SHM Converge Scientific Abstract ePoster Gallery-When Sepsis Is Subtle: Lessons Learned From a Case of Diagnostic Error

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This case describes a woman in her 60s with ESRD on hemodialysis and a history of bilateral lung transplant who presented from a rehab facility with weakness and anemia after missing dialysis. Although she initially had no clear localizing infectious symptoms, she later developed fever, elevated procalcitonin, atrial fibrillation with rapid ventricular response, hypotension, and ultimately septic shock from a left gluteal wound infection seen on CT.<br /><br />The main lesson is that sepsis was not recognized early enough. Clinicians appear to have anchored on anemia and missed dialysis, and sepsis was not included in the initial differential diagnosis despite subtle warning signs. Communication breakdowns also contributed: overnight fevers were apparently not relayed to the primary team on more than one occasion. In addition, the response to changing clinical status and abnormal testing was delayed—antibiotics were not started for several hours after fever was documented and procalcitonin returned elevated. System-level delays between ordering and administering antibiotics further prolonged treatment.<br /><br />After deterioration, the patient required ICU care, vasopressors, incision and drainage of the gluteal infection, and infectious disease-guided antibiotics. She was eventually weaned off pressors within 24 hours and later discharged to rehab, though her hospital course was complicated and prolonged.<br /><br />Overall, the case highlights how sepsis can present subtly, especially in medically complex patients, and underscores the importance of maintaining a broad differential, promptly communicating new fever or instability, and rapidly acting on abnormal vital signs and labs to reduce delays in diagnosis and treatment.

Asset Subtitle

Donna Coetzee

Meta Tag

Author List Andrew P.J Olson, Brian Hilliard, Donna Coetzee, Elizabeth Davis

Category Clinical Vignettes

Concept Sepsis

Concept Diagnostic Anchoring

Concept Sepsis Evaluation

Concept Sepsis Treatment

Concept Antibiotic administration

Distinguished Non-Finalist

Presenter Organization University of Minnesota

Presenting Author Donna Coetzee

Track Adult

Keywords

sepsis

hemodialysis

ESRD

lung transplant

anemia

gluteal wound infection

septic shock

procalcitonin

atrial fibrillation

ICU care

Sepsis

Diagnostic Anchoring

Sepsis Evaluation

Sepsis Treatment

Antibiotic administration