Sepsis

iShaybie, ADN · Jan 13, 2016

I was just hospitalized with sepsis a few months back! I had been sick for a couple weeks and finally decided to go the ER (well, my mom made me). They told me they had to admit me and I was soooo surprised! lol. It sneaks up on you.

All from a UTI/Kidney Infection. :/ I'm so glad I saw my mom that day because I would've kept brushing it off!

KatieMI, BSN, MSN, RN · Jan 13, 2016

Is that sepsis, SIRS or sepsis quick tool criteria applied wrong way?

(the following scenarios are NOT from real patients):

40+ y/o found unconscious in the company of empty gallon bottle of cheap gin. Agitated, bt 102.3, rr 36, bp 90/60, hr 170, Afib/RVR, sweating, tremor, hallutinations. Goes to MUCU, Dx: "sepsis according to criteria". Cultures drawn, vanco is running, nobody bothered to take CIWA. Thanks.

30+ y/o female, caring for a child sick with "cold". Child got flu shot, she did not. Did not eat, drink or sleep much for 48 hours due to driving right across the country. Felt bad, came to ER. A,Ox2, weak, bt 102.3, rr 28, hr 128, BMP looks "dry", bp 110/60 (baseline 120/80), myalgias, dry cough, all other stuff clear. Got a liter of fluids IV, felt better, sent to MICU, Dx: "dehydration, sepsis according to criteria". In two hours, flu test back positive. Thanks again.

A type I diabetic guy broke his pump and did not notice it. Came to ER in blooming DKA with all the trimmings. Sent in MICU with insulin and vanco running, Dx: DKA, SIRS. Thanks again and yes, yes, fever is a symptom of DKA.

Every single patient in LTACH on wean has two or more of that critetia, just because weaning, especially on high CPAP, just works this way. It drops blood pressure, you know. If, good Lord forbids, they also on hyperalimentation (most of them are), their CBG will be also in and above that zone, and what will I do then? Thanks again, and no, I will not call doc till I see something else.

I can continue... that's why I have to carry a piece of laminated paper with me at all times, with things like "working bp 90 - 100/50-60, baseline hr 90-100". I do not care if someone ER's "critetia" says again that everyone must have bp 120/80 and my lawful 90/60 satisfy someone's imaginary ideas. No more 5 liters of NS with following worst headache of my life and happy RN who managed to push my bp over that magic number for some few hours.

Dranger · Jan 13, 2016

SIRS

Sepsis

Severe Sepsis

Septic Shocks

Lots of broad categories and lots of reasons for sepsis occurring leads to so many of these diagnoses.

AJJKRN · Jan 14, 2016

Honestly the new (I think it's called) ICD-10 stuff is prompting hospitals to start having more and more protocols in place and sepsis prevention/risk/treatments is one of them. We have a newer protocol and posters up at my work that makes it look like my entity has just been forward thinking about sepsis but in reality it's a push for getting paid in full and meeting benchmarks for the government...if I'm explaining what I mean correctly anyways.

Plus I kinda think that we as healthcare professionals are seeing sicker and sicker peeps and we are developing better and better screening tools and experience all the time. It's like cancer or schizophrenia just as loose examples, they've both been around for centuries but seeing an increase is related to what...having more cases or having better screening/diagnostic tools.

Forgive me but if I'm hazy in my descriptions, I'm barely getting over the horrible hell hath no fury cold that's going around and need another nap even though I'm on the 4th/5th day of being a slug. :lurking:

Been there,done that, ASN, RN · Jan 14, 2016

Huge increase in sepsis hospitalizations. Sepsis is identified by two or more criteria. Temp. > 100.4 , heart rate >90 sustained , WBC > 12 /

Now the CAUSE of the sepsis is Huge. Most likely an organism not yet recognized by the CDC.

That "respiratory thing" is the new super bug.

KatieMI, BSN, MSN, RN · Jan 14, 2016

Huge increase in sepsis hospitalizations. Sepsis is identified by two or more criteria. Temp. > 100.4 , heart rate >90 sustained , WBC > 12 /
Now the CAUSE of the sepsis is Huge. Most likely an organism not yet recognized by the CDC.
That "respiratory thing" is the new super bug.

The problem is, these criteria can be seen in quite a few conditions, each of them having nothing to do with sepsis or any infection, for that matter. DT, DKA, dehydration of any kind, even missed STEMI can all produce "criteria".

It is internal problem with criteria sets and guidelines, which are designed to have low specificity and encompass as many clinical scenarios as possible at once. This wouldn't be a big deal if only people would remember that no critetia set or guideline is intended as effective substitution to clinical analysis and critical thinking. What happens in reality, I guess you know better than me:yes:

It wouldn't bother me so much, but I am tired to see patients getting "big guns" antibiotics and having all these endless cultures of everything drawn, collected and sent for no reason except the "critetia" above, which are clearly not connected with any infection. This happens among laments about MDRO "epidemics" and me shredding isolation gowns like autumn leaves. Only one hope is that it would be another medical fashion which comes and goes, like putting everyone still breathing on warfarin around 2005 and treating cancer and FBM with Bextra a few years earlier.

Been there,done that, ASN, RN · Jan 14, 2016

Understand 100 %. EBP does not always apply. I am saying EBP or not... there is a new bug out there.

And it scares the h*ll out of me.

KatieMI, BSN, MSN, RN · Jan 14, 2016

Understand 100 %. EBP does not always apply. I am saying EBP or not... there is a new bug out there.
And it scares the h*ll out of me.

Why??

Ok, here us a new bug. "New bugs" are different from the old ones because they are resistant to antibiotics, right? If yes, this means that new bugs have new, more flexible and changible DNA. This, in turn, means that their DNA is generally LESS stable. DNA is not like a rope in a big box in which you can add a piece here, cut there and nothing visibly changes. It has its own strict limits, and if there is a mutation which significantly changed or added a new gene which will encode a protein to close a channel through which antibiotic gets into the bacterial cell, the whole molecule of DNA will be changed and became less stable, mire prone to lethal mutations. Drug resistance is extremely "energy -costly" function for a cell, and so bugs that got this functions as result of mutations, have LESS chances to survive on the long run, not more, as well as LESS chance to infect healthy host and MORE chances to become sensitive to less used drugs. In 2003, MRSA was a horror of healthcare; in 2005 community-acquired MRSA were treated with good ol' Bactrim, now hospital-acquired MRSA are becoming sensitive to Bactrim.

The whole problem would slow down if only we would stop use Vancomycin as tap water, treat asymptomatic infections (do they aware that uretra and trachea are normally not sterile environment?) and treat "sepsis" where there might be normal inflammatory responce. And duagnose and treat it even if "criteria are not satisfied".

Let's just keep eyes open, patients assessed and our brains free of fog and unnecessary instructions. Let's treat people, not the critetia. Then it will be all right:up:

AJJKRN · Jan 14, 2016

The problem is, these criteria can be seen in quite a few conditions, each of them having nothing to do with sepsis or any infection, for that matter. DT, DKA, dehydration of any kind, even missed STEMI can all produce "criteria".
It is internal problem with criteria sets and guidelines, which are designed to have low specificity and encompass as many clinical scenarios as possible at once. This wouldn't be a big deal if only people would remember that no critetia set or guideline is intended as effective substitution to clinical analysis and critical thinking. What happens in reality, I guess you know better than me:yes:
It wouldn't bother me so much, but I am tired to see patients getting "big guns" antibiotics and having all these endless cultures of everything drawn, collected and sent for no reason except the "critetia" above, which are clearly not connected with any infection. This happens among laments about MDRO "epidemics" and me shredding isolation gowns like autumn leaves. Only one hope is that it would be another medical fashion which comes and goes, like putting everyone still breathing on warfarin around 2005 and treating cancer and FBM with Bextra a few years earlier.

Is your facility not also using serum lactate levels to rule out the possibility of sepsis? I think that a lactate level >2 will get you on the radar, along with two of the other parameters present, or just being symptomatic. A lactate of >4 gets all of the stops and an ICU visit pulled off.

http://sepsis.org/resources/literature/

Sepsis

KatieMI, BSN, MSN, RN · Jan 14, 2016

Is your facility not also using serum lactate levels to rule out the possibility of sepsis? I think that a lactate level >2 will get you on the radar, along with two of the other parameters present, or just being symptomatic. A lactate of >4 gets all of the stops and an ICU visit pulled off.
http://sepsis.org/resources/literature/
Sepsis

Yes, sometimes. But lactate can be elevated because of anything collapsing peripheral circulation/disrupting glucose metabolism. Alone, it is just another number.

martymoose, BSN, RN · Jan 14, 2016

Id say most of the sepsis I'm noting is not just by criteria. Of course someone with afib is going to probably have a HR >90, but the fevers some of these guys are getting spanked with- no misunderstanding that!also the lactates and other symptoms.

yes it is scary