Patient Presentation
K.S., a 75-year-old female presented to the orthopedic clinic for her
two-week postoperative check up after her right total knee replacement.
Her previous 4 day in-hospital stay had been unremarkable in which she was
discharged home with physical therapy and a continuous passive motion
machine. She presented in the clinic with a temperature of 39.8 degrees
Celsius with chills and general malaise. She complained of shortness of
breath and a low urine output x 2 days. Her VS were: BP 91/53, P 118, RR
16 and SaO2 91% on RA. Her surgical incision was hot to touch, edematous
and reddened, and had copious purulent fluid draining from the lower
incision site. She also had 2+ pitting, bilateral lower leg edema. She was
immediately admitted as direct admit to the hospital.
Diagnostic tests
Upon arrival to the hospital floor labs and tests were completed including
a CBC, BMP, Coags, UA, anaerobic and aerobic wound cultures and blood
cultures x 2. An EKG was completed which showed NSR and the chest X-ray
was grossly normal with bilateral lower lobe infiltrates. A renal US was
performed to rule out renal obstruction. A CT scan of the right knee
without IV contrast (due to elevated Cr) was completed revealing an
abscess to the right knee.
Lab results were as follows:
WBC: 18 BUN: 22 Mg: 3.0
HBG: 28 Cr: 2.0 Phos: 4.9
HCT: 8.5 Na: 129 Ca: 8.2
K: 5.3
Cl: 105
UA: Grossly normal
Preliminary BC results: Gram + cocci in clusters. (final analysis 2 days
later +MRSA)
Preliminary WC results: Gram + cocci in clusters (final analysis 2 days
later +MRSA)
Diagnosis
Right knee postop infection with abscess; with associated Septic Shock and
Acute Renal Failure.
Treatment
K .S. was placed on contact isolation for the MRSA infection and put into
a private room. She was given a 2 liter bolus of LR for her hypotension
followed by LR @ 125 ml/hr for hydration and renal flushing. She was
started on IV antibiotics vancomycin 1gm every 12 hours and Zosyn 3.375gm
q6 hours. She was given 2 liter O2 per NC for her low SaO2 and q4 hour
nebulizer treatments.
Outcome
Septic shock has a high death rate. The death rate depends on the
patient's age and overall health, the cause of the infection, how many
organs have failed, and how quickly and aggressively medical therapy is
started. K.S. will have long-term IV antibiotics for the MRSA infection
and short-term hemodialysis to counteract the Acute Kidney Failure
associated with the Septic Shock. She will also undergo surgery to incise
and drain her right knee MRSA infected abscess. However if there are no
other complications with the MRSA infection and her kidney function
returns to normal, which is expected, K.S. has a good outlook to full
recovery.
Case created by Kimberly Schuelke, 2011.