Clinical Vignette VIII

• If the continuous intravenous infusion of 3% hypertonic saline solution is not immediately discontinued, which of the following will most likely happen to this patient?

A 60-year-old male is evaluated in the Medtigo Medical Center Emergency Department for two days of rapidly worsening fever, chills, night sweats, cough productive of thick mucoid sputum, dyspnea, headache, and generalized weakness. The patient reports feeling perfectly healthy until two days ago when he woke up feeling like he was starting to develop a cold. The patient states he dismissed the symptoms since they were very minor and would probably self-resolve within a day or two like they always have in the past. Unfortunately, the patient’s symptoms quickly worsened and he became so ill that he was basically bedridden. The patient does not recall ever being this sick before and had to call his daughter to drive him to the hospital. To the best of his knowledge, he is not aware of any friends or relatives with recent similar illnesses. He does not consume alcohol, smoke cigarettes, chew tobacco, or use recreational drugs. He receives an influenza vaccination each year and has already received a pneumococcal vaccination. The patient’s past medical history is significant for systolic heart failure with moderately reduced ejection fraction with an LVEF of 45%, atrial fibrillation, hypertension, and hyperlipidemia. His current medications are lisinopril, furosemide, carvedilol, aspirin, clopidogrel, and rosuvastatin. He has no known allergies. The remainder of his past medical history, family history, and social history is unremarkable.  

On physical examination, temperature is 103.1°F (38.5°C), blood pressure is 118/75 mm Hg, pulse rate is 85 beats/min, respiration rate is 22/min, and oxygen saturation is 88% breathing ambient air. Body mass index is 22.4 kg/m². The patient is diaphoretic with dry mucous membranes and decreased skin turgor. Cardiopulmonary examination reveals an irregular heart rhythm, late inspiratory crackles, and dullness to percussion in the right upper lobe region. The rest of the physical examination is unremarkable. Initial lab and imaging workup reveals the following:  

12-lead Electrocardiograph shows atrial fibrillation with ventricular rate of 87 beats/min.

Chest x-ray shows alveolar consolidation in the right upper lobe. 

  Chemistry Panel

  CBC

                               
 WBC/Diff

 ABG

After being thoroughly evaluated and systematically worked-up, the Emergency Medicine physician decides the patient needs to be admitted to the inpatient Hospitalist service for further medical management with the diagnoses of lobar pneumonia, severe dehydration, and electrolyte abnormalities. The patient is immediately started on the proper treatment regimen which includes supplemental oxygen titrated to 90-92% SpO₂, intravenous broad-spectrum antibiotics, and intravenous fluid rehydration with 0.9% normal saline at 200 ml/hr with 40 mEq KCl and 4 grams magnesium sulfate IV piggyback. Upon reviewing the workup results and preliminary orders written by the Emergency Medicine physician, the admitting Hospitalist physician agrees with his colleague and merely adds a DVT prophylaxis and a GI prophylaxis for the patient.

Approximately 48 hours after being admitted to the inpatient Hospitalist service, the attending physician is notified by the lab personnel that the patient’s sputum culture and sensitivity testing confirms the presence of multi-drug resistant Klebsiella pneumoniae Carbapenemase-producing Klebsiella pneumoniae (KPC-Kp).The attending Hospitalist physician immediately alters only the patient’s antibiotic treatment regimen to appropriately target the identified pathogen. When the hospital personnel changed the patient’s antibiotic treatment, the individual also accidentally changed the patient’s intravenous fluid replacement to 3% hypertonic saline solution instead of the originally ordered 0.9% normal saline solution.

• Which of the following antibiotic treatment regimens would be clinically indicated for targeted therapy against Klebsiella pneumoniae Carbapenemase-producing Klebsiella pneumoniae (KPC-Kp) pneumonia?