Sepsis

Patient 1: 107 y.o. Female

Situation

• 107-year-old female, resident of SNF, fully dependent with history of dementia.

• Admitted for sepsis (unspecified organism, unspecified acute organ dysfunction, HC code).

• Currently experiencing acute hypoxic respiratory failure with O₂ sat 78% on room air → improved after DuoNebs en route, now on 2L NC.

• Additional issues: agitation/combative behavior, AKI on CKD, SIRS, elevated troponin, lactic acidosis, chronic anemia, hypertension.

• Code status: DNR/DNI (No Code).

Background

• PMHx: Asthma, HTN, CAD s/p PCI, AVB s/p PPM, PE, GIB (off anticoagulation), brain CA s/p resection, CKD, anemia, dementia.

• Medications: Amlodipine, Metoprolol ER 50 mg (held on admission).

• Recent events:

  • Found hypoxic in SNF, transferred to ED.

  • Combative/agitated, received haloperidol in ED.

  • SIRS criteria met: WBC 12.7, fever 102°F, tachycardia.

  • CXR: mild edema but exam suggests patient is dry; COVID negative.

  • Code status: DNR/DNI.

  • Medication reconciliation not confirmed with facility.

Assessment

1. Acute hypoxic respiratory failure — likely asthma exacerbation or aspiration pneumonitis; viral infection possible. Improved after DuoNeb. Mild CXR edema but no crackles, exam suggests dry.

2. Agitation/Combative behavior — recurrent, per family since Sunday. Received haloperidol in ED.

3. AKI on CKD — Creatinine 1.4 (baseline 1.1).

4. SIRS/Sepsis — Meets SIRS criteria; no focal infection yet. Received vanc + pip-tazo. UA pending.

5. Elevated troponin — Mild, likely demand; no chest pain.

6. Elevated lactic acid — Likely volume depletion.

7. Chronic anemia — Stable.

8. Hypertension — On amlodipine, metoprolol (held).

Recommendation / Plan

• Respiratory: DuoNeb q4h while awake; consider prednisone if not improving (hold for now due to agitation).

• Agitation: Continue trazodone, order Zyprexa PRN, consider Geri-psych consult.

• Renal: Gentle IV hydration for AKI.

• Sepsis/SIRS: Order RVP, UA, procalcitonin; follow blood cultures. Continue empiric vancomycin + pip-tazo.

• Cardiac: Monitor troponin.

• Metabolic: Monitor lactic acid after fluids.

• Anemia: Monitor.

• HTN: Hold antihypertensives for now.

• Other:

  • DVT prophylaxis: heparin.

  • Diet: regular.

  • Code: DNR/DNI (No Code).