstrate that delay in first
antibiotic administration was associated with increased in-hospital mortality. In addition,
there was a linear increase in the risk of mortality for each hour delay in antibiotic
administration. These results underscore the importance of early identification and treatment
of septic patients in the hospital setting.

Effects of different time cutoffs from triage to antibiotic administration, qualification

for early goal-directed therapy to antibiotic administration, triage to appropriate antibiotic
administration, and qualification for early goal-directed therapy to appropriate antibiotic
administration on in-hospital mortality were examined. There was no significant association
between time from triage or time from qualification for early goal-directed therapy to
antibiotics and mortality when assessed at different hourly cutoffs. When analyzed for time
from triage to appropriate antibiotics, there was a significant association at the <1 hr time
cutoff; similarly, for time from qualification for early goal-directed therapy to appropriate
antibiotics, a significant association was seen at the ≤1 hr time cutoff. Elapsed times from
triage and qualification for early goal-directed therapy to administration of appropriate
antimicrobials are primary determinants of mortality in patients with severe sepsis and septic
shock treated with early goal-directed therapy.

Certain isolated organisms were associated with inadequate antibiotic treatments more often
than were other organisms. In particular, S. aureus, P. aeruginosa, and fungi were more likely
to have been associated with inadequate antibiotic treatments, which most likely reflects the
increase in resistance associated with these organisms in hospitalized patients. The site of
infection did not appear to be associated with the adequacy of antibiotic treatment. However,
higher numbers of infecting organisms per patient were significantly associated (P < .01)
with inadequacy of antibiotic treatment.

In conclusion, these data suggest that continuing efforts should be aimed at reducing
the administration of inadequate empiric antimicrobial treatment to septic patients. Goal-
directed therapy provided at the earliest stages of severe sepsis and septic shock, though
accounting for only a brief period in comparison with the overall hospital stay, has significant
short-term and long-term benefits. These benefits arise from the early identification of
patients at high risk for cardiovascular collapse and from early therapeutic intervention to
restore a balance between oxygen delivery and oxygen demand. In the future, investigators
conducting outcome trials in patients with sepsis should consider the quality and timing of the
resuscitation before enrollment as an important outcome variable.
REFERENCES

1. Dulhunty, J. M., et al. “Continuous Infusion of Beta-Lactam Antibiotics in Severe

Sepsis: A Multicenter Double-Blind, Randomized Controlled Trial.” Clinical
Infectious Diseases, vol. 56, Issue 2, Jan. 2013, doi:10.1093/cid/cis856
2. Ferrer. R, et al. “Empiric Antibiotic Treatment Reduces Mortality in Severe Sepsis
and Septic Shock From the First Hour: Results From a Guideline-Based Performance
Improvement Program” Critical Care Medicine, vol. 42, Aug. 2014, pp. 1749–1755.,
doi: 10.1097/CCM.0000000000000330.
3. Gaieski, D., et al. “Impact of time to antibiotics on survival in patients with severe
sepsis or septic shock in whom early goal-directed therapy was initiated in the
emergency department.” Critical Care Medicine, vol. 38, issue 4, Apr. 2010, p.
101045-1053, doi: 10.1097/CCM.0b013e3181cc4824.
4. MacArthur, R.D., et al. “Adequacy of Early Empiric Antibiotic Treatment and
Survival in Severe Sepsis: Experience from the MONARCS Trial.” Clinical Infectious
Diseases, vol. 38, Issue 2, Jan. 2004, pp. 284-288., doi: 10.1086/379825.
5. Rivers, E., et al. “Early Goal-Directed Therapy In The Treatment Of Severe Sepsis
And Septic Shock.” The New England Journal of Medicine vol. 345, Nov. 2010, p.
1368-1377.. doi: 10.1056/NEJMoa010307.