Assignment Overview
Case study: pseudonym Jane
Jane 64 yr old female admitted to the Intensive care unit with severe septic shock secondary to multilobe pneumonia.
Jane had been feeling unwell for 2 weeks with GI symptoms and cough, lethargic and unable to work. Found at home by husband after having fallen out of bed. GCS 7/15 with NSWAS.
Jane was intubated on scene with size 7.5 ETT secured at 24cm at teeth and brought into the emergency and then transferred to ICU. R4 positive for Flu A- Commenced on Oseltamivir and blood culture positive for strep pneumonia.
Illoprost, Augmentin and azithromycin commenced.
On arrival in the ICU Heart Rate 146 AF- Amiodarone infusion 2.1ml/hr commenced, Labile BP 88/56 MAP 65. Noradrenaline commenced at 0.3mcg/kg/min, Dobutamine at 2.5mcg/kg/min, Noradrenaline was then able to wean however blood pressure became unstable post repositioning of the patient systolic dropped to 60s MAP 40s. 250ml bolus of CSL IVF given. Noradrenaline increased to 0.38mcg/kg/min. Pt BP remained hypotensive, Vasopressin (Argipressin) added at 2u/hr and dobutamine increased to 5mcg/kg/min to achieve MAP 65.
Centrally warm, mottled peripherally. Cold lower peripheries with weak pulses and delayed capillary refill 6-8 seconds in lower limbs and 3-5 sec in upper limbs. Temperature 37.9
GCS 3/15. PEARL 2mm brisk, nil movement in limbs. Sedated with Propofol 17ml/hr and Fentanyl 3.5ml/hr. Urine output 20ml/hr.
Ventilation settings: PRVC + PS (SIMV/PRVC + PS) Fio2 80%, PS 10, PEEP 10, RR 20, TV 500
Achieving spo2 95%. Bilateral bronchial sounds with diminished bases on chest AE. Moderate thick yellow secretions.
Line access: Arterial line L) Radial arm and Central venous catheter (CVC) inserted R) Internal jugular (IJ). R) Lower arm peripheral IVC (PIVC) and L) Lower arm peripheral IVC. OGT 53cm NBM
Other infusions commenced:
Magnesium 20mmol (10ml/hr)
Potassium 30mmol (10ml/hr)
Hartmann’s IVF 40ml/hr.
Arterial blood gas on arrival:
- pH: 7.24
- pCO₂: 50 mmHg
- pO₂: 98 mmHg
- HCO₃: 19 mmol/L
- K⁺: 3 mmol/L
- Na⁺: 140 mmol/L
- Glucose: 28 mmol/L
- Lactate: 4.4 mmol/L
- Haemoglobin (Hb): 124 g/L
Formal bloods: Urea 6.2 mmol/l, Creatinine 132micromol/l, GFR 37, Troponin 1035nanog/l, Magnesium 0.85mmol/l, WCC 36, Platelets 517, INR 1.7, APTT 32, PT 18.
MRI attended on the same day showed Filling defects in superior sagittal sinus and right transverse sinus consistent with thrombosis. Heparin infusion commenced.
Past medical history:
- Hypertension
- High BMI
- T2DM on OHAs
- Hypothyroidism