Case 091: Sepsis

PATIENT PRESENTATION

Chief Complaint

My mother is confused and feeling lightheaded

History of Present Illness

An 84-year-old female presenting from a nursing home with vital signs, physical examination, and laboratory tests consistent with sepsis

Link to EMR

Student Work-Up

TARGETED QUESTIONS

1. What signs and symptoms of sepsis does this patient have?

   Hint: See Table 84-1 and Clinical Presentation and Diagnosis in PPP

2. What parameters should be monitored to determine the patient’s response to initial therapy?

   Hint: See Treatment and Outcome Evaluation in PPP

3. What approach should be taken regarding IV fluid therapy administration in this patient?

   Hint: See Treatment and Outcome Evaluation in PPP

4. What factors should be considered when determining appropriate antimicrobial therapy for this patient?

   Hint: See Treatment and Outcome Evaluation in PPP

5. Which vasoactive agent(s) would be an appropriate initial choice in this patient and why?

   Hint: See Hemodynamic Support in PPP

FOLLOW-UP

The patient has been stabilized with intravenous fluids and is receiving vasopressor therapy. Cultures have been sent to the laboratory and broad-spectrum antimicrobial therapy has been initiated. The ICU nurse calls the medical team to notify them that the patient’s most recent fingerstick blood glucose levels both returned at over 200 mg/dL. The on-call resident asks you if insulin therapy should be initiated, and what the target blood glucose levels should be for this patient.

Hint: See Hemodynamic Support in PPP

CASE SUMMARY

Global Perspective

The Surviving Sepsis Campaign guidelines provide updated guidance surrounding the overall treatment of sepsis and septic shock.¹ Notable updates include strengthening of the recommendations surrounding initiation of corticosteroids, recommending against use of intravenous vitamin C, and the suggestion for use of balanced crystalloids over normal saline for resuscitation. Balanced crystalloids may offer reduced risk of acute kidney injury (AKI) and need for renal replacement therapy (RRT) compared to chloride-rich solutions such as normal saline. The SMART trial demonstrated positive outcomes with balanced solutions compared to normal saline; however, the trial was single center, did not randomize patients, and the intervention was unblinded.² Following publication of the guidelines, two large randomized controlled trials, BaSICS and PLUS, did not find significantly improved outcomes with use of balanced crystalloids compared to normal saline but there were trends that will likely lead to ongoing debate of this issue.^3,4

Key References