Errors in Sepsis Management 
Commentary by David Shimabukuro, MD
A 72-year-old woman with pulmonary hypertension, chronic obstructive pulmonary disease (COPD) on home oxygen, and coronary artery disease presented to the hospital with left-sided abdominal pain and shortness of breath. She had been hospitalized for an exacerbation of her COPD 3 weeks prior but had been doing well at home on home oxygen. In the emergency department, she was ill appearing and in some respiratory distress. Her vital signs were notable for a temperature of 38.6° C, heart rate of 115 beats per minute, blood pressure of 104/68 mm Hg, respiratory rate of 28 breaths per minute, and oxygen saturation of 86% on her baseline 2 liters. She was found to have decreased breath sounds at the left base and appeared dehydrated. She had a white blood cell count of 21.4 x 109/L, creatinine of 2.1 mg/dL (up from a baseline of 1.3 mg/dL), a lactate of 3.9 mmol/L, and an international normalized ratio (INR) of 1.5. A chest radiograph revealed an infiltrate in the left lower lobe and she was diagnosed with pneumonia.
The patient was given 1 liter of normal saline in the emergency department. However, because of her history of pulmonary hypertension and coronary artery disease, she was not given any additional intravenous fluids. Blood cultures were drawn, and she received levofloxacin (administered approximately 3 hours after presentation).
She was admitted to the transitional care unit but slowly worsened. Twenty-four hours after admission, her blood cultures were growing methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin was added to her antibiotic regimen. Despite the antibiotics and additional intravenous fluids, she continued to deteriorate. The patient developed respiratory failure requiring mechanical ventilation as well as septic shock requiring vasopressors. Her illness progressed and in discussions with her family, the decision was made to withdraw life-sustaining therapies and allow her to die peacefully. She died on hospital day 4 with her family at her bedside.
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