It has been 2 years and 10 months since I graduated nursing school. I will not summarize that in one blog post do not worry. What I want to write about is sepsis and how I ended up on this sepsis committee at work.
I am anti-social Jane. (*gasps*) I was not interested in the performance and improvement committee, or the wound care task force (not my cup of tea), or anything that would bring me into the hospital on my days off (other than mandatory education requirements). Yeap, even during my first yearly evaluation, I got a raise but was informed by my director that I lack involvement. *sighs*
Involvement. I had this sepsis cloud following me for a while. It seemed that every week I would get report, assess the patient and end up with a septic shocker spiralling down the drain in front of my eyes. Working working working never leaving the patient, and worrying about the stability of my other patients since I was unable to even get to them. I kept seeing it over and over: hypotension, febrile, tachycardia, infection and risk factors for sepsis.
I was such a new nurse and I knew the basics of what to do but it was always a long drawn out process. I mean: I knew to get the blood cultures and some fluids and antibiotics but the process was so unorganized and ineffective. My patients always ended up going to intensive care eventually, after I tried the minimal interventions ordered by doctors and waited for progress that sometimes never came. The interventions were minimal because I was not pushing hard enough to present the clinical situation. And my heart always sank into my stomach after the patient was finally transferred to ICU: and I hear: code blue ICU: and call up later to find out: yeap, that was your patient.
My documentation would read something like this: Notified Attending MD that patient is hypotensive SBP 70s, sinus tachycardia, admitted with pneumonia, yesterdays CXR showing infiltrates, febrile, lethargic, WBC doubled since yesterday. Attending (usually an internal med) would order 250ml saline bolus, Tylenol, blood cultures, antibiotics.
And new nurse would do all that not realizing that 250ml saline is not going to butter the bread at this point in her nursing career. And she would call back the MD, give another 250ml bolus and go round and round and round . It is just not working.
And then she found me, or I found her in desperation and she recruited me: to the sepsis committee to educate other nurses about this, how to treat it, and how to get your point across to the MD when they try to order the minimal interventions that are just not enough (usually because the nurse is not getting the whole clinical picture into that phone call). And she is the critical care nurse educator for the hospital and she runs this committee trying to get everyone on the same page.
I mean I can not write about every single septic patient I ever had, that would be too much. Just know that there are nurses who have patients in early sepsis on the floors and if it is not turned around, the patient is eventually going to get worse. I can not say how many times I have received report from the night shift about a patient with a blood pressure in the 70s and febrile and they call the House MD and get Tylenol and a 250ml fluid bolus and then call it a night without even investigating the clinical situation.
My deal goes like this now:
Suspicion of sepsis when:
You assess your patient and find any of these new changes in status: hypothermia, hyperthermia, tachycardia (not on beta blockers) tachypnea, acute change in mental status, hypotension, hyperglycemia (without being diabetic), tachypnea, leukocytosis (or bands > 10%), or leukopenia.
Your patient has an infection or risk factors: pneumonia, empyema, UTI, wounds, foley catheter, device infection, central line. risks: long term hospitalization, nursing home patients, immunosuppression, aspiration, etc…
If you find those clinical assessments and you know your patient has an infection or risks you can guess on sepsis AND get blood cultures times two, lactate level, cbc w/ diff, and coags (PT/PTT). Where I work it is protocol, just do it.
AND you do not stop there.
Does your patient have evidence of ACUTE organ dysfunction? (not talking about chronic conditions). Is the systolic blood pressure <90 or the MAP < 65 or a 40mmHg drop from the baseline? Yessss. I have been there with my patients. What is on that chest x ray from yesterday? Are there infiltrates? Do you keep turning up the oxygen on the nasal cannula to maintain a SpO2 >90%? What is the urine output? Is it less than 0.5ml/kg/hr for more than 2 hours? *gasps* when the foley bag is empty! What is the creatinine? Is the creatinine >2? What are the platelets? Are they less than 100,000? You checked the lactate when you initially suspected sepsis right? If you are on a medical floor and the lactate is >2 or definitely >3 (but still maintaining blood pressure) the patient needs to be transferred to telemetry. If you are on telemetry and the lactate is >4, or >3 with hypotension the patient needs to be transferred to ICU. All of the above criteria resemble suspicion of severe sepsis and organ dysfunction and guess what?
We have treatments for this do not worry, just get it done.
Here they are by standard protocol and clinical judgement, it is the sepsis resuscitation bundle to be done withing the first six hours.
1. Mandatory diagnostics: lactate and repeat lactate in 6 hours, blood cultures prior to a broad spectrum antibiotic within 1 hour.
2.Optional diagnostics (usually done): CXR, cardiac enzymes, cortisol level, urine culture and analysis, EKG, sputum if you got it.
If you and your patient are on telemetry and you are already waiting for an ICU bed to be available: you start initial fluid resuscitation and if there is no response to the initial resusc you apply vasopressors to maintain a mean arterial pressure >65. AND you are finding out who is going to drop in the central line.
If you are on a medical floor you call a rapid response and let them start resuscitation.
It goes like this: for hypotension SBP < 90, MAP < 65 or lactate >4 you deliver: minimum 20-30ml/kg of crystalloid–then, NSS 500ml bolus over 30 minutes repeating till getting an adequate urine output or if you have a central line and are in ICU you want a CVP 8-12mmHg. If this does not work you get on the vasopressors.
After getting all that going hopefully your patient will be in ICU receiving further treatments like steriods, drotrecogin alfa activated maybe, with tight glucose control among all the rest of whatever they do up there so well.
So now my phone call to the MD sounds more like this:
Attending MD (with this verbage) your patient is hypotensive with a systolic pressure in the 70s, febrile on rectal temp, has new tachycardia, acute change in mental status revealed by lethargy and confusion and the patient was previously alert and orientated, the patient (your patient) admitted with infection, white blood cells are doubled since yesterday, I already drew lactate and it is greater than 4, blood cultures have been sent. I would like to start fluid resuscitation at 30ml/kg, administer a STAT broad spectrum antibiotic and transfer this patient to ICU where you can continue the sepsis protocol and monitor CVP? Does that sound ok to you?
It just kept happening to me over and over, this sepsis cloud following me. After awhile I just knew where to start and ended up helping every nurse that cries in the nurses station: I think my patient is septic. I would just go get the basin, start filling it with blood tubes, foley catheter, 18-20 gauge IV catheter, normal saline, and just start working.
That is how anti-social nurse Jane got on the itty bitty sepsis committee.