Sepsis in the Short Gut Patient, by Dr. Nina Gluchowski, and Dr. Bram Raphael.
Hi, I'm Nina Gluchowski, and now we're going to review a case of a GI patient with a central
line and sepsis.
You're taking care of a 3-year-old boy with short bowel syndrome, secondary to malrotation
with volvulus in infancy.
The patient is dependent on home parenteral nutrition infused via a Broviac line.
He is admitted now for observation after a few hours of sleepiness and vomiting.
The nurse pages you that his oral temperature is 102 degrees Fahrenheit.
On the way to the patient's room, you think about your differential diagnosis, which should
include the following: central line-associated bloodstream infection, visceral perforation,
intestinal obstruction, intestinal pneumatosis, infectious gastroenteritis, a viral syndrome,
or pneumonia.
What are you going to do when you get to the room?
You're going to perform a targeted physical exam.
The patient's vitals are now a temperature of 39.9 degrees Celsius.
Heart rate of 140.
Blood pressure is 120 over 75.
Respiration's at 28 breaths per minute, and oxygen saturation 98% on room air.
You then look for signs of sepsis or shock.
At Boston Children’s Hospital, there is a sepsis trigger tool that should be utilized
to prompt a multidisciplinary team sepsis huddle and guide further management whenever
there is a concern for sepsis.
The patient appears to be mentating clearly, has moist mucus membranes, is breathing comfortably,
and capillary refill is less than two seconds.
The patient has a tunneled central venous catheter in place, with an occlusive dressing.
The exit site appears clear.
There is no surrounding warmth, erythema, or exudate.
Scars from previous central line insertions are present.
The central line is currently hep-locked with nothing infusing.
You then move to the abdominal exam and see well-healed surgical scars, a gastrostomy
tube, and the abdomen is soft, non-distended, and non-tender.
Are you reassured by the normal physical exam?
The answer is no.
Patients with central venous catheters and fever are at high risk of central line-associated
bloodstream infections.
There are no characteristic physical findings for central line-associated bloodstream infection.
Therefore, a non-focal exam is never reassuring.
The physical exam, however, might yield information regarding an alternative focus of infection.
But this does not rule out central line-associated bloodstream infection.
Infections of the soft tissues surrounding the central line exit site are also serious
and deserve medical attention.
However, bloodstream infections are often unrelated to surrounding tissue and involve
only the bloodstream and catheter.
What are you worried about?
Central Line-Associated Bloodstream Infection, or CLABSI.
Patients with gastrointestinal disease or intra-abdominal pathology and central venous
catheters are at an increased risk of CLABSI.
Patients receiving parenteral nutrition are also at higher risk for CLABSI, when compared
to patients with central lines for other indications.
What do you do next?
You obtain central and peripheral blood cultures.
The CDC defines central line-associated bloodstream infection as one of the following: cultures
from peripheral blood culture and catheter tip grow the same organism, or cultures from
peripheral and central blood cultures grow the same organism, or two or more central
blood cultures grow the same organism.
You now decide to initiate empiric broad spectrum antibiotics.
As long as feasible, blood cultures should be obtained prior to starting antibiotics.
The antibiotics should cover for methicillin-resistant Staph aureus and enteric gram negatives.
Multi-drug resistant gram negative bacilli, such as pseudomonas, should be considered
in patients that are neutropenic, severely ill with sepsis, or have previous colonization.
At Boston Children's Hospital, empiric coverage typically includes vancomycin and zosyn.
Empiric anti-fungal treatment should be considered in patients with a history of the following:
recurrent fungal sepsis, candidal colonization, immunodeficiency, such as neutropenia, as
well as in any patient presenting with severe septic shock.
A fungal source should also be considered in patients with persistent fevers and no
growth in bacterial blood cultures.
When thinking about antibiotic coverage, it is helpful to keep in mind the distribution
of pathogens causing CLABSI.
This chart shows the distribution in neonates with gastrointestinal conditions.
Other next steps in patient care should include a bolus of isotonic intravenous fluids of
20 cc per kilogram.
Once you determine the patient appears stable, you can plan for continued close monitoring.
It's now approximately 30 minutes later, and the patient's nurse pages you that his blood
pressure is now 70 over 40.
What are you going to do now?
You again perform a focused physical exam, looking for signs of perfusion.
Vital signs are now a temperature of 37.5 degrees Celsius.
Heart rate of 180.
Blood pressure 70 over 40.
Respiratory rate of 50, and oxygen saturation 98% on room air.
They again appear to be mentating clearly, but their mucous membranes appear dry, they
have increased work of breathing, and their capillary refill is more than three seconds.
The central line is now connected to tubing for antibiotic infusion.
What is your next step?
You decide to bolus another 20 CCs per kilogram of isotonic fluids.
You call for an ICU consult and admission, and you call for a surgical consult.
The red flags to prompt ICU admission and surgical consultation for central venous catheter
removal include a sudden change in hemodynamic status.
Note that this may or may not be associated with accessing central venous catheter and
infusing intravenous antibiotics.
Other red flags include tachycardia, or hypotension that is unresponsive to an intravenous fluid
bolus, or respiratory distress or hypoxemia.
Further treatment considerations in patients with central line-associated bloodstream infections
are removal versus salvage of the line.
This should be determined by the patient's clinical status, long-term need for central
venous access, as well as the infectious organism.
Whenever a line is salvaged, systemic antibiotic therapy, along with antibiotic lock therapy
is recommended.
You then think, can these situations be prevented?
Yes.
In fact, many central line-associated bloodstream infections are preventable.
It is suggested that up to 70% of CLABSIs are preventable, with the implementation of
evidence-based prevention practices.
This may actually be related to a learning curve.
The highest rates of CLABSI in patients receiving home parenteral nutrition occur during the
first month, post-hospital discharge.
That concludes our case of a GI patient with a central line and fever.
Thank you for participating.
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