What do you do?

[DrCurious2]

Patient presents to your office with a productive cough and occasional chest pain. Sats 90%, cxr shows LLL pneum. Confer with associate, admit to hosp. U note allergy to augmentin as it causes sob and facial swelling. Admitting orders keep sats >92%, Azithromycin 500 iv today and 250 dly, cbc cmp hscrp day, IV d51/2 ns @ 125/hr, rocephin 1 gram q 12h-aware pcn allergy, toradol iv 15mg q6h prn pain, ekg, trop. Shortly after initiation 2nd dose rocephin given patient becomes hypotensive and resps are labored and sats dropping, O2 started 2lpm and says back up to 92, but continues hypotensive. Admitted to ICU and symptoms persist. Little to no urine open, rfp shows renal failure, hgb 8.3, ABGS show primary respiratory alkalosis with secondary metabolic acidosis...what do you do?

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[VA Hopeful Dr]

Consult pulmonology

 

[deleted87716]

Do your own homework.

 

[DrCurious2]

Sorry

Do your own homework.

Not homework, is a real life scenario.

 

[VA Hopeful Dr]

Sorry

Not homework, is a real life scenario.

Then if you're a resident, talk to your attending.

If you're an attending, why are you asking an anonymous message board for clinical advise on a patient who looks super sick?

 

[DrCurious2]

Then if you're a resident, talk to your attending.

If you're an attending, why are you asking an anonymous message board for clinical advise on a patient who looks super sick?

Just wondering if there was something else that could've been done differently. Just looking for opinions. Sorry. I've asked several different docs and had several different opinions. Trying to broaden rational with opinions from other docs in training. End result she died. So it isn't to help my patient I guess it's more to make sure everything we could've done was done.

 

[deleted87716]

Sounds like she was probably septic. You might find this interesting: A cure for sepsis? | EVMS Magazine 9.4

 

[Druggernaut]

Just wondering if there was something else that could've been done differently. Just looking for opinions. Sorry. I've asked several different docs and had several different opinions. Trying to broaden rational with opinions from other docs in training. End result she died. So it isn't to help my patient I guess it's more to make sure everything we could've done was done.

Why do you think she died? Do you think something else could have been done?

A lot of this comes down to details not given (age, comorbidities, patient appearance and your gestalt), but a few things to think about. She apparently decompensated after her second dose of Rocephin, so anaphylaxis might be contributory in addition to the obvious sepsis. The cross-reactivity of penicillins and cephalosporins is overblown, but I'd consider going with Levaquin rather than azithromycin/Rocephin if her previous reaction was severe to be extra safe and to avoid the Monday morning quarterbacking if things go bad.

I consider Toradol to be a very short term use drug and would almost never schedule it. It's been shown to be equivalent to ibuprofen in efficacy, and has a higher rate of kidney injury than other NSAIDs. It sounds like your patient went downhill pretty quickly, so I doubt this had any real role in your patient's renal failure, but it's something that could've been crossed off the differential if her pain was treated with other agents.

Any reason to suspect PE? You can get consolidation on chest xray, hypoxia, and hypotension, and it can progress pretty rapidly.

 

[VA Hopeful Dr]

Sounds like she was probably septic. You might find this interesting: A cure for sepsis? | EVMS Magazine 9.4

Honestly, dudes outcomes were way too good. I'm very skeptical.

 

[deleted87716]

Honestly, dudes outcomes were way too good. I'm very skeptical.

Dunno. I haven't done hospital or critical care since residency (16 years ago). I went to med school at EVMS, however, and worked with Marik. He's awesome.

 

[VA Hopeful Dr]

Dunno. I haven't done hospital or critical care since residency (16 years ago). I went to med school at EVMS, however, and worked with Marik. He's awesome.

I think that's part of it as well. I have heard great things about him and have heard other CC folks wonder if that's part of why this hasn't gotten more scrutiny.

 

[septoplasty]

This is probably a clear case of Sepsis (Pulm?)... and what I would have also done was to look for is source (B/U Cx), and change the abx to boarder coverage.. i mean, i'm sure the intensivist did this.. also, may I ask why you did D5 as your fluid? lol

Also, if they actually got Toradol when they were in ARF.. you probably made it worse

 

[Bacchus]

Not enough info. Can't tell you what went wrong. But, bad things happen to healthy patients. Patient most likely was septic. I wouldn't think it was the cephalosporin.

 

[Bacchus]

I would say with infection and as sick as this patient was I would have checked a lactate ASAP.

 

[FrustratedFamDoc]

Lots of missing info here. We talking about a 30 y/o gym rat or a 70 y/o nursing home resident lifelong smoker? Was a flu checked? Pseudomonas/MRSA risk? How did BP look on admission compared to that pt's normal? Was the patient admitted to the ICU at some point for more intensive care? Pressors?

I haven't done inpatient in a few years but had I just admitted a pt for PNA and they're on their way to crump town, I transfer to the ICU, Vanc/Zosyn, sputum culture from resp therapy, fluids, and consult pulm. Pressors as needed. You never want to look back and wish that you would have been more aggressive.

 

[Ericslv]

Patient presents to your office with a productive cough and occasional chest pain. Sats 90%, cxr shows LLL pneum. Confer with associate, admit to hosp. U note allergy to augmentin as it causes sob and facial swelling. Admitting orders keep sats >92%, Azithromycin 500 iv today and 250 dly, cbc cmp hscrp day, IV d51/2 ns @ 125/hr, rocephin 1 gram q 12h-aware pcn allergy, toradol iv 15mg q6h prn pain, ekg, trop. Shortly after initiation 2nd dose rocephin given patient becomes hypotensive and resps are labored and sats dropping, O2 started 2lpm and says back up to 92, but continues hypotensive. Admitted to ICU and symptoms persist. Little to no urine open, rfp shows renal failure, hgb 8.3, ABGS show primary respiratory alkalosis with secondary metabolic acidosis...what do you do?

Perhaps ARDS.

 

[normtheniner]

What were their baseline labs on arrival to the hospital? Any evidence of end organ damage? If their creatinine was already tanking on arrival or shortly after they may have been approaching severe sepsis ----> septic shock. Did they check a lactate? If so how high was it and how high did it get?