My septic patient

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Specializes in ICU/Critical Care.

Not to go into much detail about my patient, I'm just going to say that he was septic, hx of previous abdominal surgeries, came in with complaints of abdominal pain, most likely the same issue from previous admission. Temp was 39.3. WBC 30. Hypotensive and tachycardic. Patient was immediately lined in the ICU where I took care of him. Vasopressin and Levophed drips started. Vasopressin was infusing at 0.04unit/min, the physiologic dose. Levophed started at 2mcg/min although I eventually increased it to 14mcg/min by the end of my shift . Patient received 9 liters of LR as well as two units of PRBCs. Now throughout the night his urine output was 60-80ml/hr. CVP-11. SVV- 10%.

At 4am, his urine output was 400cc, made this aware to the resident who I swear thought I was crazy but dumping that much urine to me seemed strange. Then around 5am, the patient dumped 900cc of urine. Called the resident who made me start cc per cc replacement. I don't understand what was happening. The vasopressin should have been helping to conserve the water thus reducing urine volume. Patient's mean arterial pressure remained around 60. Should the vaso have been increased?

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Would have been helpful to know what the urine electrolytes were as well as specific gravity. Any other underlying pathologies that you didn't mention?

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Specializes in ICU/Critical Care.

Well, his liver enyzmes were elevated as well as his lipase. I can't remember what his specific gravity was. I do remember that his sodium was a bit low 130 then 133 when I rechecked his labs. Creatinine was 2.0. The rest of his electrolytes were ok, I did replace magnesium. I do believe he had a liver abscess his previous admission and the docs were suspecting the same thing this time around. He had necrotizing pancreatitis, had partial pancreatectomy previous admission.

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Maybe he is in SIDH. His sodium was low, maybe his sodium was correcting too quickly with the LR. Why did they use LR. I thought it should never be used in a patient with lactic acidosis (which the patient was probably in since he is septic and having liver issues). It should never be given in a patient in liver failure since the liver can not metablize the lactate. Maybe that had something to do with it. CVP was 11. Maybe he is adequatly fluid resucitated (it was never poor since 60-80ml urine/hr is pretty good)and there is another issue causing the increased need for pressors (was he in an acidosis)

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Specializes in ICU/Critical Care.

You know what, I totally didn't think about that, the SIADH. Can't believe I didn't think about that. You have a point, the LR most likely wasn't the best. I'm guessing they gave it because they were suspecting blood loss and he wasn't urinating much prior to coming to the ICU. His ABG was actually fine with the exception of his lactate which was 8 when he first came to me then 6 when I repeated his labs. Perhaps the elevated lactate was due to his impaired liver function?

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Specializes in M/S, MICU, CVICU, SICU, ER, Trauma, NICU.

Acute Renal Failure?

Creat 2.0

High output is sudden--that or fluid balance was achieved with the 9 L of LR (don't get that with the liver failure--did the patient come from surgery?)

Need to see all the labs; and a full hemodynamic study would be exemplary. What was his CO? SVR? etc.,....(PA line needed of course).

The pressors aren't that high--yet.

You are watching a slow decline....probably another acute abdomen with dead bowel or pancreatitis...

SIADH? Hm...not sure..

Need the whole picture...=(

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Specializes in ICU/Critical Care.

He didn't have a PA line but we had vigileo set up on his a-line so his CO was actually 9.0. SVV 10%. When I did measure his SVR it was 600...not sure how accurate it was. I'm assuming this is all attributed from his problems last admission, which was pancreatitis. He only part of it removed then had a couple of episodes of GI bleeding. When he got to me, he hadn't had any type of surgery yet. They ordered a cat scan of his abdomen as I was leaving.

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Specializes in Oncology.

Hi vaso was at 0.04 units/hr? Is that a typo? We typically start at 2 units/hr, titrate up to 4 units/hr, then titrate up other pressors. Typically our septic people go from 2 to 4 units of vaso in like 30 minutes before we're adding a 2nd or 3rd pressor.

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Specializes in MICU for 4 years, now PICU for 3 years!.
Hi vaso was at 0.04 units/hr? Is that a typo? We typically start at 2 units/hr, titrate up to 4 units/hr, then titrate up other pressors. Typically our septic people go from 2 to 4 units of vaso in like 30 minutes before we're adding a 2nd or 3rd pressor.

I think you read wrong... the original poster wrote 0.04 units/min, which is the typical dose. According to Lexicomp, the dose for septic shock it 0.01-0.04 units/minute.

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Specializes in ICU/Critical Care.

0.04units/min is equal to 2.4units/hr.

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