ABSTRACT
An 80-year-old woman presents to the Emergency Department with fever and right upper quadrant pain. Ultrasonographic evaluation reveals acute cholecystitis. Her systolic blood pressure is 70 mm/Hg as is her heart rate; her temperature is 40°C and her white blood count is 30,000/mm3. She had many prior myocardial infarctions and occasionally requires home oxygen for chronic obstructive pulmonary disease. The patient is given two 1 L boluses of crystalloid. Blood cultures are obtained, and she is started on broad spectrum antibiotics to cover biliary and enteric flora. Despite this, the patient has a systolic blood pressure of 80 mm/Hg. A central venous catheter is placed and the patient is started on norepinephrine and transferred to the surgical intensive care unit. Upon arrival, the patient is in worsening respiratory distress and she is intubated. An arterial line is placed at this time, and the norepinephrine drip is titrated to maintain a mean arterial blood pressure of 65. The patient’s central venous pressure (CVP) is 4 and her hematocrit comes back at 25%. Her ScVO
transfused with two units of blood and the interventional radiologist team is consulted to place a percutaneous cholecystostomy. Twelve hours after the procedure, the patient is requiring 25 mcg/min of norepinephrine, and she is started on activated protein C. Four days later, the patient is off of pressors and is afebrile with a normal white blood cell count. However, she is fluid overloaded, and she fails her spontaneous breathing trial. Two days later, she spikes a new temperature to 39°C, has a new infiltrate on chest X-ray, and has to go back on norepinephrine. New blood cultures and a bronchoalveolar lavage are obtained and her antibiotics are broadened to cover for new onset ventilatorassociated pneumonia. Two days later, her cultures grow out methicillin-resistant Staphylococcus aureus. The patient is continued on gram negative and anaerobic coverage for her biliary sepsis and gram-positive antibiotic coverage for her pneumonia. The patient’s pressors are weaned to off 2 days later. On ICU day number 10, the patient receives a tracheostomy for an inability to be weaned from the ventilator. After a 3-week hospitalization, she is tolerating weaning trials and is transferred to a rehabilitation facility with her cholecystostomy tube still in place.
