Antibiotic initiation/effectiveness

[1fastRN]

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!

[Sassy5d]

I hear where you're coming from.

In all honesty, I don't think 30 mins or so delay in atb really would have made a difference.

I think it's a nature reaction to feel bad (means you're human) and to second guess yourself.

Pts do go south sometimes. How many times have you sent a stable pt up to a floor and then maybe the next day or even hours later heard a code blue called?

Now I do have to ask.. How long was the pt in the ER before the doc even ordered the med?

[Ikikaeru]

Im not an expert but I dont think getting antibiotics a few min earlier would have "saved" her. She was already pretty bad if she crashed that hard. Not sure about the MD but maybe he was jsut willing to get everything going so it covered him as well.

Assertive may have gotten toe antibiotis a little sooner but who knows if that would have done much.

I hate when you have a pt that doesnt seem to be that bad off just go down the toilet so quick. You always look back and think what could I have done differently. I think when you dont really have that "oh crap this is a bad one" and then they pass you look harder at what you did and less at what the pt had going on.

Hope you are doing well.

FYI if anyone has information on antibiotics or a different opinion please let me know!

[Esme12, ASN, BSN, RN]

Thirty minutes would not have made a difference....in fact they administration of antibiotics if they are that close to circling the drain and even cause them to crash.....

n blood, bacteria or bacterial products elicit a systemic inflammation characterized by massive activation of both macrophages in the reticuloendothelial system and circulating leukocytes, release of cytokines, adhesion molecule expression on endothelial cells, and development of hypotension. The consequences of this systemic inflammation may progress to sepsis, septic shock, and multiple organ failure Also known as Jarisch-Herxheimer reaction (JHR)The Jarisch-Herxheimer reaction is a reaction to endotoxins released by the death of harmful organisms within the body. That in combination of dehydration and vasodilation caused by sepsis caused a critical sequence of events.

check out this thread.....Septic shock and reaction to Rocephin/Ceftriaxone

[Ikikaeru]

Thanks for the info. Lots of good posts and information in that thread.

[WAheartnurse]

This is what I have seen: the patient fits sepsis criteria so we are bolusing with fluids to keep BP/MAP up. The pt develops flash pulmonary edema (hence the wheezes from nowhere) and they crash quickly. I would suspect the death could be more attributed to a pt with underlying heart troubles/CHF (diagnosed or not) and they just couldn't handle the fluids.

I have had a little old CHF lady pt come from ED on her second liter of fluid "wide open." Holy cow, I stopped that in a heartbeat, called the hospitalist and our STAT nurse and we ended up trying to stop her from dying from fluid overload all day.

Of course there is the saying of better wet than dead so sometimes you are not going to have a good outcome either way.

[Esme12, ASN, BSN, RN]

Thanks for the info. Lots of good posts and information in that thread.

there is isn't there....:)

[1fastRN]

Wow I learned a ton from this thread! Thanks for posting all the great info.

To answer your question, the doc ordered them pretty quickly but it just so happened it was an antibiotic we dont normally stock in the med room hence contributing to the delay.

I am doing better and dont blame myself really so to speak...I guess we always think we could have done more!

And the fluid overload thing makes total sense in retrospect, even though she wasnt a known CHFer.

Thanks for the support and information!

[1fastRN]

Another question, if we are going to assume pulm edema is what caused the wheezing (which makes total sense) would a nebulizer treatment be counterproductive?

Ive been told neb treatments are a no no for pulmonary edema, is this the case?

Just asking bc another nurse was very set on getting a neb tx for this particular pt.

Sorry for all the questions, i am a new nurse in a busy trauma center so i am trying to learn as much as possible!

[Esme12, ASN, BSN, RN]

Thread moved to critical care for best response

The neb probably would not have helped but it wouldn't hurt.....when patients go sour nurses feel it's necessary to do something.

Your patients presentation is associated with her infection and she finally decompensated and went into septic shock.....it sounds to me like she had SIRS...Systemic inflammatory response syndrome (SIRS) is an inflammatory state affecting the whole body, frequently a response of the immune system to infection. SIRS is a serious condition related to systemic inflammation, organ dysfunction, and organ failure. It is a subset of cytokine storm, in which there is abnormal regulation of various cytokines.....as described in the other thread.

Criteria for SIRS were established in 1992 as part of the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference. The conference concluded that the manifestations of SIRS include, but are not limited to:

• Body temperature less than 36°C(96.8°F) or greater than 38°C(100.4°F)
  
• Heart rate greater than 90 beats per minute
  
• Tachypnea (high respiratory rate), with greater than 20 breaths per minute; or, an arterial partial pressure of carbon dioxide less than 4.3 kPa (32 mmHg)
  
• leukocytes less than 4000 cells/mm³ (4 x 10⁹ cells/L) or greater than 12,000 cells/mm³ (12 x 10⁹ cells/L); or the presence of greater than 10% immature neutrophils (band forms) band forms greater than 3% is called bandemia or a "left-shift."
  

Systemic Inflammatory Response Syndrome is a great article about SIRS....it is on medscape. You have to register to see it but it is completely free and a great resource!

Other great resources...tutorials

http://www.ccmtutorials.com/

Surviving Sepsis Campaign | Guidelines

[ktliz]

Great thread! Especially the info about abx while the patient is circling the drain.

Here's my question: Can ARDS itself cause flash pulmonary edema (i.e. not in the setting of CHF)? Or will the onset be more gradual?

[Esme12, ASN, BSN, RN]

Yes it can cause flash pulmonary edema that may not be responsive to diuretics at all because of the massive inflammatory response from the overwhelming infection.