phil ukrainetz thursday, may 7, 2009. objective are we adequately identifying septic patients in...
TRANSCRIPT
Phil UkrainetzThursday, May 7, 2009
Objective
Are we adequately identifying septic patients in the ED?
Are we optimally managing septic patients in the ED?
How can we better manage the septic patient in the ED?
What are our next steps if any?
“Straight forward patient” Hx: 76 F, sent from Cardiac Function Clinic, precarious CHF, new bilateral leg cellulitis with heel ulcers
PMHx: Aortic Valve Replacement, CHF, bilateral leg DVT’s, DDR pacemaker, RA, hypothyroid, Afib
Meds: ASA, Amiodarone, Candesartan, Lasix, Imdur, Nitro patch, Losec, Coumadin, K-Dur, Metoprolol, Prednisone, Adalimumab
Jehovah Witness – No blood products
And by the way…
BP 80/50 (normal as per pt SBP 90), P 78, T 37.1, Sat 94% on 3L NP
Already juicy and Cr rising as per function clinic – so please avoid saline infusions
Over next 2 hrs – SBP’s as low as 58/38
Positive urine
Patient c/o:
Little “dizzy” Swollen warm legs No chest pain, no SOB on 3L NP – 92%
NAD
EP Mngmt:
Foley Antibiotics 250 NS boluses Dopamine after 750 NS Central line and then norepi MTU/ICU/CCU consults
Patient outcome – did fine admit to CCU Mentated throughout 20 hr stay – vague, nonclinically helpful complaints
Vitals of approx SBP 80/50 and Sats of 92% maintained throughout
ICU 5 hrs to assess – gave fluid/norepi/?ccu
CCU 5 hrs to assess- chf/minor infection - admit
Non-Fatal Harm Morbidity Case Patient was felt by CCU to be more CHF then sepsis
Worried about excessive fluids given
Couldn’t get off pressor – never changed urine output or oxygenation with mngmt
Admitted
Long and short of it
Pt given 3L fluids/20 hrs but never had incr O2 needs
Patient did well Most of us would manage similarly
Lets learn from this difficult case
Sepsis Priorities
Identify sepsis early Early antibiotics Early “liberal” fluids Monitor frequently, accurately and “fly ahead of the plane”
Sepsis Management
EGDT – Emmanuel Rivers 2001 U/S?? Arterial Line Tracing Interpretation??
Early Sepsis Hotline??
EGDT – Hard to Deny
“Golden hours” means ED must be involved
Who is best suited to do CVP placement monitoring? Detroit Model??
Will it aid and abet longer ED stays?
What if it were your mom?
Ultrasound CVP Equivalent? Looks promising – train our own Non-invasive – don’t add to nurse burden
Longer ED stays? Do we see enough to be true experts?
Arterial Line Tracing Interpretation
RTs are now putting in arterial lines
Promising but promotes long ED stays??
Will we truly have the expertise?
Sepsis Hotline
We identify the patient Stroke team like “swoop down” – glorious!
If central line/CVP needed patient is fast-tracked
No beds then CVP placed/ICU manages in ED or in ICU depending on bedspace
Objective
Are we adequately identifying septic patients in the ED? - yes
Are we optimally managing septic patients in the ED? – no – CVP’s should be utilized
How can we better manage the septic patient in the ED? – open dialogue with ICU
What are our next steps if any? -who else is doing ED CVPs in Alberta or Canada? what does ICU think of EGDT team? identify a champion/Jason for the cause
Thanks
Shawn Dowling Jason Lord Rob Hall Gavin Greenfield Tom Rich My mom