Gram negative sepsis

Question 1

You are asked to review a patient on the ward who was admitted 48 hours prior with features of sepsis, and a provisional diagnosis of bronchitis. His blood cultures have returned today 4/4 bottles growing E.coli. How would you assess and manage him?

Answer 1

Impression:
This is a case of gram negative sepsis. This is a serious presentation that should be regarded as a medical emergency given that patients can rapidly deteriorate. Need to consider the infective source, as E. Coli not commonly a cause of bronchitis. Consider, urinary, wounds, lines, GIT.

Goals:

• assess for haemodynamic instability
• Initiate empirical treatment/ modify treatment accordingly
• identify source of infection

Question 2

Gram -ve sepsis - History

Answer 2

History:

• SX: fever, chills/sweats, cough, SOB, dysuria, frequency, urgency, flank pain, respiratory sx
• PMHx: immunosuppression, chemotherapy, past surgical
• Medications: ABx already started
• SNAP

Question 3

Gram -ve sepsis - Examination

Answer 3

Exam:

• Vitals, initially take an A to E approach
• A: patency, maintaining own, speaking
• B: RR, SP02,
• C: BP, cannula, fluid resus
• D: GCS,
• E: other sites of infection
• respiratory exam: cap refill, wob, consolidation, air entry, added sounds
• abdominal exam: suprapubic tenderness/ peritonitis/ tenderness

Question 4

Gram -ve sepsis - Investigations

Answer 4

Investigations:

• Septic scree –> CXR, urinalysis,
• Bedside: VBG (lactate), urine cultures
• Bloods: FBC, UEC, LFT
• Imaging: renal tract ultrasound

Question 5

Gram -ve sepsis - Management

Answer 5

Management:
Unstable
- Dispositoin: ICU/escalation to reg
- manage haemodynamic instability
     - fluids
     - 02 therapy as required
     - BP control (?vasopressors, start with sernior input)
     - IDC + IVC
     - DVT prophylaxis

Treatment of urosepsis:
- empirical ABx or modify existing according to sensitivities