Sepsis and septic shock can result from an infection anywhere in the body, including pneumonia. Pneumonia can be community-acquired, meaning that a person becomes ill with pneumonia outside of the hospital or a healthcare facility. Pneumonia can also be caused by a healthcare-associated infection (HAI), which affect 1.7 million hospitalizations in the United States every year. An HAI is an infection that is contracted by people while the hospital for a different reason, such as surgery or treatment for another illness.Sometimes incorrectly called blood poisoning, sepsis is the body’s often deadly response to infection. Sepsis kills and disables millions and requires early suspicion and rapid treatment for survival.Sepsis and septic shock can result from an infection anywhere in the body, such as pneumonia, influenza, or urinary tract infections. Worldwide, one-third of people who develop sepsis die. Many who do survive are left with life-changing effects, such as post-traumatic stress disorder (PTSD), chronic pain and fatigue, organ dysfunction (organs don’t work properly) and/or amputations.The most common source of infection among adults is the lungs.What is pneumonia?Pneumonia is an infection in the lungs. The infection can be only in one lung, or it can be in both. There are several causes of pneumonia but the most common are:BacteriaVirusFungusLeft untreated, pneumonia can be deadly. In the days before antibiotics, it’s estimated that about one-third of those who developed bacterial pneumonia died.
Chronic
liver disease secondary to chronic hepatitis C (CHC) and previous
excessive alcohol consumption. Child
Pugh score A5, previous episode of decreased level of consciousness and
peripheral oedema, chronic hypoalbuminaemia 26 g/L, mild elevation
bilirubin 22 umol/L. INR 1.4,
platelets 48 x 109/L (chronic suppression), normal bone marrow
biopsy previously. Dr John Gibson,
RPAH. Ongoing moderate hepatitis
ALT 56 U/L.
1.1 Chronic hepatitis C (CHC) genotype
1A, viral load 5.6 log IU/mL likely contracted through intravenous drug use in
1972, treated in 1997, no ongoing injecting drug use or Opioid substitution
therapy.
1.2 Previous excessive alcohol use until 9/1997
now resolved. No ongoing alcohol use.
1.3 Hepatitis B core antibody positive,
hepatitis B surface antigen negative.
Hepatitis B surface antibody 54 IU/ml consistent with previous exposure
with ongoing immunocompetency.
1.4 Hepatocellular carcinoma screening,
November 2015; cirrhotic liver with splenomegaly, no liver lesions., organs
otherwise unremarkable. November 2015
alpha-fetoprotein 13 ug/L.
1.5 No previous bone mineral density.
1.6 No previous dietician reviewed
albumin 26 g/L for nocturnal protein supplementation.
Previous
cardiomegaly with no specific diagnosis.
Echocardiography November 2015 normal LV size and systolic
function, mild to moderate dilatation of left atrium, mild pulmonary
hypertension, ejection fraction 64%.
Morbid
obesity. Weight 100 kg. Height 152 cm. BMI is 42.8. No previous dietetic intervention.
MEDICATIONS: Frusemide 20 mg daily,
Spironolactone 50 mg daily and Salbutamol prn ALLERGIES: No known.
Thank you for referring Lynne to clinic regarding her chronic
liver disease secondary to chronic hepatitis C (CHC) and resolved alcohol
excess. She is a 66-year-old woman living independently in Urunga with
significant history of bereavement and health crisis during 2014, which nearly
resulted in death. Since that time she
has improved significantly and been able to resume home life independently. She
has not previously had specialist liver review.
She is known of CHC for many years and nominates intravenous drug use from
1972 onwards as the likely source of infection. During the period 1972 through 1987 she
consumed alcohol and used intravenous drugs and was able to control substance
abuse initially with IV substitution therapy and eventually through Narcotics
Anonymous to avoid all ongoing issues with drug and alcohol since that
time. She has not previously had therapy
for CHC.
Lynne’s health issues in 2014 were described as
decompensation of her cirrhosis in the setting of severe pneumonia which
resulted in loss of consciousness and ICU care for several weeks and involved significant
fluid overload. Since that time, her fluid overload has mostly resolved and she
has no ongoing features of encephalopathy that previously troubled her. Her other health issues relate to dyspnoea and
morbid obesity; I believe these to be linked.
She is morbidly obese with BMI of 42.8 and has significant difficulty moving
with this weight. She has not undertaken
exercise or diet programs and has no previous referral for bariatric surgery.
She was previously described as having cardiomyopathy with dilatation of the cardiac
changes, however her most recent echo does not demonstrate features of
cardiomegaly and has normal left ventricular size and systolic function. Her
echo shows mild pulmonary hypertension which may contribute to breathlessness,
however I feel that her muscle bulk is likely to be quite modest in her body which
is requiring significant exertion and I believe her breathlessness relates to both
her liver disease and her obesity rather than cardiac or respiratory
function. She is not previously known to
have ischaemic heart disease.
On examination, Lynne is obese with a soft abdomen and
no evidence of ascites. She has splenomegaly and otherwise unremarkable abdomen
with minimal tenderness. She has very mild peripheral oedema and few other stigmata
of chronic liver disease. Her respiratory examination is unremarkable without
crepitation at the bases. She had dual heart sounds which were faint. She had
no signs of encephalopathy. Blood testing from November 2015 shows moderate
elevation in ALT 56 U/L with other enzymes elevated, deranged liver synthetic
function with albumin 25 g/L, bilirubin 22 umol/L, INR 1.4. She had profound
thrombocytopenia 39 x 109/L with normal haemoglobin and normal iron
studies. She has recent testing for HCV infection with genotype IA, viral load
5.6 log IU/mL and evidence of previous exposure to chronic hepatitis B with HBc
antibody positive in the absence of other markers of ongoing infection.
Ultrasound of the abdomen performed in November 2015 shows a cirrhotic liver
with no evidence of hepatic lesions, splenomegaly and no note of ascites present.
Her alpha-fetoprotein was marginally elevated consistent with her level of elevation
in ALT. She has not previously had gastroscopy and has never had upper GI
haemorrhage.
Lynne is reluctant to have antiviral therapy for her
CHC and is unsure where she would like to be treated should this became
available. The standard of care in 2016 for genotype IA infection would be three
months of oral antiviral therapy using either Viekira Pak or Harvoni both of
which are due to became available through the PBS over the coming months. Liverpool Hospital treatment team consist mainly
of nursing and medical staff with significant experience that are dealing with advanced
liver disease and this would be an appropriate environment for Lynne. This is a long way from home and presents
significant logistics complications. I am
happy to work with local services in Coffs Harbour or in the Bega area where her
son lives should treating physician be available. In the meantime, I have asked her to alter
her diet to involve high protein supplementation nocturnally (for instance, Sustagen
in milk prior to sleep), a low salt diet low in other carbohydrates to try to
reduce her weight. I will seek advice on
diet solution for Lynne by involving the dietician from the Royal Prince Alfred
Liver Unit who has specific skills in this area. Certainly, salt free diet will
benefit her with respect to fluid overload and to this end I have introduced
Spironolactone 50 mg daily to assist in loss of fluid. I would recommend water based exercise such
as walking around the shallow swimming pool to assist with weight loss. I think
that prophylactic banding of varices should they be present would be
ideal. However organising gastroscopy
may be complex and I have not addressed this as yet. Lynne needs bone mineral
density study and should have vitamin D supplementation with or without osteoporosis
care if indicated. I frequently use Zoledronic acid annually and for
osteoporosis care. I think that Lynne has intermediate prognosis from her
cirrhosis and may benefit from control of her viral infection, however with the
current profile of obesity she may struggle to overcome her significant health
issues. She requires ultrasound of the abdomen every six months to assess for new
lesions related to hepatocellular carcinoma and six monthly alpha-fetoprotein
as a standard of care. I will be happy to see her on ongoing basis and/or
provide support to treating physician who may review her regularly.
So, you’ve survived SEPSIS! Congratulations!! No, seriously.CONGRATULATIONS! You are one of the few who has left the hospital as a living person. This is a good thing. Now what?
Well if you
thought “sepsis” was gloomy and spoken of only in
hushed tones; wait until you read about “post sepsis syndrome”. This
will knock your socks off.
According
to the Sepsis Alliance here are a few basics on post sepsis syndrome;
Post-sepsis
syndrome is a condition that affects up to 50% of sepsis survivors. They are
left with physical and/or psychological long-term effects, such as:
Insomnia,
difficulty getting to sleep or staying asleep
Nightmares,
vivid hallucinations and panic attacks
Disabling muscle
and joint pains
Extreme fatigue
Poor
concentration
Decreased mental
(cognitive) functioning
Loss of
self-esteem and self-belief
Here’s the rest of my
story.
As I was wheeled out
of the hospital’s front doors I was immediately overwhelmed by the outside
world. I know it may not seem understandable, but as I looked around and saw
everyone going about their lives and felt the warm spring wind and sunlight on
my face, I felt very “small and insignificant”. Everything I’d been through,
all the complications, surgeries, fevers, pain and suffering seemed so
pointless, and I began to cry. The attendant and my husband were frightened by
my crying. They asked questions trying to understand. I couldn’t explain. I
mumbled and spoke in words that were more confusing than my tears. It was
surreal. I couldn’t understand myself, so how was I to explain it to
others? I waved them off in a reassuring manner.
On the 110-mile drive
home, I seemed to settle into “this is my new normal” and questioned
each movement, thought and more. By the time I walked through the door, my
complicated and confused thinking and feeling was overwhelming. I was
frightened in my own home. At one point, I came close to turning around and
wanting to return to the hospital. In a sense, the hospital felt safer than
home. Spring was in full bloom. I could hear our cow in the fields. It was my
home. It was normal, I was the problem. It was me.
I could only walk
about 6 feet with the help of my walker. I needed help getting out of bed, out
of a chair. I settled into a newer routine of physical therapy three times per
week. The PT was reassuring that my strength would improve. IV antibiotics were
given at the end of my dialysis treatments at home. There were practice walks
through the house to try and increase my strength; a chair to sit on for
showering as I couldn’t stand that long on my own. My hair began to
fall out; by the hands full daily. My pillowcase was covered in it when I
awoke and the drain in the shower was clogged with my hair when I’d finished
washing up. That was daunting for me.
Then came the night
sweats, the nightmares (being eaten by giant cockroaches in ER or ICU) and
waking in the darkness of night. It would always take me about a minute to
recognize or realize where I was. I would reach across the bed to feel my
husband and was always reassured when he would pull my arm close and tuck it
under his arm. This was the comfort and assurance I needed. Often, I
would awake thinking I was still in hospital. The near constant whining in
my mind of how very weary I felt and how deeply my muscles, joints and bones hurt
added to my mental fog. I couldn’t read books like I used to. I couldn’t seem
to focus so I tried only short bursts of ten minutes here or there and
increased when I could and stopped when I could go no further.
To my family I had
seemingly endless questions of, “then what happened?” I felt like a
failure and more. Although I had returned home, I was in worse
condition than before, a broken person with a broken body as if I’d been a doll
and shaken so hard I was a limply, sad shell of what used to be. I felt
hungry—yet little appealed to me. There was still some nausea and vomiting even
weeks later. I seemed to live on English muffins with butter and a side of
cheese. It was mild and seemed to stay down. I’d lost weight, but not so much
fat as muscle. I worked hard to walk our hall multiple times daily to regain
what I could, and went back to work once to say hi to my co-workers and
friends. I could see the shock in their faces of how badly I looked, and didn’t
return again for months.. I saw it in my own face every time I looked in the
mirror.
I grasped for certain
words and if I wrote anything I always seemed to displace every few words or
so. It was frustrating: it felt I couldn’t even think in the proper context of
a thought. The routines continued, dialysis, walking, thinking and speaking
with the right thoughts in the right place. I quit cooking nearly
altogether. To this day, one leg is always weaker than the other and my
balance is way off. Depending upon my pain on any given day, its likely I won’t
walk further than 20-30 feet on my own. Since my first stay with sepsis I now
have chronic low blood pressure and I mean low—often 60/30. No
explanation, it’s just part of my daily life. I’ve tried the meds to no avail.
My husband has taken over many of the chores of daily living, which often makes
me feel a failure. Now, due to other issues, I hunch over unable to stand or
sit straight for longer than a few minutes. I manage the budget, pay
the bills, make the calls, appointments and volunteer wherever and whenever I
can; it helps me stay sane. It helps me feel accepted, valued, needed. Isn’t
that what we all want?
Finally, the worst is
the constant, quiet, ever present state of fear. Every time I need
dialysis done in a hospital or clinic I think “is this the day I get sepsis”?
I wait for the fevers, the chills the vomiting. I count the hours and days
until I’m sure it passed. I have panic attacks and often cancel appointments,
fearful that if I touch this or that, shake someone’s hand it will quietly make
its way inside. The untrusting part of me glares out to monitor those part of
my healthcare team, ME wanting to safeguard ME. If I start to feel punky I
worry “is this it, do I have sepsis again? Will I die this time”?
Eventually some of my
strength returned, so I graduated to a cane. Lost memories, night sweats, insomnia, loss of
self-esteem, lack of confidence, pain and poor concentration are now to be my
life-long friends. You see, once you’ve had sepsis you’re at a higher risk of
acquiring it again. I did. I have. Three years later found me in the hospital
with sepsis, pneumonia and c-diff. Two years after that I ended up with
sepsis twice, my fifth time two years after and again in two years
my sixth episode with my most recent episode just nine months later. In
all seven episodes of sepsis each requiring weeks in the
hospital, with procedures, high fevers, weakness and worse. So, when someone
looks at me and says, “you just don’t look like you’re doing well”, I
just smile and think to myself “actually I’m doing pretty darn good,
considering.”
I still suffer most
if not all post sepsis syndrome (PSS) symptoms, some days more than others but
they’re there waiting to let me know “Hey, you’re going to be okay, but in
the meantime…” On the inside, I remind myself that this body of
mine has served me well. I’ve overcome horrendous odds and survived. So,
you see I don’t call myself a survivor; I am an “overcomer”.
The
Sepsis Alliance also states that:
The risk of having
PSS is higher among people who were admitted to an intensive care unit (ICU)
and for those who have been in the hospital for extended periods of time. PSS
can affect people of any age, but a study from the University of Michigan Health System, published in
2010 the medical journal JAMA, found that older severe sepsis
survivors were at higher risk for long-term cognitive impairment and physical
problems than others their age who were treated for other illnesses. Their
problems ranged from not being able to walk—even though they could before they
became ill—to not being able to do everyday activities, such as bathing,
toileting, or preparing meals. Changes in mental status can range from no
longer being able to perform complicated tasks to not being able to remember
everyday things.
The authors wrote, “…60
percent of hospitalizations for severe sepsis were associated with worsened
cognitive and physical function among surviving older adults. The odds of
acquiring moderate to severe cognitive impairment were 3.3 times higher
following an episode of sepsis than for other hospitalizations.”
What causes PSS?
For some patients,
the cause of PSS is obvious: blood clots and poor blood circulation while they
were ill may have caused gangrene and the need for amputations of
fingers, toes, or even limbs. Damage to the lungs can affect breathing. For
example, in another University of Michigan Health System study,
published in 2012 in the journal Shock, researchers found that
sepsis survivors may be more vulnerable to developing viral respiratory (lung)
infections.
Other organs may be
damaged as well, such as the kidneys or liver.
These lasting
physical issues can be explained, but there is more to PSS that cannot
yet be explained, such as the disabling fatigue and chronic pain that many
survivors experience. Others complain of seemingly unrelated problems, like
hair loss that may occur weeks after their discharge from the hospital.
Many sepsis survivors
also report symptoms of post-traumatic
stress disorder (PTSD). Researchers have already
recognized that ICU stays can trigger PTSD, which can last for years.
According to a 2013 Johns Hopkins study that looked at PTSD
after ICU stays, people with a history of depression were twice as
likely to develop PTSD after being in an ICU. The researchers also found
that patients who had sepsis were more likely to develop PTSD. They wrote about
the possible sepsis/PTSD connection: “The delirium often associated with ICU
stays and post-ICU PTSD may be partially a consequence of inflammation caused
by sepsis. This inflammation may lead to a breakdown in the blood-brain
barrier, which alters the impact on the brain of narcotics, sedatives and other
drugs prescribed in the ICU.”
It is important to
note that PSS does not happen only in older patients or in those who were
already ill. An editorial published in JAMA in October 2010,
addressed PSS. In “The Lingering Consequences of Sepsis,” the author
wrote, “The new deficits were relatively more severe among patients who
were in better health beforehand, possibly because there was less room for
further deterioration among patients who already had poor physical or cognitive
function prior to the sepsis episode.”
In other words,
healthy people may be expected to rebound quickly from such a serious illness,
but healthier people may actually have the opposite experience.
What can be done
about PSS?
Post-sepsis syndrome
must be recognized by the doctors and other healthcare professionals who care
for sepsis survivors, so patients can be directed to the proper resources.
Resources may include:
Referrals for emotional and
psychological support (counseling, cognitive behavioral therapy or
neuropsychiatric assessment).
Physical support, such as physical
therapy or neurorehabilitation.
What is post-ICU
syndrome and is it the same thing as PSS?
Post-ICU syndrome
(PICS) is a recognized problem that can affect patients who have spent time in
an intensive care unit or ICU, particularly if they have been sedated or placed
on a ventilator. It is not unusual for someone in an ICU to become
delirious – sometimes called ICU delirium. The longer a patient is in such
a unit, the higher the risk of developing delirium or PICS. A study published
in the New England
Journal of Medicine found that some of these
patients continued to have cognitive (mental) problems a year after discharge.
Here is what the CDC
has to say about post-sepsis syndrome:
Do all you can to
stay sepsis-free.
If you do get sepsis and have post sepsis syndrome, keep yourself, friends and
family aware and educated about the risks and how to get help once it’s
past. Ask for help: you deserve it. Be a survivor. Be a
champion. Be a warrior. Be an overcomer. Be whatever you want—just keep living.
Amy,
I just wanted to take a minute to thank you for sharing your heartfelt and
emotional journey.
There is SO much to CKD that us ‘Professionals’ and Partners don’t know until
it’s shared as clearly and concisely as you have written.
Again, a heartfelt thank you.
See you on FB!
Ann
You just described
me. I had Septic Shock five years ago. Discharge from the hospital was surreal.
Not being able to walk, could only stand for a minute or two, couldn’t get up
the stairs to my own bed.
I would stop in my tracks and think, “I could die right here, right now”.
Only therapy and medication has given way to some resemblance of a normal life.
I had a phone call at 9am from Miss 5. She wanted me to go and see their new ENORMOUS TV. I put her off till later but one hour later I got a Video call from her so I gave up on my sleepin and headed up. It IS enormous.
Today was heavy flooding in Sydney. It looked like it would here but it passed over us.
I am on a new antibiotic. The ulcer on my leg is not going away.
I went to Toormina with Miss 5 and Kaybee today. I was very much looking forwards to it but I was worse even than normal .Barely able to walk even with a trolley to lean on. Couldn’t even do Aldi. I sat in the car with Miss 5. I could not choose Xmas gifts or food.
Its too hard. Too hard indeed.
I have pain in my right side. Great weakness.Blurry thinking.Some days I think I am simply dying a little bit at a time.
I have a microwave and an air conditioner ordered. It doesnt seem to matter tonight.
“Resting is not laziness, it’s medicine!” Glenn Schweitzer
It is a tough path this one. I am now so confined to home through a combo of weakness and lack of a vehicle and steep hills. I am so weary and so ill that finally I have lost all humour about it. O God I could do with a companion who wasn’t fazed by this.
I seem to have dropped from 100kg to 89 with the infections dormant and the fluid dropped. That feels better. But everything else is so hard. So many things I would like to do and I cannot do them.
I wish I had someone who would take me for drives and maybe a saltwater swim.
I wish that I could see sustained improvement – but I can’t. Tonight a despair is settling upon me and a total dearth of ideas.
I DID HOWEVER HAVE SOME GOOD TIMES EARLIER IN THE WEEK.
“If opening your eyes, or getting out of bed, or holding a spoon, or combing your hair is the daunting Mount Everest you climb today, that is okay.” Carmen Ambrosio
“All great and precious things are lonely.” John Steinbeck, East of Eden
“The loneliest moment in someone’s life is when they are watching their whole world fall apart, and all they can do is stare blankly.” F. Scott Fitzgerald
“I have heard the mermaids singing, each to each.
I do not think that they will sing to me.” T.S. Eliot, The Love Song of J. Alfred Prufrock
“Sometimes you will be in control of your illness and other times you’ll sink into despair, and that’s OK! Freak out, forgive yourself, and try again tomorrow.”
Today I took a walk and went visiting. Had a great time. Home made pizza and toys and bubbles. I vomited at the table this time and couldn’t even get up to move away.
We went for a drive for school pickup and I was going to tap dance but became too ill. Miss 8 loves her tap dance.
I cooked steamed vegies tonight. My favourite meal and I have not had it for ages. Its rare that I can last an entire meal preparation but I did tonight and I feel well.
I feel a little better and the car feels a little worse.
ONE MORE DAY.
DOROTHY DAY : “Writing is an act of community. It is a letter, it is comforting, consoling, helping, advising on our part, as well as asking it on yours. It is a part of our human association with each other. It is an expression of our love and concern for each other.”
Sepsis and septic shock can result from an infection anywhere in the body, including pneumonia. Pneumonia can be community-acquired, meaning that a person becomes ill with pneumonia outside of the hospital or a healthcare facility. Pneumonia can also be caused by a healthcare-associated infection (HAI), which affect 1.7 million hospitalizations in the United States every year. An HAI is an infection that is contracted by people while the hospital for a different reason, such as surgery or treatment for another illness.Sometimes incorrectly called blood poisoning, sepsis is the body’s often deadly response to infection. Sepsis kills and disables millions and requires early suspicion and rapid treatment for survival.Sepsis and septic shock can result from an infection anywhere in the body, such as pneumonia, influenza, or urinary tract infections. Worldwide, one-third of people who develop sepsis die. Many who do survive are left with life-changing effects, such as post-traumatic stress disorder (PTSD), chronic pain and fatigue, organ dysfunction (organs don’t work properly) and/or amputations.The most common source of infection among adults is the lungs.What is pneumonia?Pneumonia is an infection in the lungs. The infection can be only in one lung, or it can be in both. There are several causes of pneumonia but the most common are:BacteriaVirusFungusLeft untreated, pneumonia can be deadly. In the days before antibiotics, it’s estimated that about one-third of those who developed bacterial pneumonia died.
the SILVERBIRD 12 