septic shock with respiratory distress
HPI: 45 y/o female from the virgin islands admitted for the infected left stump. Transferred to ICU for worsening septic shock with respiratory distress. Last night had active bleeding from a stump, surgery at beside. Patient in cardiac arrest x2 with ROSC. 4 units PRBC, 2 FFP, 1 of platelets given.
> PMH: chronic- HTN, PVD, DM, Mitral regurgitation, MI, HFrEF 20-25% (8/17), pulmonary hypertension
> FH: Mother HTN, Father DM.
> SH: Denies use of alcohol, drugs, or smoking.
> ALL: NKDA
> MEDS: Metformin 500 mg BID, Metoprolol succinate 100 mg PO daily, aspirin 81 mg PO daily
> VS: BP 97/55, HR 98, RR 20, MAP: 69, O2: 100%, Ht: 5’3”, Wt 89 kg, BMI 34.9
> LABS: AST 396/ ALT 63 ^, WBC 14.8 ^, H/H 7.6/30, platelets 350, aPTT 40, Glucose 202 ^, Na 144, K+ 3.9, lactic 10^. BUN 40, creat 3.0. Leg wounds culture: achromobacter. Tracheal aspirate: stenotrophomonas (9/9)
> PE: Anasarca. Mechanical ventilation, diminished breath sounds. Wet gangrene of leg stump debrided. Dry gangrene of right lower extremity. Lines: NG tube, PICC, left IJ.
> Assessment: 1. Septic shock 2. Acute Hypoxic respiratory failure 3. Left stump infection, dry gangrene of RLE 4. Post cardiac arrest 5. Apical thrombus
> Plan :
> 1. Septic shock. Continue vasopressors, levophed currently at 15 mcg/min. Analgesia with fentanyl drip, dilaudid 0.5 mg q4h PRN. Monitor CBC/BMP and lactic levels. Daptomycin is to be continued for 6 weeks (from 8/25). Mondays check CKP, ESR, CRP levels while on daptomycin. GI prophylaxis with Pepcid 20 mg IV daily. Glucose checks q8h.
> 2. Acute hypoxic respiratory failure. Continue mechanical ventilation and monitoring of patient oxygenation. Fio2 successfully titrated from 60 to 40%.
> 3. Left stump infection, dry gangrene of RLE. Zosyn 3.375 IV to be continued for 6 weeks from 8/25. Consult ID.
> 4. Pending CT brain post-cardiac arrest.
> 5. DVT prophylaxis with heparin drip (apical thrombus). Continue to monitor coagulation levels.