Antibiotic initiation/effectiveness

Specialties Critical

Published

Hey guys,

I lost my first patient the other night....a patient that was actually my assignment. Ive had other patients that were in cardiac arrest upon arrival but I dont consider that the same.

It was an older (but walkie talky healthy) lady who came in for AMS. She was juat very lethargic when she arrived but responsive and was even singing a song with her daughter while i was starting a second line haha

Anyway, she was uroseptic and all of a sudden decompensated and became mottled. She went into SVT and got SOB with audible wheezes OUT OF NO WHERE.

The doc had ordered antibiotx but they were a little delayed Since they are not a normally stocked med. As she was decompensating, the doctor kept askimg me "where are her antibiotics?" I told him pharmacy was tubing them to me. They finally came and we ended up bolusing three difff antibiotics as a last stitch effort.

After five hrs we managed to get her to the ICU but she passed shortly after.

I feel like I could have been more assertive about getting the medication sooner and maybe it would have given her a better shot. Maybe it was because the doctor made me feel like i wasnt doing enough or maybe it was because the pt was "fine" when she came in.

Would an earlier initiation have done much help? There was a good 30min delay in starting the antibiotics. I cant help but feeling guilty!

Specializes in critical care.

Also, 1fastRN, look at it this way: if abx were a "life saving" med, they would be at our fingertips and not have to be tubed from pharmacy! That's why we have intubation and hemodynamic drugs at our fingertips. ABCs first--the rest can wait. :)

Specializes in Emergency Nursing.

Great words of wisdom. Thanks guys!

Specializes in Emergency Nursing.

There's no way to have known this was coming. Sepsis can "gallop" on an elderly patient, but it doesn't usually. There doesn't seem to have been any indication that she was moribund.

She came from the ED with abx started, right? I think that's pretty much procedure anywhere. I'm currently in the ED (having transferred from medical step-down) and we start abx on all elderly pts of whom we suspect UTI/Urosepsis/Pneumonia, also waiting 0:45 for a reaction. Additionally, with pna we're now doing blood cultures first. No pt gets abx without cx being drawn

The point above about flash edema is also well-made.

Other questions: I am assuming that since she clearly went into shock her BP was tanking, did you bolus her fluids (if she could tolerate them)? Did you start pressors upon adequate hydration (this is posted in critical care so I am assuming you can start pressors where you work, I could be wrong). This may be something they would have done once they got her to the unit, I don't know how your facility works.

All of this said, we need better education in the elderly population about the dangers of UTIs.

What was her lactic acid?

Specializes in Trauma/Tele/Surgery/SICU.

You reach a point of no return with sepsis. You can do everything humanly possible and you are just not going to save these people. I am often shocked at how sick some of these people are when they first present, and at how long they can maintain their BP, especially the elderly. The delay in ABX did not cause her death and nebs would not have fixed pulmonary edema.

The ccm link ESME provided has an excellent tutorial on sepsis. Love that website, which incidentally, I also discovered via an ESME link. :inlove:Esme12:inlove:

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