Case for October 28th 2025

Situation

78-year-old male with history of atrial fibrillation (on Eliquis), moderate aortic stenosis, insulin-dependent type 2 diabetes mellitus complicated by polyneuropathy, end-stage renal disease on hemodialysis (TThS), and chronic bilateral foot wounds with prior osteomyelitis due to Pseudomonas CRE.
Admitted to MICU for pressor-dependent septic shock secondary to pneumonia (PNA).

Background

• Recent events: Presented febrile, hypotensive, tachycardic with elevated lactate and leukocytosis. CXR: right lobe infiltrate.

• Comorbidities: ESRD, Afib, moderate AS, CAD, PAD, diabetic neuropathy, chronic osteomyelitis.

• Course: Started on vasopressors, broad-spectrum antibiotics, and transitioned to maintenance regimen as infection identified and patient stabilized.

Assessment

NEURO/PSYCH

• Chronic pain and neuropathy from diabetic polyneuropathy and prior surgeries.

• Currently alert, oriented ×4, moves all extremities.

• On IV dilaudid 0.5 mg daily; home buprenorphine, dilaudid PO, venlafaxine, and Lyrica held except Lyrica resumed.

Rationales:

• IV route ensures pain control when NPO and avoids erratic oral absorption.

• Lyrica resumed to address neuropathic pain, improving comfort and decreasing opioid needs.

• Thiamine continued to prevent Wernicke’s encephalopathy due to chronic illness and ESRD.

• Monitoring on COWS ensures early detection of opioid withdrawal symptoms.

CARDIOVASCULAR

Septic Shock (Resolved)

• Etiology: Likely pulmonary source (pneumonia), given leukocytosis, fever, CXR findings.

• Lactate normalized; levophed titrated off overnight; MAP >65.

Interventions & Rationales:

• Levophed weaned off: Maintains perfusion during hypotension; discontinued as hemodynamics stabilize.

• Goal MAP >65: Ensures adequate organ perfusion, particularly for kidneys and brain.

• Monoclonal antibody (septic adjunct): Enhances immune modulation; reduces inflammatory cascade.

• Monitor lactate: Trending down confirms perfusion improvement and shock resolution.

Atrial Fibrillation (Chronic)

• Back in Afib with RVR 100–120s.

Interventions & Rationales:

• Telemetry: Detects arrhythmia burden, rate control effectiveness.

• Coreg 6.25 mg BID (post-pressor): Beta-blocker to control rate; initiated after hemodynamic stability.

• Unhold Eliquis once PO tolerated: Prevents embolic stroke due to Afib.

• Maintain K⁺ >4, Mg²⁺ >2: Prevents ectopy and promotes rhythm stability.

CAD / PAD

• Continue statin, Plavix, Eliquis. Hold Repatha inpatient.

Rationale: Statin and antiplatelets reduce atherosclerotic risk; holding Repatha as non-essential inpatient therapy.

HTN

• Hold antihypertensives (Amlodipine, Coreg high-dose, Hydralazine, Torsemide).

Rationale: Prevents worsening hypotension during septic recovery.

Elevated Troponin

• Likely demand ischemia from septic stress; EKG unchanged.

Rationale: Trend to exclude ongoing myocardial injury; monitor for ACS symptoms.

PULMONARY

Acute Hypoxic Respiratory Failure 2° PNA

• Initially required 2 L NC; now stable on room air.

Rationales:

• Wean O₂ as tolerated → prevents oxygen toxicity, encourages lung recovery.

• Continue antibiotics → targets infectious source, prevents progression to ARDS.

INFECTIOUS DISEASES

Septic Shock 2° Pneumonia

• Source confirmed: right lower lobe infiltrate; MRSA neg; urine strep/legionella neg.

Interventions & Rationales:

• De-escalate from Zosyn to CTX (3/5): Narrowed coverage per culture results, reducing nephrotoxicity.

• Stop Tobramycin and Vanc: No active wound or MRSA infection, avoiding renal strain.

• Follow blood, sputum, urine cultures: Confirms infection clearance.

• Monitor CRP and procalcitonin: Track inflammatory resolution.

Pathophysiology: Pneumonia → systemic infection → vasodilation and capillary leak → hypotension → septic shock.

GI / NUTRITION

Interventions & Rationales:

• Passed bedside swallow → Resume diet; prevents aspiration.

• Omeprazole → GI protection while NPO/stressed.

• Bowel regimen PRN → Prevent constipation from opioids and immobility.

RENAL / ELECTROLYTES

ESRD on HD (TThS)

• Nephrology managing; LUE AVF in use. Permacath in place; remove once stable.

Rationales:

• Dialysis scheduled 10/27: Corrects fluid, electrolyte, and toxin imbalance.

• Continue Sevelamer: Controls phosphate in ESRD.

• Permacath removal post-pressor: Decreases infection risk once stable.

Hyperkalemia (Resolved)

• Initial K⁺ 6.1 → treated with insulin, dextrose, Lokelma; normalized.

Rationale: Potassium-shifting and binding therapies prevent arrhythmia; continue BMP to monitor recurrence.

HEME / ONC

Anemia 2° ESRD

• Hb goal >7 g/dL.

Rationale: Prevents tissue hypoxia; transfuse only if below threshold to reduce volume overload risk.

ENDOCRINE

IDDM2 (Insulin-Dependent Type 2 DM)

• Home regimen: Toujeo 10u QHS + Humalog 5u TID.

• Transitioned to high-dose SSI + Tresiba 7u QHS + Humalog 3u TID (30% reduction).

Rationales:

• Reduced basal/bolus insulin → Prevents hypoglycemia with decreased appetite/illness.

• High-dose SSI → Corrects hyperglycemia from stress and steroids.

• ACHS glucose monitoring → Early detection of hypo/hyperglycemia.

Pathophysiology: Infection + stress hormones (cortisol, catecholamines) increase insulin resistance and glucose output.

MUSCULOSKELETAL / SKIN

Left Wrist CTS s/p Decompression

• Continue IV Dilaudid and resumed Lyrica.

Rationale: Adequate analgesia facilitates mobility, prevents pain-induced stress response.

Chronic Foot Wounds / s/p Amputation

• Betadine paint and DSD dressings; offload in Prevalon boots; vascular consult.

Rationales:

• Betadine → Antiseptic, dries necrotic tissue.

• Offloading → Prevents pressure necrosis.

• Vascular evaluation → Ensures perfusion for wound healing.

New L3 Compression Fracture

• Ortho consult for bracing.

Rationale: Stabilization prevents further injury, improves mobility safety.

LINES / ACCESS

• Right chest Hickman (single lumen)

• Right chest Permacath

• Left arm AVF

• Peripheral IVs intact

Rationale: Maintain aseptic technique; Hickman for meds, Permacath for HD, AVF for chronic use.

Recommendation / Plan

1. Continue to monitor hemodynamics; maintain MAP >65.

2. Trend lactate and CBC to monitor infection resolution.

3. Wean O₂ as tolerated; maintain SpO₂ >92%.

4. Resume Eliquis when oral intake stable.

5. Continue antibiotics (CTX) to complete 5-day course.

6. Coordinate dialysis with nephrology; reassess fluid status daily.

7. Maintain glucose control with current insulin regimen; monitor ACHS.

8. Strict skin care, turning Q2H, offload heels.

9. Physical therapy when stable; prevent deconditioning.

10. Continue pain control; reassess daily.

S – Situation:
28-year-old male with a history of class II obesity, GERD, alcohol use disorder (AUD), prior alcohol-related hepatitis, anxiety, and depression presented with cough, congestion, and new-onset jaundice. Found to have left lower lobe pneumonia with small effusion and markedly elevated bilirubin and liver enzymes. GI consulted for evaluation of jaundice and abnormal liver function tests.

B – Background:

• PMH: Obesity, GERD, AUD (1 pint vodka/day since 2019), alcohol-related hepatitis, anxiety, depression.

• Social: Quit smoking in 2024, reports last alcohol intake 1 month ago.

• Labs:

  • WBC 14.6 (↑), Hgb 10.7 (↓), Na 128 (↓), K 2.8 (↓), CO₂ 16 (↓), BUN 35 (↑), Cr 2.7 (↑), Albumin 2.7 (↓), INR 2.07 (↑), Tbili 33.3 (↑↑), Dbili 23.7 (↑↑), AST 98 (↑), ALT 47 (↑), ALP 250 (↑).

  • MELD 39, MDF 88 → severe liver dysfunction with poor short-term prognosis.

• Imaging:

  • RUQ US: Cirrhotic morphology, portal hypertension, cholelithiasis, mild intrahepatic biliary dilation, no cholecystitis.

  • CXR: LLL pneumonia with effusion.

• Diagnosis: Acute-on-chronic liver disease (likely alcoholic hepatitis with underlying cirrhosis) complicated by AKI, hyponatremia, hypokalemia, and pneumonia.

A – Assessment:

• Acute issues:

  • Severe hyperbilirubinemia (Tbili 33.3 mg/dL).

  • Elevated INR 2.07 → impaired hepatic synthetic function.

  • AKI (Cr 2.7) possibly hepatorenal syndrome or prerenal from sepsis/dehydration.

  • Hyponatremia and hypokalemia → risk for encephalopathy and arrhythmia.

  • Left lower lobe pneumonia (likely community-acquired).

  • Cirrhosis with portal hypertension.

  • Active alcohol-related liver injury, though last intake was over 1 month ago.

• Neurologic: No asterixis, alert and oriented → no overt hepatic encephalopathy at this time.

• MELD 39 and MDF 88 indicate poor hepatic reserve and possible need for transplant evaluation once infection stabilizes.

R – Recommendations / Plan with Rationales:

1. Diagnostics

• Trend LFTs, INR, Tbili/Dbili daily; check GGT once.
  Rationale: Serial monitoring detects worsening hepatic failure or improvement; GGT helps confirm cholestatic vs hepatocellular pattern.

• Check AFP.
  Rationale: Screens for hepatocellular carcinoma (HCC) in cirrhotics.

• Viral, metabolic, autoimmune, and toxicology panels.
  Rationale: Rule out other causes of liver injury (viral hepatitis, autoimmune hepatitis, Wilson’s, hemochromatosis, drug-induced injury).

• Broad infectious workup (blood/urine cultures, RVP, sputum culture, stool studies if diarrhea).
  Rationale: Cirrhosis increases susceptibility to bacterial translocation and sepsis; early identification guides antibiotic therapy.

• Triple-phase MRI abdomen/pelvis.
  Rationale: Evaluates for hepatic lesions, portal flow, biliary obstruction, or malignancy missed by ultrasound.

• Strict I&O, daily weights, and urine electrolytes.
  Rationale: Detects volume status changes and helps assess prerenal vs intrinsic AKI.

2. Therapeutic Interventions

• Continue ceftriaxone 1 g IV daily + doxycycline 100 mg PO BID.
  Rationale: Covers typical and atypical organisms for community-acquired pneumonia.

• Replete K⁺ (60 mEq PO) and Mg²⁺ if needed.
  Rationale: Prevents cardiac arrhythmia and corrects metabolic acidosis; hypokalemia can worsen hepatic encephalopathy.

• Administer IV thiamine 100 mg daily x3 days, then PO.
  Rationale: Prevents/treats Wernicke’s encephalopathy due to chronic alcohol use.

• Continue folic acid and multivitamin supplementation.
  Rationale: Corrects nutritional deficiencies common in AUD and supports hematopoiesis.

• Avoid nephrotoxins (NSAIDs, IV contrast).
  Rationale: Minimizes further renal injury, especially if hepatorenal syndrome suspected.

• High-protein liver diet and nutrition consult.
  Rationale: Prevents catabolism and supports liver regeneration unless overt encephalopathy develops.

• No corticosteroids for now.
  Rationale: Although MDF > 32 would normally indicate steroids, active infection (pneumonia) contraindicates their use.

• EtOH abstinence counseling + addiction medicine referral.
  Rationale: Continued alcohol use is the strongest predictor of mortality; abstinence is critical for recovery and transplant eligibility.

• Monitor for hepatic encephalopathy; initiate lactulose/rifaximin if AMS develops.
  Rationale: Reduces ammonia levels and prevents progression to overt encephalopathy.

• GI follow-up and consider transfer to Klatskin Service (liver specialty unit).
  Rationale: MELD 39 signifies high mortality risk—requires hepatology team for transplant evaluation and advanced management.

3. Monitoring / Supportive Care

• Vitals q4h, monitor for signs of sepsis or hypotension.
  Rationale: Infection and hypotension can precipitate hepatic decompensation.

• Monitor mental status every shift.
  Rationale: Early detection of hepatic encephalopathy.

• Monitor for ascites development; perform diagnostic paracentesis if fluid accumulates.
  Rationale: Rules out spontaneous bacterial peritonitis (SBP).

• Maintain SpO₂ > 94% on room air; escalate O₂ if pneumonia worsens.
  Rationale: Prevents hypoxia-induced hepatic ischemia.

Summary:

This is a 28-year-old male with severe alcohol-associated hepatitis and likely underlying cirrhosis, complicated by pneumonia and AKI. Primary goals are infection control, metabolic correction, hepatic support, and renal protection. Close monitoring and multidisciplinary coordination (GI, nephrology, nutrition, and addiction medicine) are essential to prevent multi-organ decompensation and prepare for possible liver transplant evaluation.