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