Discussion: 68 year old African American female presented to the ED with fever, nausea, vomiting, and diarrhea. She is being admitted to the ICU with diagnosis of acute on chronic kidney failure and septicemia. Previous PMH includes CKD on dialysis MWF, hypertension, DM2 insulin dependent, and left above knee amputation 3 years ago. Patient is full code
Discussion: 68 year old African American female presented to the ED with fever, nausea, vomiting, and diarrhea. She is being admitted to the ICU with diagnosis of acute on chronic kidney failure and septicemia. Previous PMH includes CKD on dialysis MWF, hypertension, DM2 insulin dependent, and left above knee amputation 3 years ago. Patient is full code
68 year old African American female presented to the ED with fever, nausea, vomiting, and diarrhea. She is being admitted to the ICU with diagnosis of acute on chronic kidney failure and septicemia. Previous PMH includes CKD on dialysis MWF, hypertension, DM2 insulin dependent, and left above knee amputation 3 years ago. Patient is full code.
ORDER A CUSTOMIZED, PLAGIARISM-FREE Discussion: 68 year old African American female presented to the ED with fever, nausea, vomiting, and diarrhea. She is being admitted to the ICU with diagnosis of acute on chronic kidney failure and septicemia. Previous PMH includes CKD on dialysis MWF, hypertension, DM2 insulin dependent, and left above knee amputation 3 years ago. Patient is full code HERE
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Vitals: BP 189/105, HR 118, T 101.8, RR 28, O2 86% on 15L NRB
Assessment:
A/O to self only, crackles bilateral lower lobes. 2+ edema in LE, distended abdomen with hypoactive bowel sounds x 4 quadrants
Labs:
CBC- HGB 7, HCT 23.8, RBC 2.8 WBC 15.1
Chem: Na+ 132, K+ 6.1, Ca+ 9.3, Phos 6.0, Glucose 189, BUN 77, Creatinine 7.18, eGFR 10, BNP 182
Blood culture pending
Urinalysis: Dark tea colored and cloudy. Protein 28mg/dL, + for casts, + for RBCs, + SBC, +Glucose and ketones
The patient’s septicemia could very well likely be from a urinary tract infection. The goals of care in handling MODS focus on treatment of underlying source of infection as well as maintenance of tissue oxygenation, and adequate perfusion. For the UTI, and waiting on pending blood cultures the patient should be started on broad spectrum antibiotics. The patient is in severe respiratory distress. Mechanical ventilation is indicated. Hemodialysis is indicated for support of the kidneys. At this point she has adequate blood pressures and can most likely tolerate hemodialysis without severe threat of circulatory collapse. CRRT could be utilized if the patient were to become hemodynamically unstable. The patient should have continuous cardiac and hemodynamic monitoring. Monitoring frequent ABGs Q4 hours to continue to assess oxygenation and assess acid base balance( Al-Khafaji, 2020).
Organ involvement currently is exacerbated renal insufficiency, as well as respiratory compromise. Cardiovascular/circulatory involvement should be diligently monitored. This patient is at increased risk for acute heart failure. While the patient is already hemodialysis dependent, the risk for increased preload can already be seen with the patient’s pitting edema. As fluids and antibiotics are given this risk is further increased. Priority goals include preserving organ perfusion and function, targeted antibiotics, electrolytes, and acid base balance. Differentials include sepsis induced MODS, and acute abdomen. The GI system has long been speculated as the “motor” of MODS. The GI system is made up of a unicellular epithelial layer, localized immune system, and its own microbial environment. All three of these make up a microenvironment in the intestines and are crucial for maintaining homeostasis. The occurrence of SIRS/Sepsis within this environment disrupts the equilibrium and an inappropriate immune response can be created. The increase the intestinal permeability and facilitate the entry of pathogens into extraluminal spaces and mesenteric lymph nodes. Studies have shown that shock or trauma can cause failure of the gut barrier that results in migration of the gut microorganisms to distant sites. “Resulting in tissue injury factors and proinflammatory cytokines carried via mesenteric lymphatic system could cause endothelial cell activation and injury, neutrophil activation, RBC injury, acute pulmonary injury, bone marrow dysfunction, and cardiac failure” (Asim et al., 2020)
Al-Khafaji, A. (2020, January 27). Multiple organ dysfunction syndrome in sepsis treatment and managment . MedScape. https://emedicine.medscape.com/article/169640-treatment
Asim, M., Amin, F., & El-Menyar, A. (2020). Multiple organ dysfunction syndrome: Contemporary insights on the clinicopathological spectrum. Qatar medical journal, 2020(1), 22. https://doi.org/10.5339/qmj.2020.22