Sepsis case

[poppy07]

Pt arrived to unit in respiratory distress, was intubated and put on CMV 80% FiO2. B/P low on arrival in 70's-80's and pt got 500ml NS bolus.

B/P remained low in 70's after bolus (boluses were given over 1 hr)

HR 130-138

Temp 40.2 C

RR maybe 16-22

0 urine out for 2 hours upon arrival (until started on pressors)

report states pt has hx of HTN, CHF, and possible UTI and PE

Pt got bolus of 500ml NS, B/P still low with MAP about 50-52.

Started another 500ml bolus but B/P remained low, medicated for temp, and started on Vaso 0.04units/minute to achieve MAP> 65.

>>>>Would you argue that Phenylephrine should have been started first?

The Vaso combined with continuous bolusing of 250ml NS per hour achieved MAPs in 65-70's and Syst B/P 90's. o2 sat stayed 97% the whole time (even with weaning Fio2 to 50%) Neo was added later to assist B/P

Pt on Heparin gtt, then determined to have definite DVT in leg. PE undetermined bc poor kidney functioning. Creat 6.3

When checking labs, lactate came back 1 something, and the ICU fellow states "pt is not septic-they don't even have an elevated lactate"

>>>>>I have not found anywhere that lactate level is a determinant of sepsis or MODS.

PLEASE COMMENT!

[labman]

My understanding of septic shock.

Septic- HUGE bacterial infection all over the body

Shock- There is not enough nutrients/ oxygen for the bodys needs.

So if there isn't enough oxygen/ blood flow to the tissues the body starts to use anerobic processes to create energy and dumping the lactic acid into the blood stream. So I think the doc was talking about the patient being in shock more then septic.

Hope this helps

kent

[poppy07]

the literature, though, defines them as follows:

Systemic Inflammatory Response Syndrome (SIRS)- at least 2:

>>> Body temp > or = 38 C or

>>> Heart rate >90/min

>>> Respirations >20/min or PaCO2

>>> WBC count >12 x10^9/L or

SEPSIS= SIRS plus Infection (in this case, possibly that UTI)

Severe Sepsis= Sepsis associated with organ dysfunction, systemic hypoperfusion, or hypotension (in this case, pt was hypotensive, had altered neuro status, impaired respiratory function, impaired kidney function, legs cool)

Septic Shock= Sepsis with arterial hypotension despite adequate fluid replacement (in this case, despite multiple boluses of fluid resuscitation and pressors, syst. B/P remained in 90's- so you could call this case septic shock.)

If the lactate level was normal, perhaps the ventilation was adequate and prevented the anaerobic processes from occurring?

[ghillbert, MSN, NP]

I think vaso was a reasonable choice. I would have liked a line to know what my CVP was though - a patient with hx of CHF would need a lot more tanking with fluid before increasing LV workload by starting pressors.

[kerikiwi2004]

Lactate level above 1 is cause for our sepsis protocol to be initiated.

[meandragonbrett]

If the lactate level was normal, perhaps the ventilation was adequate and prevented the anaerobic processes from occurring?

The lactic acid production is related to tissue hypoxia. One can easily obtain adequate ventilation. The problem occurs often times with oxygenation, i.e. the combination of inadequate oxygenation and hypotension alters your DO2 which results in tissue hypoxia.

[MaryAnn_RN]

Elevated lactate levels may indeed be a sign of sepsis but there are other causes too

http://www.survivingsepsis.org/bundles/individual_changes/serum_lactate

[poppy07]

forgot to mention CVP was 5-7 the whole day despite continuous fluid resuscitation, an no edema

[poppy07]

The lactic acid production is related to tissue hypoxia. One can easily obtain adequate ventilation. The problem occurs often times with oxygenation, i.e. the combination of inadequate oxygenation and hypotension alters your DO2 which results in tissue hypoxia.

what i mean is, maybe the patient was not hypoxic long enough because intubated quickly upon s/sx onset, and the pressor with fluid resuscitation was started early enough to forego seeing the lactate build up that would have resulted from anaerobic metabolism.

[athena55, BSN, RN]

I agree with everyone....SIRS/SEPSIS....Did he have an APACHE score done? (Not that that score is a great indicator of how well or poorly the patient will actually do....Kind of like the Murray Lung Injury Score) I would have been curious to see his P/F ratio, as well

So, how is the patient doing?

athena

[slcpicu]

Interesting case....I agree with the other posters that this is a Septic shock state as evidenced by the hypotension the pt had. The latic acid was within normal because the pt was actually managed well and that prevented the anerobic metabolism from starting. They maintained O's to the toes and therefore the latic didn't rise as of yet.

I think that the vaso was a good choice. Probably provider preference and it seem that the pt responded well to it.

As ghillbert stated, probably could have used some more volume due to being sick and a temp that high, the pt was probably pretty dehydrated. But there are 100 ways to skin this cat. Most importantly the pt responded to the intial treatments.

[poppy07]

I stabilized the patient, went and saw him 2 days later, he's still on Dobutamine with good B/p and good urine output. He looked okay.