Nurul Huda Ahmad Shahrir

PRP
Introduction
1.Sepsis is a medical condition characterized by a whole-body
inflammatory
state called systemic inflammatory response syndrome and
presence of
known or suspected infection.
2.It can be with or without organ dysfunction.
3.Systemic inflammatory response syndrome:
a. T > 38°C or below 36°C
b. Heart rate > 90 beats/min
c. Respiratory rate >20 breaths/min
d. WBC > 12000 cells/mm3
4. Can cause organ dysfunctions of
a. Lung
b. Brain
c. Liver
d. Kidney
e. Heart
Mechanism of Sepsis
1.Bacteria, virus or parasite will attack
the host
cell.
2.Body will response by releasing the
TNF, IL, PG,
Leukotrienes, Bradykinin and Platelet
Activating Factor
3.These will produce the systemic
inflammatory
response syndrome
Patient’s Particulars
Name : KK
Gender : Male
Age : 28
Race : Indian
Weight : 70.5kg
Date of Admission : 2/5/11
Ward : ICU (B)
History of Presenting Illness
Patient was admitted to Hospital Kulai
because of fitting in bathroom. He
developed fit for 30 minutes, a general
tonic clonic seizures with tongue lifting
and drooling of saliva. Given IV Valium in
the A&E and admitted to the ward. After 5
hours in the hospital, patient suddenly
stopped breathing and vomitted. CPR was
done and patient revived after 10
minutes. Patient had history of fall earlier
in the morning before the admission.
Past Medical History
Patient has history of epilepsy since childhood but defaulted
treatment and follow-up. He was admitted to Hospital Muar 4
years ago and told that he had blood clot in the brain but he
refused operation.

Social History
He’s a chronic smoker and alcoholic.Drank 2
bottles of whisky a day. Not working and staying
with parents. Denies any drug use.
Diagnosis
1.Status epilepticus with hypoglycaemic
coma
2.Nosocomial Sepsis
 Vital Signs
Date 2/5 3/5 4/5 5/5 6/5 7/5 8/5 9/5 10/5
BP Systole 122- 88-112100- 96-132105- 120- 105- 98-11399-128
144 138 123 133 145
Diastole 56-67 49-69 55-88 54-74 68-72 80-93 58-86 55-77 61-80

Temperatur 37.5 40 37 36.3 36.5 34.6 34.5 39 37

e

RR 30 30 38 13 20 17 19 20
PR 121- 59-84 70-83 71-73 79-13278-10878-84 85-11889-120
145
Lab Values
2/5 3/5 4/5 5/5 6/5 7/5 8/5 9/5 10/5
Full Blood Count
TWBC 12.8 12.9 8.4 8 6.3 4.0 4.7 18.5 16.29

HB 13.0 15.7 13.4 13.5 13.3 12.1 11.6 11.1 10.1

HCT 0.38 0.45 0.40 0.40 0.38 0.36 0.36 0.34 0.31
PLT 125 160 135 79 152 78 47 35 90
BUSE/Renal Profile
Urea 8.2 10.8 17.1 14.9 8.4 6.6 10.4 20.1
Na 135 130 130 133 136 137 134 132
K 3.22 3.78 6.4 5.08 3.2 3.89 4.61 4.76
Cl 97 96 89 96 105 102 102 97
Ca 1.81 1.74 1.69 2.05 2.30 2.68 2.68 2.59
Mg 0.92 0.79 0.78 1.24 0.57 0.85 0.85 0.78
PO4 0.47 0.88 1.38 1.51 0.67 0.45 0.45 0.57
Scr 410 570 790 560 410 210 210 210 510
CrCl 23.65 17.01 12.27 17.31 23.65 46.16 46.16 46.16 19.01
Lab Values
Medication Chart
Drug Regimen Date Date Indication
Start Stop
IV EES 250mg BD 3/5 4/5 Prophylaxis
IV Augmentin 1.2g BD 3/5 4/5

IV Augmentin 1.2g OD 4/5 6/5

IV Acyclovir 500mg 3/5 1 dose Meningitis

12H
IV Ceftriaxone 2g BD 3/5 1 dose
IV Tazocin 2.25g TDS 8/5 10/5 Sepsis
IV Augmentin 1.2g BD 6/5 8/5

IV Polymyxin E 2MU 10/5 Azinobacter Baumanii

OD
S/C Fondaparinux 3/5 1 dose
2.5mg OD
 Medication Chart
Drug Regimen Date Date Indication
Start Stop
IVPhenytoin 100mg TDS3/5 seizures

IV Na Valproate 200mg 2/5 6/5 seizures

TDS
IV Mannitol 150ml QID 3/5 Diuresis
Primasol 4/5 Metabolic acidosis
Syr Na Valproate 6/5 seizures
400mg TDS
Culture & Sensitivity Test
Date Source Microbes Sensitivity
Sensitive Resistance
5/5 Broncoscopic Klebsiella Unasyn, Ampicillin
Pneumoniae Augmentin,
Gentamycin,
Cefuroxime,
Bactrim,
Tazocin
5/5 broncoscopic Staphylococcu Methicillin, Penicillin
s aureus Erythromycin,
Gentamycin

8/5 Blood Azineobacter Polymycin B Unasyn,

Baomani Imipenem,
Meropenem,
Gentamycin,
Ciprofloxacin
Pharmaceutical Care Issues
Management of Status Epilepticus
1.In A&E Hospital Kulai, patient was given IV Diazepam 10mg.The seizure
resolved
2.In A&E HSA, patient developed fit again, was given IV Mida/Morphine
followed by loading dose of IV Phenytoin 1g.
3.Patient’s GM = 1.8mmol/L and was given IV Dextrose 50%-50ml
4.In ward, continued with maintenance dose of 100mg TDS and given IV
Thiamine 100mg OD for 3 days followed by T.Thiamine 30mg OD
5.Patient still develop fit in the ward, add on with IV Sodium Valproate
200mg TDS
6.This steps follow the Consensus Guidelines on the Management of
Epilepsy 2010 and Emergency Medicine Handbook (refer next slide)
Brown & Cadogan vs
Consensus Guidelines
Management of GTC by Brown & Cadogan,
Emergency Medicine
Maintain oxygen saturation above 94%.

Check blood sugar:

i Give 50% Dextrose 50ml if low
Ii Give Thiamine 100mg if chronic alcoholism is likely.
Give Lorazepam 0.07mg/kg or Diazepam 0.1-0.2mg/kg up to
20mg or midazolam 0.05-0.1mg/kg up to 10mg

If still fit:
i repeat lorazepam, diazepam or midazolam
until seizure cease
ii Then, give IV Phenytoin 15-17mg/kg
Brown & Cadogan vs
Consensus Guidelines
Pharmaceutical Care Issues
Management of Hyperkalemia (4/5 – 5/5)
1.Patient was given oral Kalimate to treat hyperkalemia (4/5 – 6/5)

Management of Hypokalemia (7/5)

1.Patient was given infusion 1g of Potassium Chloride (13.4mEq) (7/5 – 8/5)
2.According to Drug Info Handbook, if run >10mEq/H should have continous
ECG monitoring

Management of Hypophosphatemia (7/5 – 10/5)

1.Patient was given IV Potassium Phosphate 20mmol/100ml (7/5)
2.According to product leaflet, up to 10mmol phosphate administered over
12 hours
Pharmaceutical Care issues
Using IV EES
1.IV EES is used as prophylaxis agent in this patient
2.IV EES should be used cautiously in patient with hepatic impairment as it
can worsen the condition.
3.Petient’s liver profile are closely monitored in the ward

IV Tazocin
1.Result of C&S came out on 8/5 which indicates that the acinobacter
Baumani is sensitive to Polymycin B, however patient was started on IV
Piperacillin/Tazobactam 2.25mg TDS.
2.Temperature continues to spike
3.Patient was started on Polymycin E 2 days after the C&S result came out.
Pharmaceutical Care Issues
Dose of IV Augmentin
1.Given IV Augmentin 1.2g BD and reduced to 1.2g OD because
of increase in serum creatinine level.
2.According to Drug Info Handbook, dosing interval for patient
with creatinine clearance of 10-30ml/minute is 250-500mg every
12 hours.
3.According to product leaflet, the suggested dose for renal
impaired patient is 1.2g followed by 600mg 12H
Pharmaceutical Care Issues
Management of Acute Kidney Injury
1.The serum creatinine was high during admission and patient
has poor urine output.
2.Patient was given IV Frusemide 240mg/hr for 6 hours

2/5 3/5 4/5 5/5 6/5 7/5 8/5

Input 3423 5445 1749.1 2070.1 2144.4 2718 2298.1
Output 145 330 1132 2322 1952 2141 869
Balance 3278 5115 617.1 -251.9 192.4 577 1429
Pharmaceutical Care Issues
1.Patient was on Primasol which is used to normalised the
composition of the blood.