AKI on CKD stage v urosepsis (resolvin)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.

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