Pneumonia and Septic Shock

Author: V. Dimov, M.D., Department of General Internal Medicine, Cleveland Clinic

A 52 yo AAF is admitted to the hospital with CC: cough and fever for 5 days.

Physical examination

Febrile, tachycardic, hypotensive
CVS: Clear S1S2
Chest: decreased air entry on the right, dull percussion tone in R lung base
Abdomen: Soft, NT, ND, decreased BS
Extremities: no c/c/e

Imaging


A CXR done one month ago (left); the current CXR shows a RLL pneumonia and effusion (right)

Laboratory results


Laboratory results in a patient with pneumonia, septic shock, and acute renal failure (ARF)

What is the next step in the management?

The patient is hypotensive with BP 74/30, essentially in septic shock with acute renal insufficiency due to hypovolemia and hypotension.

She needs a central venous access as soon as possible in order to administer large amount of IV fluids (IVF) to correct the hypotension. A right IJ TLC (triple lumen catheter) was placed. Check the proper position of the TLC on the CXR below. It is exactly where it should be - in the distal superior vena cava (SVC).


A right IJ TLC in the distal SVC (correct position).

BP is better, SBP 101.

What ABx would you start for empiric treatment of community-acquired pneumonia and septic shock?

Check the references below for the answer.

What happened next?

The vital signs stabilized with IVF. ARF and pneumonia resolved and the patient was discharged home.

Final diagnosis

Pneumonia and septic shock.

References

Update of Practice Guidelines for the Management of Community-Acquired Pneumonia in Immunocompetent Adults. Clinical Infectious Diseases 2003;37:1405-1433, IDSA Guidelines.

Table 1. Initial empiric therapy for suspected bacterial community-acquired pneumonia (CAP) in immunocompetent adults.

Table 2. Empiric antibacterial selection for community-acquired pneumonia (CAP): advantages and disadvantages.

Other Practice Guidelines from the Infectious Diseases Society of America

Related reading

Patient Wins $30 Million. The Tampa Tribune, 5/2007. This case illustrates the complications of using pressors without adequate volume resuscitation in a hypovolemic patient.
$ 30 Million Lawsuit for Complications of Pressors Use in Septic Shock. CasesBlog, 2007.

Published: 03/12/2005
Updated: 05/26/2007

3 comments:

  1. Good case. It's not linking to IDSA guidelines though. Give broad antibiotics and then narrow after cultures are in. It's good that the term "Septic Shock" is used here since so many still use the outdated term Sepsis Syndrome. A lactic acid (lactate) level is helpful. See consensus from ER docs, critical care docs etc by looking up the 2008 Surviving Sepsis guidelines.

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  2. Agree--broad spectrum antibiotics geared to the most likely source per IDSA guidelines is best for septic patients. This is not the time to withhold antibiotics since over 40% die if untreated. Narrow the antibiotic after cultures ID the microbe.

    According to the VA/NIH Acute Renal Failure Trial Network 54.6% of acute renal failure pts have sepsis and 80.9% of acute renal failure is due to ischemia such as when in hypovolemic shock from sepsis.

    Even CHF pts need fluids if they are septic if they are not currently in heart failure. If in doubt, do CXR, BNPT, listen for crackles. Start with 250cc IVF if BNPT not less than 150 or give carefully while checking lung bases posteriorly after each bolus along with pulse ox, etc as above.

    Look for sources of sepsis such as pneumonia, foreign body, pyelonephritis, joint infections. A pt may be afebrile/ low temp or low WBCs and still be septic if 2 of the other 4 criteria are met.*

    Do cultures, check lactate ASAP to detect sepsis BEFORE the BP drops. Lactic acid "the troponin of sepsis".* If septic, give a lot of fluids (up to 10 liters often) since capillary leak syndrome will lead to severe hypotension. If septic expect edema to develop with IV boluses yet be aware pt is intravascularly depleted. No pressors without fluids "pressors are not your friend"* See Surviving Sepsis 2008 guidelines and research at such sites as www.ihi.org

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  3. what r the microorganisms that causes pneumonia with hypotension

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