Nurul Huda Ahmad Shahrir

PRP

1.Sepsis is a medical condition characterized by a whole-body inflammatory state called systemic inflammatory response syndrome and presence of known or suspected infection.

2.It can be with or without organ dysfunction.

3.Systemic inflammatory response syndrome:a. T > 38°C or below 36°Cb. Heart rate > 90 beats/minc. Respiratory rate >20 breaths/mind. WBC > 12000 cells/mm3

4. Can cause organ dysfunctions ofa. Lungb. Brainc. Liverd. Kidneye. Heart

Introduction

1.Bacteria, virus or parasite will attack the host cell.

2.Body will response by releasing the TNF, IL, PG, Leukotrienes, Bradykinin and Platelet Activating Factor

3.These will produce the systemic inflammatory response syndrome

Mechanism of Sepsis

Name : KK

Gender : Male

Age : 28

Race : Indian

Weight : 70.5kg

Date of Admission : 2/5/11

Ward : ICU (B)

Patient’s Particulars

Patient was admitted to Hospital Kulai because of fitting in bathroom. He developed fit for 30 minutes, a general tonic clonic seizures with tongue lifting and drooling of saliva. Given IV Valium in the A&E and admitted to the ward. After 5 hours in the hospital, patient suddenly stopped breathing and vomitted. CPR was done and patient revived after 10 minutes. Patient had history of fall earlier in the morning before the admission.

History of Presenting Illness

Patient has history of epilepsy since childhood but defaulted treatment and follow-up. He was admitted to Hospital Muar 4 years ago and told that he had blood clot in the brain but he refused operation.

Past Medical History

Social HistoryHe’s a chronic smoker and alcoholic.Drank 2 bottles of whisky a day. Not working and staying with parents. Denies any drug use.

1.Status epilepticus with hypoglycaemic coma

2.Nosocomial Sepsis

Diagnosis

Date 2/5 3/5 4/5 5/5 6/5 7/5 8/5 9/5 10/5

BP

Systole

122-144

88-112

100-138

96-132

105-123

120-133

105-145

98-113

99-128

Diastole

56-67

49-69

55-88

54-74

68-72

80-93

58-86

55-77

61-80

Temperature

37.5 40 37 36.3 36.5 34.6 34.5 39 37

RR 30 30 38 13 20 17 19 20

PR 121-145

59-84

70-83

71-73

79-132

78-108

78-84

85-118

89-120

Vital Signs

Lab Values2/5 3/5 4/5 5/5 6/5 7/5 8/5 9/5 10/5

Full Blood Count

TWBC

12.8 12.9 8.4 8 6.3 4.0 4.7 18.5 16.29

HB 13.0 15.7 13.4 13.5 13.3 12.1 11.6 11.1 10.1

HCT 0.38 0.45 0.40 0.40 0.38 0.36 0.36 0.34 0.31

PLT 125 160 135 79 152 78 47 35 90

BUSE/Renal Profile

Urea 8.2 10.8 17.1 14.9 8.4 6.6 10.4 20.1

Na 135 130 130 133 136 137 134 132

K 3.22 3.78 6.4 5.08 3.2 3.89 4.61 4.76

Cl 97 96 89 96 105 102 102 97

Ca 1.81 1.74 1.69 2.05 2.30 2.68 2.68 2.59

Mg 0.92 0.79 0.78 1.24 0.57 0.85 0.85 0.78

PO4 0.47 0.88 1.38 1.51 0.67 0.45 0.45 0.57

Scr 410 570 790 560 410 210 210 210 510

CrCl 23.65 17.01 12.27 17.31 23.65 46.16 46.16 46.16 19.01

Lab Values

Drug Regimen Date Start

Date Stop

Indication

IV EES 250mg BD 3/5 4/5

ProphylaxisIV Augmentin 1.2g BD

3/5 4/5

IV Augmentin 1.2g OD

4/5 6/5

IV Acyclovir 500mg 12H

3/5 1 doseMeningitis

IV Ceftriaxone 2g BD 3/5 1 dose

IV Tazocin 2.25g TDS 8/5 10/5 Sepsis

IV Augmentin 1.2g BD

6/5 8/5

IV Polymyxin E 2MU OD

10/5 Azinobacter Baumanii

S/C Fondaparinux 2.5mg OD

3/5 1 dose

IV Frusemide 240mg/hr

3/5 6 hours Poor urine output

Oral Kalimate 10g TDS

4/5 6/5 Hyperkalemia

IV KCL 1g 7/5 8/5 Low chloride level

Medication Chart

Medication ChartDrug Regimen Date

StartDate Stop

Indication

IVPhenytoin 100mg TDS

3/5 seizures

IV Na Valproate 200mg TDS

2/5 6/5 seizures

IV Mannitol 150ml QID 3/5 Diuresis

Primasol 4/5 Metabolic acidosis

Syr Na Valproate 400mg TDS

6/5 seizures

Date Source Microbes Sensitivity

Sensitive Resistance

5/5 Broncoscopic

Klebsiella Pneumoniae

Unasyn, Augmentin, Gentamycin, Cefuroxime, Bactrim, Tazocin

Ampicillin

5/5 broncoscopic

Staphylococcus aureus

Methicillin, Erythromycin,Gentamycin

Penicillin

8/5 Blood Azineobacter Baomani

Polymycin B Unasyn, Imipenem, Meropenem, Gentamycin, Ciprofloxacin

Culture & Sensitivity Test

Management of Status Epilepticus1.In A&E Hospital Kulai, patient was given IV Diazepam 10mg.The seizure resolved

2.In A&E HSA, patient developed fit again, was given IV Mida/Morphine followed by loading dose of IV Phenytoin 1g.

3.Patient’s GM = 1.8mmol/L and was given IV Dextrose 50%-50ml

4.In ward, continued with maintenance dose of 100mg TDS and given IV Thiamine 100mg OD for 3 days followed by T.Thiamine 30mg OD

5.Patient still develop fit in the ward, add on with IV Sodium Valproate 200mg TDS

6.This steps follow the Consensus Guidelines on the Management of Epilepsy 2010 and Emergency Medicine Handbook (refer next slide)

Pharmaceutical Care Issues

Management of GTC by Brown & Cadogan vs Consensus GuidelinesManagement of GTC by Brown & Cadogan, Emergency MedicineMaintain oxygen saturation above 94%.

Check blood sugar:i Give 50% Dextrose 50ml if lowIi Give Thiamine 100mg if chronic alcoholism is likely.

Give Lorazepam 0.07mg/kg or Diazepam 0.1-0.2mg/kg up to 20mg or midazolam 0.05-0.1mg/kg up to 10mg

If still fit:i repeat lorazepam, diazepam or midazolam until seizure ceaseii Then, give IV Phenytoin 15-17mg/kg

Management of GTC by Brown & Cadogan vs Consensus Guidelines

Management of Hyperkalemia (4/5 – 5/5)1.Patient was given oral Kalimate to treat hyperkalemia (4/5 – 6/5)

Management of Hypokalemia (7/5)1.Patient was given infusion 1g of Potassium Chloride (13.4mEq) (7/5 – 8/5)

2.According to Drug Info Handbook, if run >10mEq/H should have continous ECG monitoring

Management of Hypophosphatemia (7/5 – 10/5)1.Patient was given IV Potassium Phosphate 20mmol/100ml (7/5)

2.According to product leaflet, up to 10mmol phosphate administered over 12 hours

Pharmaceutical Care Issues

Pharmaceutical Care issuesUsing IV EES1.IV EES is used as prophylaxis agent in this patient

2.IV EES should be used cautiously in patient with hepatic impairment as it can worsen the condition.

3.Petient’s liver profile are closely monitored in the ward

IV Tazocin1.Result of C&S came out on 8/5 which indicates that the acinobacter Baumani is sensitive to Polymycin B, however patient was started on IV Piperacillin/Tazobactam 2.25mg TDS.

2.Temperature continues to spike

3.Patient was started on Polymycin E 2 days after the C&S result came out.

Pharmaceutical Care IssuesDose of IV Augmentin1.Given IV Augmentin 1.2g BD and reduced to 1.2g OD because of increase in serum creatinine level.

2.According to Drug Info Handbook, dosing interval for patient with creatinine clearance of 10-30ml/minute is 250-500mg every 12 hours.

3.According to product leaflet, the suggested dose for renal impaired patient is 1.2g followed by 600mg 12H

Pharmaceutical Care IssuesManagement of Acute Kidney Injury1.The serum creatinine was high during admission and patient has poor urine output.

2.Patient was given IV Frusemide 240mg/hr for 6 hours

2/5 3/5 4/5 5/5 6/5 7/5 8/5

Input 3423 5445 1749.1 2070.1 2144.4 2718 2298.1

Output 145 330 1132 2322 1952 2141 869

Balance

3278 5115 617.1 -251.9 192.4 577 1429

1.Patient was on Primasol which is used to normalised the composition of the blood.

Pharmaceutical Care Issues