A 70-year-old woman was admitted to the intensive care unit (ICU) with acute change in mental status a few days after lumbar laminectomy. Her medical history was significant for a ventriculoperitoneal (VP) shunt for suspected normal pressure hydrocephalus. She was febrile with nuchal rigidity. Her white blood cell (WBC) count was over 20,000 cells/μl. Blood cultures were positive for E. coli, and appropriate antibiotic therapy was initiated. The patient responded well—she began to have brief but meaningful conversation with her family. Her WBC started to trend down, and she was afebrile for 48 hours.
On day 4 of her ICU admission, a Friday, she exhibited fluctuating mental status with prolonged episodes of drowsiness. The ICU team attributed this to recent use of sedatives. Signout to the incoming night float team did not highlight the change in mental status. Over the course of the ensuing night she became drowsier. The night float team assumed it was her baseline mental status. After transfer to the incoming cross-covering team for the weekend, the patient was found comatose.
Magnetic resonance imaging (MRI) showed ventriculitis with possible infectious cerebritis. The patient developed generalized tonic clonic seizures and was treated with IV phenytoin. She was emergently transferred to surgery for removal of the VP shunt and placement of ventricular drain for intraventricular gentamycin. The patient received 8 days of intraventricular gentamycin with resolution of ventriculitis as documented by negative E. coli cultures from the ventricular cerebrospinal fluid. She made a gradual recovery after spending 6 weeks in the ICU.
Subsequent root cause analysis determined that earlier recognition of the change in mental status might have altered the patient's course. It identified inadequate signout to the night float team as the primary reason why that team did not identify the patient's deteriorating mental status.
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