62 Y Male with Altered sensorium

AKI on CKD stage v urosepsis (resolving)B/L consolidation of lungs (pneumonia) altered sensorium secondary to?septic enchephalopathy ? uremic enchephalopathy. Type 2 respiratory failure septic shock with grade 2 bed sore

C/C

Patient was bought to the casualty on 30/5/2023 in altered sensorium since 1day

HOPI

Patient was apparently asymptomatic 3days back then he had anuria and was taken to the hospital for the same and is diagnosed to have Aki with urosepsis with severe anemia with scrotal cellulitis AKI  with uremic encephalopathy s/p 1unit prbc transfusion

Decreased urine output with fever of high grade intermittent, nausea+, vomiting+ and pedal edema+

N/h/o sob,chest pain, palpitations 

Patient was treated conservatively and is referred to hospital in view of requirement of hemodialysis

Past illness

N/k/c/o DM HTN ASTHMA CAD ,TB or EPILEPSY

H/o ??CKD 5 years back

Personal history 

Farmer by occupation stopped since 2 years 

Appetite -lost

Non veg

Bowels -regular 

Micturition-decreased since 3 days 

Addictions 

Occasional alcoholic since 20years stopped 2years back

Smoker  stopped 2 years back

General examination 

HR -115Bpm

RR-20cpm

Bp-140/70mmhg

Spo2. 100% on 5 lit

Grbs -96mg/dl

CNS 

GCS -E2V2M5

pt is drowsy but arousable 

Speech - no response 

No signs of meningeal irritation 

reflexes +1 in all limbs 

Plantars flexors 

30/5/23.    31/5. 1/6.      2/6.    3/6---

Hb -8.4--->8.3-->7.8--->7.3-->7.4

Tlc-50K-->43K-->31K-->24K-->35k

PLT-2.1-->1.9-->1.85-->1.81-->2.2

Urea-211-->139-->168-->89--126--150

Creat 8.2-->5.5-->5.8-->3.4-->4-->4.8

Na-133-->134-->135-->137-->132-->139

K-5.9-->4.2-->4.2-->3.6-->3.8-->4.6

Cl 102-->98

2sessions of dialysis done on 31/5 and 1/6

Abg

30/5/23.   1/6           3/6.   3/6         4/6.     5/6

Ph-7.13.    -->7.33--->7.31--> 6.94-->7.19-->7.17

Pco2-8.8. -->22.7-->39.9-->105-->56.3-->43.5

Po2-118. -->138 -->145-->65.8-->396---->43.5

Hco3-2.8--->11.7-->19.9-->79.6-->22.2-->58.7

St hco3-5.3-->13.7--20.1-->21.5-->19.1-->15.3

Rbs 73mg/dl

5/6/23

Aptt -41sec

Pt-20sec 

Inr -1.4

Blood lactate 9mg/dl

Cue 

Alb 1+

Pus cells 4-6

Sr iron 65.5

Blood and urine culture negative

Outside hospital 

On 27/5

Hb 5.0-->5.5--8.3-->8.8

Tlc 9000-->12900-->31700-->38100

Plt- 2.62-->2.13-->2.03-->2.22

One prbc transfusion done 

Creat 7.5-->6-->6.9

Urea.             92

Na 147-->152-->149

K 4.1-->5.1-->6.5-->4.8

Cl 106---->105-->95-->104

At the time of admission pt was in altered sensorium urea 211 and tlc 50k /cue pus cells 11-13(outside hospital)

Altered sensorium due to?septic enchephalopathy ? Uremic enchephalopathy

Started on piptaz and clindamycin 

2 sessions of dialysis done on 31/5 and 1/6 

Pt sensorium improved but drowsy

GCS E4V2M6

On 3/6/23 10pm I/v/o low GCS ,falling saturation and type 2 respiratory failure pt was intubated 

He was hypotensive and triple ionotropes were started

31/5

4/6

5/6

Treatment-

1.Ryles tube Feeds- 100ml water 2nd hrly

                                  - 200ml milk 4th hrly

2.Salt restriction < 2 gm/day

3.Inj.PIPTAZ 2.25gm IV/TID

4.Inj.CLINDAMYCIN 600mg IV /TID

5.Inj.NOR ADRENALINE - 4ml+46ml NS @ 24ml/hr  changed accordingly to maintain MAP >65 mm Hg

6.Inj.DOBUTAMINE 5ml+ 45ml NS @ 13ml/hr changed accordingly to maintain MAP >65mmHg

7.Inj. VASOPRESSIN 2ml (40 IU) + 48ml NS @ 2ml/hr changed accordingly to maintain MAP > 65mmHg

8.Inj.LASIX 40mg IV /BD if SBP > 110mm Hg

9.Inj.NEOMOL 1gm IV /SOS if Temp. >101°F 

10.T.OROFER -XT  Rt/OD 

11.NEOSPORIN powder for LA over Bedsores 

12.Frequent position change every 2nd hrly 

13.Monitor Vitals 

14.GRBS charting 4th hrly

15.Strict I/O charting.