226. Sorcerer's Apprentice, part 2

Though septic shock seemed the most likely scenario, her distended belly raised other possibilities. Cytokines are increase blood vessel permeability. The liquid part of blood--serum, can now leak out of vessels and cause swelling.  Accumulation of this or similar fluid in the abdominal cavity is called ascites.  So her distended abdomen can fit the septic shock scenario

But internal bleeding--perhaps from a ruptured uterus--coiuld also cause this distension. Now that's something we could/should address. So once the BP stabilized, an immediate laparoscopy (camera inserted through a half-inch umbilical incision) showed that the fluid was ascites not blood; a quart and a half were removed to take pressure off the lungs (more could have been removed, but we wanted the laparoscopy to be as quick and atraumatic as possible).  

She was taken to the ICU, who found her condition so perilous that transfer by helicoptor to the local county hospital/medical school training site/multi-state trauma center was recommended.

There massive antibiotics were administered and a hysterectomy performed (to remove the most likely source of continuing infection.  She improved slowly, discharged after three weeks.  The mortality of septic shock can be as high as 50%.  She did well.

225. The Sorcerer's Apprentice, part 1

Laney's first pregnancy was uncomplicated. At 26 and healthy her delivery should have been uncomplicated, and it was. Well, a little more than average bleeding, but no need for a transfusion.  For several days she didn't feel well ("must be the low blood count"), but on the fifth day postpartum, she came in to urgent care , having not been able to empty her bladder for several hours.  The bladder is stretched and pushed during labor, so not uncommon to experience urinary retention. A catheter was placed, more than a quart of urine drained, and she was told to return in three days for its removal--three days being enough to swelling and inflammation to subside and normal bladder function return.

On that day her mother called saying Laney was "hot" so she was told to go to urgent care. There her blood pressure was low, labs abnormal; sent to the ER thinking she was in septic shock.  At the ER, her blood pressure continued to drop, and blood oxygen levels were dangerously low. She was immediately intubated and given oxygen and "vasopressors"--medicines that keep the blood pressure up by causing blood vessels to constrict, thus promoting blood flow and oxygen to her brain and other vital organs.  

But what caused the blood vessels to dilate in the first place? Probably cytokines--small proteins released by bacteria or the overwhelmed immune system.

Consider the sorcerer's apprentice, who tasked with cleaning the dungeon, animated some brooms, mops and buckets to do his work. While he slept, the animated objects reproduced themselves and soon there was a stick army and a flood.

In septic shock, cytokines act as the apprentice's spell, causing blood vessels to dilate, which lowers the blood pressure, depriving vital organs of oxygen.