Intern Report 7.7

Case Presentation by Dr. Joe Wollman, MD

History of Present Illness:

A 71-year-old Caucasian woman is brought to the emergency department from a long-term health care facility with altered mental status.  The patient was reported to be agitated and combative with nursing staff at the care facility. At her baseline the patient is alert and oriented x2, and is able to perform some of her Basic Activities of Daily Living (including feeding and functional mobility) but now appears confused and has been unable to respond appropriately to questions and commands.

Past Medical History (per EMS report):
-Alzheimer’s dementia
-Kidney stones

Physical Exam:
Vitals: BP 79/36, P 123, RR 25, T 38.4, O2 sat 95% room air, Wt 52 kg.
General: Lethargic elderly woman appears agitated when disturbed.
HEENT:  Normocephalic, atraumatic. Anicteric sclera. No conjunctival injection, but pallor present. Tympanic membranes non-bulging, non-erythematous. Edentulous with dry mucus membranes. No posterior oropharyngeal exudates. No lymphadenopathy.
Cardiovascular: No JVD. Regular rhythm, no murmurs, and no peripheral edema.
Respiratory: Coarse breath sounds with rhonchi auscultated over bilateral anterior lung fields, no rales or wheezes.
Gastrointestinal:  Abdominal is soft, non-distended.
Musculoskeletal: Extremities warm to touch with brisk capillary refill.
Genitourinary: Foley catheter in place draining dark yellow urine.
Neurologic: GCS 11 (opens eyes to voice, inappropriate words, localizes to painful stimuli). Extra ocular movements intact. Pupils 5 mm and equally reactive to light.

Labs / Imaging / ED course:

Blood sugar is 110. WBC is 15,000 with 68% neutrophils, 3% bands, and 23% lymphocytes.

Urinalysis shows 3+ leukocyte esterase, nitrite negative, trace blood, 50 WBC and 3 RBC per HPF with many bacteria present.

Chest x-ray shows poor inspiratory effort with slight enlargement of the cardiac silhouette, but no signs of pulmonary edema, and no focal consolidations.

The patient receives bolus IV fluids (2 liters) with repeat blood pressure measured as 88/55. Arterial blood gas reveals a pH of 7.21, and a lactic acid of 9 mmol/L.

1. Please select the most accurate statement:
a.  Infection is the primary cause of death in approximately two-thirds (66%) of individuals aged 65 years and older.
b.  Urinary tract infection is second only to respiratory tract infection as the most common site of infection in nursing homes.
c. Less than one-third (33%) of patients with an indwelling catheter and bacteriuria develop UTI symptoms.
d.  Systemic antimicrobials are recommended to prevent catheter associated urinary tract infections in patients requiring long-term catheterization.

2. In patients with septic shock, the strongest predictor of survival/mortality is:
a. Whether or not initial antimicrobial therapy has appropriate coverage.
b. Time to initiation of antimicrobial therapy with appropriate coverage.
c. APACHE II score at ICU admission.
d. Time to initiation of vasopressor/inotropic support.
e. Volume of fluids infused in the first hour of hypotension.

3. Regarding fluid resuscitation of patients with severe sepsis and septic shock, which statement is most accurate?
a. Mortality rates are lower in patients who receive crystalloid solution verses patients who receive albumin solution.
b. There is no statistically significant difference in mortality rates in patients who receive hydroxyethyl starch or pentastarch verses patients who receive crystalloid.
c. Liberal fluid resuscitation has not been shown to prolong duration of mechanical ventilation even if Acute Respiratory Distress Syndrome develops.
d. Mechanically ventilated patients require higher Central Venous Pressures for resuscitation.


Answers & Discussion

1. c.
The clinical significance of asymptomatic bacteriuria in catheterized patients is uncertain. Only 10 to 25% of those with bacteriuria develop symptoms of UTI (1, 2, 3).  Infection is the primary cause of death in approximately one third (33%) of individuals aged 65 and older (4). Urinary tract infections are the most common site of infection in nursing homes (5). The CDC recommends against the routine use of systemic antimicrobials to prevent catheter associated urinary tract infections in patients requiring either short or long-term catheterization (6).

2. b.
In a retrospective cohort study performed by Kumar and Wood between 1989 and 2004, with the objective to determine the prevalence and impact on mortality of delays in initiation of effective antimicrobial therapy from initial onset of recurrent/persistent hypotension of septic shock, multivariate analysis (including APACHE II score and multiple therapeutic variables), time to initiation of effective antimicrobial therapy was the single strongest predictor of outcome (7).

3. d.
Mechanically ventilated patients may require higher CVP targets (i.e. 12-15 mmHg rather than 8-12) to account for impediments in filling (8).  The SAFE trial (an RTC involving 6997 critically ill patients) showed no differences in mortality between resuscitation with crystalloid verses albumin (9). Scandinavian Starch for Severe Sepsis and Septic Shock trial (an RTC involving 804 patients) showed increased mortality at 90 days with hydroxyethyl starch verses crystalloid (10). The VISEP trial, designed compare pentastarch to crystalloid was stopped due to trend toward increased 90-day mortality with pentastarch (11). In patients with ARDS who are hemodynamically resuscitated, a liberal approach to IV fluid administration prolongs duration of mechanical ventilation (12).

1. Catheter-associated urinary tract infection is rarely symptomatic: a prospective study of 1,497 catheterized patients. Tambyah PA, Maki DG Arch Intern Med. 2000;160(5):678.

2. Clinical and economic consequences of nosocomial catheter-related bacteriuria. Saint S. Am J Infect Control. 2000;28(1):68.

3. Complications of Foley catheters–is infection the greatest risk? Leuck AM, Wright D, Ellingson L, Kraemer L, Kuskowski MA, Johnson JR. J Urol. 2012 May;187(5):1662-6.

4. Common infections in older adults. Mouton CP, Bazaldua OV, Pierce B, Espino DV. Am Fam Physician. 2001;63(2):257.

5. Important sites and pathogens causing infections in long-term care facilities. Richards M, Stuart R, Up to Date. 2013.

6. CAUTI guidelines 2009 – Category IB recommendation.

7. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Kumar A, Roberts D. Crit Care Med. 2006;34(6):1589.

8. Surviving Sepsis Campaign. Dellinger RP, Levy MM, Rhodes A. Critical Care Medicine. 2/2013;41(2):580–637.

9. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. Finfer S, Bellomo R. N Engl J Med. 2004;350(22):2247.

10. Hydroxyethyl starch 130/0.42 versus Ringer’s acetate in severe sepsis. Perner A, Haase N, Guttormsen AB. N Engl J Med. 2012;367(2):124.

11. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. Brunkhorst FM, Engel C, Bloos F, Meier-Hellmann A. N Engl J Med. 2008;358(2):125.

12. Comparison of two fluid-management strategies in acute lung injury. National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network, Wiedemann HP, Wheeler AP, N Engl J Med. 2006;354(24):2564).

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