Code Blue: Just Trying Figure Out What Happened?

[Binz]

I recently started in the ED. I had a patient who came in with Pnuemonia and sepsis. Was on a norepinephrine drip to maintain a MAP>65. Her BP went up, MAP was 80ish. We had to get a stool sample, so me and my preceptor sat her up at the bedside. She started feeling nauseous, felt like she was going to vomit, was very sweaty, and then it's like the life left her eyes. She passed out, became unresponsive. We activated a code and she had to be intubated. I'm just trying to understand how we went from MAP>80, pt talking, eating to intubating. What should I have done/not done? Thank you.

[MunoRN, RN]

It's hard to evaluate what occurred without knowing more about what happened,was it a primary respiratory arrest or cardiac? Your description is of a cardiac cause, so what was their rhythm? What was the basis for determining the patient's primary issue was pneumonia and sepsis?

How much norepi was the patient on? Why were they eating while on levo? Why was the MAP being pushed so high?

[Binz]

I believe it was cardiac. She had a history of Afib, and HF with an EF 20%, and was in afib during the code. I think based on the CXR, the MD determined it was pnuemonia and we had given her lasix 20mg and antibiotics about 30 minutes before. Not on any IV fluids, just the drip. She was AOx4, on 4 L NC 95% SpO2, breathing with retractions, but super pleasant. She started getting sweaty, so we checked her blood sugar and it was 60 so the MD said give D50 and then we sat her up because she said she needed to use the restroom, and then she went to into cardiac (?) arrest. She was at 0.05 on the drip. At the start of our shift, her BP was like 70s/50s, so we increased it to 0.07 I think and I guess she responded pretty quickly. But that's been my frustration with starting drips in ED. There are usually no parameters. Nurses seem like they're just winging it. Also, are pt's not allowed to eat while on levo (sincerely asking...there is so much I don't know!!)? She only was able to eat one bite of a sandwich and couldn't really tolerate it. Please help. Thank you.

[MunoRN, RN]

23 minutes ago, Binz said:

I believe it was cardiac. She had a history of Afib, and HF with an EF 20%, and was in afib during the code. I think based on the CXR, the MD determined it was pnuemonia and we had given her lasix 20mg and antibiotics about 30 minutes before. Not on any IV fluids, just the drip. She was AOx4, on 4 L NC 95% SpO2, breathing with retractions, but super pleasant. She started getting sweaty, so we checked her blood sugar and it was 60 so the MD said give D50 and then we sat her up because she said she needed to use the restroom, and then she went to into cardiac (?) arrest. She was at 0.05 on the drip. At the start of our shift, her BP was like 70s/50s, so we increased it to 0.07 I think and I guess she responded pretty quickly. But that's been my frustration with starting drips in ED. There are usually no parameters. Nurses seem like they're just winging it. Also, are pt's not allowed to eat while on levo (sincerely asking...there is so much I don't know!!)? She only was able to eat one bite of a sandwich and couldn't really tolerate it. Please help. Thank you.

First I should point out that I don't think there was anything wrong with the care you provided, my post came across as more accusatory than intended.

There are reasons to avoid or at least be cautious about feeding patients on high dose pressors, but your patient's dose of 0.05 is a fairly low dose. There are two reasons for this; pressors can contribute to bowel ischemia, and feeding an ischemic gut can cause necrosis and perforation. I know this seems counterintuitive since the purpose of pressors is to improve perfusion, but they don't improve perfusion everywhere in the body. The most visible example of this is that's it's not unusual for the fingers and toes of patients on high dose, long term pressors to become necrotic. The other reason is that digesting food increases the body's metabolic demands by 25% or more, so if you're already struggling to meet the body's metabolic demands then increasing those demands sort of works against you.

I'm always leery of the initial diagnosis of pneumonia and or sepsis in a cardiac patient, since too often it turns out all of their symptoms attributed to pneumonia and sepsis were solely cardiac in nature. Tachycardia, tachypnea, elevated lactate, signs of decreased end-organ perfusion, hypotension, etc can all be explained by HF and other cardiac causes, but also typically trigger a concern for sepsis above all else, which can lead to interventions intended for septic patients that may do more harm than good in HF patients.

I think we're sometimes a bit too quick to get too aggressive with borderline low BG levels, 60 is the low end but is in the normal range for a fasting BG level. I think we also forget how damaging d50 is to vasculature as well.

My guess would be that she was just sicker than she looked while resting in bed, and then the balance between compensation and decompensation suddenly tipped.

[NickiLaughs, ADN, BSN, RN]

28 minutes ago, MunoRN said:

First I should point out that I don't think there was anything wrong with the care you provided, my post came across as more accusatory than intended.

There are reasons to avoid or at least be cautious about feeding patients on high dose pressors, but your patient's dose of 0.05 is a fairly low dose. There are two reasons for this; pressors can contribute to bowel ischemia, and feeding an ischemic gut can cause necrosis and perforation. I know this seems counterintuitive since the purpose of pressors is to improve perfusion, but they don't improve perfusion everywhere in the body. The most visible example of this is that's it's not unusual for the fingers and toes of patients on high dose, long term pressors to become necrotic. The other reason is that digesting food increases the body's metabolic demands by 25% or more, so if you're already struggling to meet the body's metabolic demands then increasing those demands sort of works against you.

I'm always leery of the initial diagnosis of pneumonia and or sepsis in a cardiac patient, since too often it turns out all of their symptoms attributed to pneumonia and sepsis were solely cardiac in nature. Tachycardia, tachypnea, elevated lactate, signs of decreased end-organ perfusion, hypotension, etc can all be explained by HF and other cardiac causes, but also typically trigger a concern for sepsis above all else, which can lead to interventions intended for septic patients that may do more harm than good in HF patients.

I think we're sometimes a bit too quick to get too aggressive with borderline low BG levels, 60 is the low end but is in the normal range for a fasting BG level. I think we also forget how damaging d50 is to vasculature as well.

My guess would be that she was just sicker than she looked while resting in bed, and then the balance between compensation and decompensation suddenly tipped.

This is an excellent answer

[Wuzzie]

Normal EF is what 50's-70ish? Hers was 20. I'm guessing, despite being on pressors, that also played a part in this scenario once you sat her up. Seen it happen with cardiac amyloid on more than one occasion.

[JKL33]

Were you able to talk with your preceptor or the physician at all following this? I would be interested to hear their take? I agree it doesn't sound like a straight straightforward pneumonia/sepsis scenario; it sounds like a lot going on and various interventions. Did you have a chance to look at things like labs to help inform your understanding of the situation?

[NICU Guy, BSN, RN]

6 hours ago, Binz said:

so me and my preceptor sat her up at the bedside.

orthostatic hypotension

[Guest219794]

"MAP>80, pt talking, eating to intubating. What should I have done/not done? "

A few thoughts.

First and foremost: This patient died because she was terribly sick. 20% is a horrible EF, and depending on how low her MAP ran for how long, there was likely multiple organ dysfunction as well.

A few other thoughts:

When a really sick patient has to poop, sometimes they die. I have no evidence to back this up other than experience- mine and others. I can't tell you why, whether there is causal or correlational connection. But, I am sure others here can confirm this anecdotally. Off the top of my head, I remember three specific cases, but I am sure I have seen more.

Pooping , or needing to poop and not pooping, can cause a vagal response. While vagal syncope is generally well tolerated in healthy people, not so much in critically ill people. Also- Vasovagal syncope is indistinguishable from about a million other things that kill people. No idea if this happened in your case, or in any that I have seen, but it isn't far fetched.

Munro has outlined some great information in an informative post. Pressors are for really sick people. We generally don't feed really sick people. In addition to what Munro laid out, there is the issue of food in the stomach. A PT who is critically ill with a respiratory chief complaint has a high likely hood of being intubated. Food in the belly increases the risks significantly.

5 hours ago, Binz said:

There are usually no parameters. Nurses seem like they're just winging it.

While the doc may not write parameters, they certainly exist. Ideally in hospital policy or guide. If not, in any IV drug guide. Consider downloading an app. MAP of 80 seems higher than needed.

[JKL33]

13 minutes ago, hherrn said:

When a really sick patient has to poop, sometimes they die. I have no evidence to back this up other than experience- mine and others. I can't tell you why, whether there is causal or correlational connection. But, I am sure others here can confirm this anecdotally. Off the top of my head, I remember three specific cases, but I am sure I have seen more.

Pooping , or needing to poop and not pooping, can cause a vagal response.

Anecdotally confirmed. My theory/observation is a little different, though, I think the need to defecate in the first place can be ominous in these scenarios, not just that an ill person experiences basic orthostatic hypotension or vasovagals when getting up or while voiding.

[ruby_jane, BSN, RN]

I love every single comment here. Y'all are a wealth of information.

OP - she was septic. You cannot ever underestimate how close a person in sepsis lives to the edge...

[Wuzzie]

Cell lysis is also something to consider.

Going forward I would think twice about feeding any ED patient who is on pressors, has any indication of respiratory distress or heart failure, or looks at you cross-eyed. Turkey sandwiches were at the bottom of my priority list when I worked in the ED.

Also, why did they want a stool sample? Seems like an odd order for a patient diagnosed with pneumonia.?