Code Blue: Just Trying Figure Out What Happened?

Wuzzie · Dec 10, 2019

48 minutes ago, Susie2310 said:
I agree. The patient's cardiac history led me to suspect that cardiac problems (maybe possibly renal problems also) were being taken into account in the treatment for pneumonia/sepsis. We need to know more about their medical history also.

Without knowing the sequence of events it seems they were first treating her for acute decompensated heart failure with hypotension then added the PNA diagnosis after CXR. It would be extremely helpful to get some more information from the OP.

This is really a great case study because there are so many factors influencing the outcome. I would love to hear some input from others. Might offer some good education for all of us.

Found this. It's a little outdated but I thought it was a good overview of the issues with treating ADHF.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1808524/

Bloop41, BSN, RN · Dec 10, 2019

8 hours 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. 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.

I learned this the hard way when I held my poop until after I had finished donated blood. Passed out in the bathroom with my pants around my ankles-- and I was a healthy 24yo F w/o any cardiac history! The experience really cemented the connection between defecation/rectal stimulation and vagal syncope.

lovingtheunloved, ASN, RN · Dec 10, 2019

Maybe I’m the weird one here, but I never ever get a patient on pressors out of the bed...things go awry fast and then you have a coding patient on the commode. Then again, I don’t do pressors all the time, maybe once every couple of months. I realize my experience is limited.

Binz · Dec 11, 2019

16 hours 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.

Not accusatory at all! I really appreciate your response! My preceptor didn't have any insight and I want to be more knowledgeable if I run into this again. This is really helpful.

Binz · Dec 11, 2019

11 hours ago, JKL33 said:
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?

I remember knowing her WBC and lactic were elevated. I think the lactic was 2.5. No, my preceptor didn't have any insight about it and I guess I'm trying to understand the patho behind it.

Binz · Dec 11, 2019

9 hours ago, ruby_jane said:
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...

This website is super helpful! Thank you.

8 hours ago, Wuzzie said:
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.?

I think, initially, the MD thought it was a GI infection. The pt had just got back from an international trip but Munro made a point that it may not have been infection at all, but cardiac.

Binz · Dec 11, 2019

5 hours ago, Susie2310 said:
From the information you've given so far I'm not seeing a reason to discount the MD's diagnosis of pneumonia and sepsis as I recall has been previously suggested (you said the MD had reviewed the CXR and was able to make a determination of pneumonia) and sepsis. You haven't mentioned what the lab values for WBC/differential and lactate were, but I assumed they supported the diagnosis of sepsis. You said the patient had heart problems with a reduced ejection fraction and a history of atrial fibrillation (which can lead to cardiac arrest) and then became hypoglycemic, which can contribute to cardiac arrest. You also mentioned the pressor wasn't being titrated to a specific MAP. As I see it, this entire combination of medical problems on top of pneumonia/sepsis would have been enough to lead to the patient experiencing a lethal arrhythmia and going into cardiac arrest.

Is there anything I could have done to prevent her from going into cardiac arrest? I remember knowing her WBC was elevated and I think her lactic was 2.5.

Binz · Dec 11, 2019

5 hours ago, Wuzzie said:
What are your thoughts on the Lasix then?

She was on 4 L NC, with O2 sat fluctuating between 90 and 95%. Based on the CXR, the MD may have suspected PNA but maybe also pulmonary edema?? When we started getting concerned, we asked the MD to look at her and she said it was definitely PNA.

Binz · Dec 11, 2019

5 hours ago, Susie2310 said:
I was thinking that this may have been because of the patient's ejection fraction. It appears to me they used pressors to restore the MAP initially instead of fluid resuscitation.

We had achieved a MAP greater than 65 but should we still have held the Lasix? Would it have brought her BP down?

5 hours ago, Susie2310 said:
I was thinking that the patient had presented as fluid overloaded and/or in heart failure.

She also had a fever. I'm sorry, I keep leaving details out. Initially when she started sweating, we thought it was either due to her fever breaking or BG being low but it may have a sign of impending cardiac arrest??

Binz · Dec 11, 2019

4 hours ago, Wuzzie said:
Without knowing the sequence of events it seems they were first treating her for acute decompensated heart failure with hypotension then added the PNA diagnosis after CXR. It would be extremely helpful to get some more information from the OP.
This is really a great case study because there are so many factors influencing the outcome. I would love to hear some input from others. Might offer some good education for all of us.
Found this. It's a little outdated but I thought it was a good overview of the issues with treating ADHF.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1808524/

I wish I had more info. I didn't get a chance to read the triage and we didn't admit her but the pt presented with fever, respiratory retractions, hypotension and tachycardia. She had gone out of the country shortly before, so the MD suspected GI infection and wanted a stool sample but based on the CXR, I think she determined it was PNA and ordered 20 mg lasix and antibiotics. A previous echo revealed an EF of 20%. Pt had a history of HF and afib and I think that was it. I remember knowing the WBC was elevated and i think the lactate was 2.5. She said she needed to "poop" so we sat her at the bedside. Her MAP had been good. But then she said he was nauseous and she was diaphoretic so we lied her back down. Checked her BG. I went to find the MD who told me to give d50, which we did. The MD came to look at her, ordered zofran, and left. We gave the zofran and then shortly after, she went into cardiac arrest. She had been super pleasant and was laughing and responsive so I'm trying to pinpoint the cause, I guess.

Subee2, BSN, MSN, CRNA · Dec 11, 2019

The lady was dying when she came in the door and nothing would have made a difference. Levophed usually means leave them dead" because it is a last line measure but actually increases oxygen consumption because of the increase in vasoconstriction. Can't use anything in her case to increase cardiac output because there is not enough heart muscle left to make a difference when she is vasodilated from the fever. Patients with heart failure usually die of.....heart failure.

marienm, RN, CCRN · Dec 11, 2019

This case is going to be on your mind for a while, sorry. The discussion about patho here has been good! The one idea I'll add is that it sounds to me like the ED provider may have been out of their depth. Elevated WBCs, hypotension, elevated lactic, febrile all sounds like sepsis. Poor EF, extensive medical hx, hypoglycemia all make it more complicated. I'm just not buying the lasix...Sat of 95% on 4L does not make me want to give lasix to a hypotensive patient (even with pressors fixing the numbers on the screen). If she had crackles that were audible without a stethoscope, lasix might have been appropriate to give in the ED, but otherwise this makes me think the provider didn't have a strong plan. What were her electrolytes pre-lasix?

In my hospital (which I'm not saying is perfect so I'd welcome any input!) this patient would have gotten an ICU consult and probably a cardiology consult while still in the ED. As you've unfortunately seen, this is not the kind of pt you want to keep in the ED...they need a primary team to start managing their case. As the nurse, you can push for this when you know your ED providers. Would it have changed the outcome? Maybe, maybe not; it sounds like she went south fast. Right now you're training your "eyes" on patients who make you nervous. These are the patients you want to be transferring out...get their labs, their stat ABC interventions and antibiotics, their tests, and get them admitted!