1. Sepsis Case study

2. A 78 year old female comes from the nursing home by ambulance. The nursing home said she seems weak and more tired than usual. She had a low grade temperature this morning and is refusing to eat or drink. She is only oriented to her name, not the date or place. What do you want to do next? Get a set of vital signs Get a stat CT to rule out strokeCT

3. Get a set of vital signs Temperature 99.4 Blood pressure 90/60 Respiratory rate 22 Heart rate 70 Do you want to initiate a sepsis alert? Yes No

4. Get a stat CT to rule out stroke You go to the ED physician, present the case and ask for CT orders. He asks you for the results of a full neuro exam which you haven’t performed yet. You mumble that you’ll be back with the information and slink back to the patient’s room. Click here to return to the main screen and make another choice screen

5. No Think about it again with the Sepsis screen: -temp (she has a low grade temp, remember that the elderly do not always mount a strong infectious response) -change in mental status (she has confusion) -high heart rate (many elderly take beta blockers which can limit the heart’s ability to mount a sympathetic response) -respiratory rate (hers is 22) -you don’t know her WBC yet… Click here to change your mind call a sepsis alertyour

6. Yes Good choice! You know that the elderly don’t commonly mount a good response to infection and a low grade temperature can actually mean something quite serious. Her heartrate isn’t elevated but she could be on a beta blocker You also know the elderly coming from nursing homes are prone to urinary tract infections. Confusion can be from low oxygenation which occurs in from low tissue perfusion commonly found in septic shock. Your next step is to get some labs… Click here

7. Initial labs WBC 22.1 Hgb 9.2 HCT 38 Lactate 5 Platelets 90,000 Na 125 K 3.8 Glucose 125 Should you call a sepsis alert now? YES NO

8. It’s time for a sepsis alert… You have an increased white blood cell count, a change in mentation, respiratory rate greater than 20, and an increased lactate. These qualify her for a positive sepsis screen. The next steps are to consider organ dysfunction and find a source… What would you like to order?

9. You have orders from the doctor for an ABG, UA, CT (head), chest xray, and an EKG. Why did he order all this and what do you expect to find? UA- CT head- ABG- Chest xray- EKG-

10. Lactic acidosis When a patient is demonstrating metabolic acidosis his or her body is pulling the HCO3 into the cells as a buffer and therefore, depletes the plasma level. The body begins compensating by increasing the ventilation and thus renal retention of the HCO3 takes place. ABG values one would see with metabolic acidosis would be: pH < 7.35; HCO3 < 22; and PaCO2 < 35 mm Hg if compensating. Understanding that without treatment metabolic acidosis will only become progressively worse, and steps will be needed to bring the patient into a compensatory mode to recovery.

11. Your patient has been getting more agititated and her blood pressure is now 80/60, heart rate 92, temp 101.4. What do you want to do?

12. Sepsis order set Determine the level of sepsis Fluid CVP? ScVO2? Blood cultures Antibiotics-3 hours from triage