64 year old hypertensive diabetic patient admitted 2 weeks ago with LRTI and LVF past h/O pulmonary cox developed type 2 respiratory failure on day 2 ventilated showed marginal improvement was weaned after 5 days and put on Bipap condition worsened 4 days ago and developed high count sepsis with ARF and was put on iv meropenem colistin linezolid blood count today has increased from 24000 to 35000 blood culture shows pseudomonas aeruginosa sensitive to meropenem but patient is drowsy and completely dependant on ventilator any suggestion?



Dear Dr Ghosh You are treating the patient in an excellent way.. What I can suggest is.. (1)Resend E t suction for culture and sensitivity (2)Cover also with antifungal like voriconazole (3) serial Monitoring of procalcitonin level if possible..

Very nice answers sir..procalcitonin level why sir?

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Correct hypernatremia, either administer half normal saline or plain water through ryle's tube urgent hemodialysis De-escalate antibiotic based on ET suction C/S report. Rule out active TB. Don't just start ATD straight away. Do regular ABG and set ventilatory parameters accordingly.

Hopefully activity of tb has been ruled out by et secretion afb /gene expert

Healed ptb with copd changes and secondary infection treat accordingly

HIV test should also be done

Dear Dr Ghosh.. Answer you selected is not scientific (1) patient is having no hypernatremia.. So why needs corrections (2) no renal failure.. No urea creatinine reports.. No oliguria or anuria.. So why haemodialysis? (3) its not the time to deescalate the antibiotics.. Patient is ventilator dependent and drowsy... Please respond to my queries... @Dr. Shubhankar Ghosh

I am sorry patient is having serum sodium level 160 urea 200 and creatinine 6.8 today It is there in the picture of the blood report I attached

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this is a case of old treated ptb with obstructive airway disease this obstruction causing type 2 resp. failure exercerbation due to sepsis just give ventilator support on prvc mode and antibioyaccording to c/s report and your hospital acquired pathogens sensitivity...send blood and et aspirate for pyo , afb and fungal culture

pt also in mods so change the dosage of antibiotics according to creatinine clearance and restrict the IVF. NS/DNS/ RL.

septicemia with Acute renal failure with hypernatremia X-ray s/o b/l upper zone consolidation with collapse looks to be ?active Koch's with upper added infection

I am thinking the same thing I believe the patient has contracted a superadded infection as initial culture report was being followed

Copd emphysema looks Lt lung collapse Lt basal effusion tapping cbnat Ards send arterial blood for abg 2 decho Ard hypernatremia leucocytosis sos bone marrow

Needs to evaluate his reversible lung tissue stats as well as his cardiac 2 D echo with colour Doppler to plan about further treatment an prognosis

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