Tag Archives: sepsis

More on Sepsis

7 Dec

Here is one awful situation that will surely make your hair stand up.

Patient comes in I think from the nursing home, foley is inserted in the ED, out comes chunky soup into the foley bag. Blood pressures in the 80s, change of mental status. Diagnosis is urosepsis. ED does blood cultures, gives one dose of antibiotics, hangs up some normal saline and gives report to night shift tele RN. ED RN tells tele RN: pt on room air, NSS infusing at 100ml hour,NSR, pt given Tylenol for rectal temp of 102F, blood cultures sent, SBP  now in the 90s, WBC count elevated. The tele RN stops and says, “This patient sounds to be septic, did you get a lactate level according to sepsis screening?” The ED RN flips out becomes verbally defensive and tells the tele RN: “Not every patient needs a lactate level drawn.” Well, after that the teleRN calls the nursing supervisor and voices her concerns, she is shut down by the nursing supervisor who verbalized, “I have worked with that ED RN, she is a good nurse, do not worry about it.”

Patient gets to the tele floor, tele RN assesses: NSS bone dry to the line (not a drop left, and wonders for how long? certainly not for the quick transport), pt is tachypnic >30 resps per minute on 5 liters of oxygen (she said room air), pt is febrile rectal temp 101, pt SBP via doppler is 70 (she said in the 90s), pt is sinus tachycardia 130s (she said NSR), peripheral pulses NOT palpable, pulse ox: unattainable.

Wow. what a big change in condition from the ED holding room to the telemetry floor in less than ten minutes, this patient appears to be crashing. I am not saying it is NOT possible, but the attitude delivered from the ED RN when questioned about sepsis screening put the tele RN on edge to start with.

Immediate interventions by telemetry RN: Fluid resuscitation with NSS started, ABG obtained now, lactate now, rapid response called now.

The outcome: Pt was found to be hypoxic and in severe metabolic acidosis followed by a lactate level >5. The patient was immediately transferred from telemetry to ICU, where the patient then arrested cardio-pulmonary style and died exactly one hour from leaving the emergency department.

I am not writing this post about the ED nurse not screening for sepsis, I know that acute care patients are not stable, hell if we only wanted to deal with stable we would be working in doctors offices or something like that. The point is that sepsis screening was missed, the patient sat in the ED holding tank for 8 hours post triage and admit orders and interventions were missed, delayed by exactly that much time. If the patient were to have been screened prior to crashing upon arrival to telemetry the patient would of been admitted to critical care and would of received aggressive antibiotics and fluid resusc and hemodynamic monitoring as per severe sepsis standards.

The response: “She is a good nurse, do not worry.” is a highly inappropriate response from the supervisor. It is not about being a good nurse or a bad nurse (we are not label givers), it is about following the hospital policy and providing standards of care. The attitude of the ED nurse just made the whole situation less tolerable.

We are all in this together and that is for the patient, our job would be so much easier if we would all just work together. And on that note: my next blog post is going to be rant about myself and how awful I have been lately. Coming soon.

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itty bitty sepsis committee

20 Oct

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.

AND

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.

 

Priorities

14 Jun

So I work in PCU. Part of the care delivered in PCU is blood pressures/complete vital signs and assessements every four hours.

12 noon assessments come quickly, almost as soon as you are done rounding your first assessment it is time to do it all over again. This frequent assessment is pertinent to progressive care, it seems that the acuity of these patients can often change that quickly.

This one particular shift I get to one of my patients on a few blood pressure medications but not anything out of the ordinary. I had just medicated him maybe 2 hours prior. He is in for chest pain: ECG normal sinus, no ectopy on the monitor, cardiac enzymes negative times 3, 2dECHO normal. No chest pain since admission to the floor 3 days prior. The patient has a history of hypertension and dementia.

I find the patient resting comfortably in the bed, no chest pain, pleasantly confused as usual, but severely hypotensive especially compared to his baseline of Systolic blood pressures in the 130s. His blood pressure now is 78/43. I check the other arm, 74/43, I get a manual blood pressure of Systolic 80. The patient is sinus rhythm- no tachycardia. The patient has no signs of infection, no white count, normal electrolytes. I was perplexed: It could be cardiogenic with the admission of chest pain, it could be a far fetched sepsis situation. I do everything. I get a more experienced nurse with me. While she is starting normal saline solution, getting all the labs including: coags, troponin, blood cultures, lactate, CBC, chemistry, inserting foley catheter, urine samples , inserting an 18 gauge IV catheter into the antecubital, all while I am on the phone with the attending basically obtaining all the orders for what we are already doing. We end up getting a fluid bolus of Normal Saline 500ml- then 125 ml per hour, and call the cardiologist to come see the patient.

We also find the patient soaked in his own urine (prior to inserting the foley) and diaphoretic. Blood sugar is normal.

Approximately 30 minutes go by during all these interventions that started with the fluid bolus. The patient is still hypotensive with a systolic blood pressure in the high 70s.

Stat ECG= normal.

The experienced nurse tells me to write all the verbal orders.

The experienced nurse tells the nurses aide: ” Get all the clean linens, we will clean him up and then call a rapid response.”

I was all laughing inside because she has got her priorities straight, right?

Everything was fine. The patient was basically asymptomatic, all the labs were normal and the patients blood pressure improved into the 90s and then low 100s. He remained on NSS at 125 ml per hour, and everyone was happy.

Except the patient of course pissedoff about the foley catheter. I felt his pain but refused to take it out so that we could monitor the output with all these fluids.

And of course all the medications were discontinued.

This was a good outcome! A rapid response was not called, the patient was stable, and became normotensive! How many times do we find a patient with a low blood pressure that ends up with severe sepsis, or some other ICU requiring transfer?

Yaay! One up for the immediate good outcomes. I am still unclear of the etiology? Maybe the medications, or maybe the patient was just volume depleted.

I was so amused by the experienced nurses calm demeanor. “Let’s clean him up then call a rapid response.”

Of course the patient presented stable clinically in no apparent distress.

Asking for Help

23 Mar

Who you work with on any given shift sometimes can make your day better or crack your twelve hours to pieces when you when you find your assignment in crisis.

I walked in on day one to crisis #1 in respiratory distress admitted to the floor by night shift RN who got ABGs and the patient on bipap but um….5 hours later I walk into this (the bipap is not helping) and the patient is getting tired with a breaths per minute greater than 40 who needs immediate intubation.  And I am stressed out but somehow managed to be calm and I even surprised myself with how clearly I “knew” how to do what I needed to do, restraints, suction, versed….very different scenario 2 years ago when I could barely find my voice in a crisis and just wished I could blend into the wall and let someone else figure it out and speak for me. I have to add that I had the awesome st respiratory therapist by my side, the calmest critical care nurse across from me, the loves to teach physician  keeping it all in perspective, as well as all the other helpful staff.

I walked into day #2 with a blood pressure in the 60s Systolic, clearly septic, on no antibiotics, and platelets count of 19 also struggling to breath and I knew and I felt sad. Blood was everywhere.

I walked into day #3 with a  patient made npo in the night, diabetic on insulin and pills with a blood sugar of 30 and no IV access due to infiltration and no palpable vein in site or touch. I learned that the glucagonIM works in about twenty minutes.  

The insanity is that I felt the adrenaline and I kind of liked it although of course it is a paradox as I would never wish that to be the norm. I think I am gearing myself towards emergency nursing or maybe intensive care at some point, sooner or later.

So the fake seizure in room #2 was annoying, but I regress.

Picture this: I am in the nurses station, the ICU RN has taken care of my intubated patient on day 1 while waiting for a bed to be available on the unit. I am officially relieved of my major responsibility for the patient and nurse A says to me all super loud, “You always get the worst group with sickest patients!” I am still trying to piece together what just happened so fast and my 4 other patients have not seen me except for my quick morning assessments and not one patient has been medicated.  Nurse B gangs in and starts chiming the same tune and I am thinking what fresh hell is this? Nurse C starts ringing in with her sympathy for me and I lose my temper! They sounded like a bunch of cackling hens pecking at me…their morning bird food. So I flipped out and demanded the cacklers get out on the floor and start medicating my stable patients so I can catch up.

It worked! They scurried out and passed all my morning medications. I was able to assess my patients and spend ions charting in detail the crisis and all the interventions provided.