The Sepsis Cloud is following me.

26 Jan

yellow-cloudI can not escape the sepsis cloud lately. Here I am Nurse Jane, a new nurse on a telemetry floor for about one and a half years. The one thing that I see over and over again is patients swirling into septic shock right in front of my eyes. It took a few patients before I realized the pattern, the scenario was repeated many times in the form of this: A patient on a medical floor developes hypotension, the MDs and Admins in Charge decide the patient is appropriate for telemetry (alot of times it is true). The patient arrives to the telemetry, receives some fluids, sepsis workup is done including: Lactate level, cbc, bmp, urine cultures, blood cultures, ABG, chest x ray etc. 2 hours later the verdict is in: Lactace levels greater than 5, WBC doubled in a day etc..patient is hypothermic, with a systolic blood pressure in the 80s, increasing lethargy, tachypnea, metabolic acidosis and you as the nurse now need a rapid response to handle this rapidly deteriorating patient and the rest of your patients get nothing! http://emedicine.medscape.com/article/167027-overview

I mean this happens alot. These patients need aggressive resuscitation with fluids and they need an intensive critical care nurse at the bedside!

Now I am not saying that every patient with an elevated lactate level needs intensive care. I have had patients with moderate lactic acidosis, that were septic from a known source, treated appropriately with antibiotics and fluids who within 24 hours have mean arterial blood pressures greater than 60, wbc decreased in half in one day, and lactate levels return to normal with no hypothermia or hyperthermia and seemed to progress towards positive outcomes. I am not going to freak out at every abnormal lab value…

On the other hand…these patients need to be monitored so closely that the nurse on the floor has to be on guard. I had a patient with a lactate level 3.9–the patient remained on telemetry because of 1. orientated mentation 2. systolic blood pressure greater than 100. So the patient was not transferred to ICU–Sepsis workup was not done–and within 12 hours the patient had severe tachypnea, severe metabolic acidosis–and a lactate level greater than 9, WBC tripled– the patient was falling apart in front of my eyes and of course a rapid response was initiated.

We all need to know that just because the patients pressure is not low or that the mental status is orientated for now, does not mean that the patient is “ok” –they can decline rapidly. Sometimes the support is there from supervisors and charge nurses~ sometimes it is not! So till then I will keep shouting out loud about suspicion for sepsis in rapidly (or even not rapidly) declining patients and what to do when it happens to you!

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