THE CASE

A 65-year old man presented to a hospital with a 2-day history of nausea, vomiting, and abdominal pain.

PAST MEDICAL HISTORY

Ischemic heart disease, type 2 diabetes with microalbuminuria, hypercholesterolemia, and hypertension.

MEDICATION HISTORY

Ramipril, Clopidogrel, Amlodipine, Bisoprolol, Atorvastatin, and Metformin.

EXAMINATION

Sweaty, tachycardic (heart rate 115), and has cool peripheries.

Central temperature is 38.2â—‹ C, BP is 95//55 mm Hg, respiratory rate is 30, and oxygen saturation is 985 on nasal oxygen.

Disoriented in time and place with a Glasgow Coma Score of 14 (E4, V4, M6). There is tenderness in the right upper quadrant with localized guarding.

He has not passed urine that day and is subsequently catheterized with residual urine of 120 ml.

Arterial blood gases demonstrate pH 7.30, base excess-12 mmol/L. lactate 5.5 mmol/L, partial pressure of oxygen 120 mm Hg, partial pressure of carbon dioxide 30 mm Hg, sodium 130 mmol/L, chloride 104 mmol/L, glucose 290 mg/dl, and capillary blood ketones are negative.

Surviving Sepsis Guidelines: Patient was given 30 ml/Kg of intravenous crystalloids was rapidly administered, blood cultures were taken and intravenous piperacillin-tazobactam is administered.

Systolic BP remains <100 mm Hg.

A CT scan of the abdomen with contrast was performed revealing dilated extra- and intrahepatic bile ducts and multiple stones in thick-walled gall bladder.

Serum creatinine was 2.3 mg/dl (outpatient baseline 1.1) and potassium was 5.1 mmol/L. Urine output was 15 ml in the first 2 hours and repeat lactate was 4.5 mmol/L. He was referred to gastroenterology for management of his obstructive cholangitis and critical care for ongoing supportive management.

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Case taken from: Prowle JR. Sepsis-Associated AKI. CJASN. 2018; 13(2): 339-342. Accessed from:

https://cjasn.asnjournals.org/content/13/2/339