MRSA sepsis leads to septic emboli/CVA r/t peripheral IV?

[megananne7]

Had a patient for a few shifts a few days ago. They were discharged middle of last week from my unit, had a CVA with that admission, but apparently had improved greatly, walking great, no issues with speech or swallowing, etc.

Was readmitted a day & a half later with sepsis/febrile/confusion. There was debate about whether it came from the IV or urosepsis. Even daughter (who is a CNA) stated urine looked horrible when she was readmitted. But they did say the arm the IV was in did get swollen at one point after discharge. Family pointed out to me where the old IV was, it seemed like some phlebitis going on there (Pt has a Hx of SLE, by the way). Her CT when she was admitted came back OK. By the time I was assigned to her as a patient, she was sleepy but A&O, no fever.

Daughter got mom up to wash her up (pt wanted shower). When I got in the room I saw how she was rocking/leaning on the toilet and said "no way!", got her back to bed. Pt obese, tough to move, took 2 of us, but her walking was not good at all. Pt had MRI & when it came back, has multiple areas of infarct, including cerebellum. MDs suspect septic emboli.

But family still thinks the IV is the cause of the MRSA sepsis. In report, I told oncoming nurse this and she said that's not likely. Anyone heard of anything like this?

[leslie :-D]

how did her arm look, other than swollen?

i would think if the phlebitis was that advanced, it would have been extremely red and painful as well...

leslie

[megananne7]

The area of phlebitis I saw was a little reddened but I wouldn't look at it and say "OMG!" When I palpated the area she made no reaction at all, either.

[leslie :-D]

i'm thinking her sle was exacerbated.

wbc's can be decreased in sle, which would increase risk of infection.

furthermore if she had a bout of vasculitis (also common in sle), emboli could be a manifestation of this process.

it 'sounds' more from the urosepsis.

especially if she was elderly, since this population does not present w/typical s/s...

even in absence of sle.

leslie

[aeauooo]

The IV may or may not have been the source of infection that lead to sepsis.

One question to ask when you see multiple cerebral infarcts is, "how old are they?" Did this person come in with hypodense areas on CT? "Okay" doesn't necessarily mean negative - a person can have a stable CT, which only means "nothing new." The MRI could have picked up small infarcts that weren't obvious on CT.

There are a number of other reasons the patient could be throwing emboli, but cerebral infarction is not always caused by emboli.

The bottom line is that septic emboli may have caused the infarctions, but not necessarily. If the patient had cruddy urine, I suspect that may be the more likely source of sepsis than an IV site.

BTW, what evidence is there that the patient had MRSA sepsis? Blood cultures?

Also, an obese patient looking toxic while sitting on the toilet is another cause for suspicion (that's how Elvis died). Valsalva while having a bowel movement, hypotensive from sepsis, compromised cerebral perfusion, SLE, all could have contributed to cerebral ischemia.

Incidentally, cerebellar infarcts are often not clinically significant, but it does indicate pathology somewhere other than the carotids.

[aeauooo]

Even daughter (who is a CNA)... But family still thinks the IV is the cause of the MRSA sepsis.

How many times have I heard that before?

A family member who is a CNA and thinks that A caused B is usually nothing more than a nuisance - just enough knowledge to be dangerous.

[leslie :-D]

i'm wondering why it's thought the iv was the source...

didn't pt have foley?

leslie

[megananne7]

Pt is in early 50s. Came in the first time with CVA, I didnt have her as a pt so I dont know what areas of infarct there were or if it was really a TIA or what (I say this b/c the CT she had when she came back to the ED after her discharge, didnt show any infarcts, even if old). But apparently she left on Wednesday with no deficits.

Came back Thur evening to ED with fever and confusion. I picked her up as a patient Sat & Sun.

Yes, MRSA was confirmed from blood cultures. Found out Sunday morning, blood cultures had been drawn in the ER. Pt sent to an isolation room as soon as we found out.

Pt during my care did have a foley, I dont know if she had a foley during her first admission. And the evidence the family had regarding "The IV Did it!" was the swelling of arm and redness/phlebitis where it was. By the way, it was the husband of the pt who was really insisting it was the IVs fault, the daughter never mentioned it but she did mention to me "Her urine looks much better".

[megananne7]

Also, an obese patient looking toxic while sitting on the toilet is another cause for suspicion (that's how Elvis died). Valsalva while having a bowel movement, hypotensive from sepsis, compromised cerebral perfusion, SLE, all could have contributed to cerebral ischemia.

She wasnt have a bowel movement. I came in the room and she was sitting on the toilet, daughter next to her. I guess she was resting? But her bed was literally 3-4 ft from the toilet.

[aeauooo]

One thing I have noticed is that people with comorbidities, especially obese people with comorbidities, tend to be candidates for becoming extremely sick with even what seem to be minor presenting illnesses. They just don't have the reserve that healthy people do to compensate for the stress response of illness. I've frequently seen people with comorbidities admitted for a single-system insult develop multi-system illness.

Lupus is a horrible disease that causes, among other things, vasculitis.

I think there are a lot of things that are more likely causes for this patient's infarcts than an IV site.

I don't know where this is going, but I think it would be very difficult to prove this patient's family's suspicion, id est, be able to sue for damages.

[iluvivt, BSN, RN]

peripheral IV sites rarely get infected but it can happen. I would look first at the most likely scenario...urosepsis would definately be more common. It sounds lkie the IV site was not only infiltrated but had a resolving phlebitis...was there a palpable cor or a red streak. Pts often confuse these 2 iv-related complications as infections