Walkie Talkie pt. that tanked.

[KY RN]

I had a very LARGE patient that had a simple procedure. He had a cath for 6 hrs. because he couldn't void all day. He spike a temp of 103.3 and was very lethargic, and Dr. said to D/C Foley and C/S green purulent discharge from urethra and give Tylenol. He was on a PCA pump for 2 days for pain control. Temp came down and I had him up and walking for non-urination for 8 hrs after removal of catheter(100 cc after ambulation) and then in AM during report he tanked. (Why do they always tank during report?) He had 6 shots of Narcan and still did not come around, usually they are jumping out of their skins. 30% on a non-rebreather, and was non responsive. His % came up to 82% but still not responding to stimuli. BS 290, HR 112, BP 80/50, temp 97' and RR of 22. Labs showed ph of 7.28. All other CBC,PT, INR, BMP and ABG's were normal. He was moved to TCU still unresponsive. At first, I thought too much meds, but after 6 shots of narcan and no response, I'm thinking he had sepsis or maybe threw a clot. What do you think? I've never had a patient that was a walkie talkie just tank like that.

[blondy2061h, MSN, RN]

I guess my thoughts are that if the BP is dropping so much and the temp was so high it's not such an early sepsis that the WBC isn't elevated yet. I don't have much experience with sepsis in people that have a white count at all, though, so I may be totally wrong.

It also seems people with sepsis tend more toward a rapid respiratory rate than a decreased one (though again, not totally sure) and that respiratory failure comes quite late in sepsis.

Very interesting hearing others' thoughts on this as my experience is obviously very specialized.

Like I said, this case is quite interesting to me.

[ChristyRN2009]

He had no urine return when you initially cathed him for no urination? Acute renal failure may be a possibility if that's the case. Could also be a sign of a larger multisystem organ failure picture which leads me right back to urosepsis.

[blondy2061h, MSN, RN]

He had no urine return when you initially cathed him for no urination? Acute renal failure may be a possibility if that's the case. Could also be a sign of a larger multisystem organ failure picture which leads me right back to urosepsis.

My understanding was that he was cathed in the OR and there was no urine in the bad when they d/c'ed the foley to do a u/a on, then he had the urine retention. Are normal chemistries possible with an acute renal failure? I guess anything is really possible.

[KY RN]

Nothing implanted. Just an analrectoplasty. Bi carb was 24. CO2 was 36

[ChristyRN2009]

Well I guess I'm confused then, did you say you cathed him? Its late and I'm not firing on all cylinders.

[KY RN]

No, I did not cath him. He came to my floor and was there 14 hrs after surgery and had a foley cath placed on dayshift. When dayshift placed the Foley they got 1000cc. When he started having large amounts of drainage, I D/C the foley and did a swab of his urethral opening. When I D/C the foley, he had no urine output for 2 hours. I waited 8 hrs and he had not had any urine output and I called the Dr. The Dr. said to ambulate him and he only put out 100 cc. Then he tanked 45 minutes later.

[ChristyRN2009]

I see, thanks for clearing that up. Well then I still think urosepsis, might not have been acute renal failure because I think he would've had off chemistries plus I see now that he did have some urine. I could theoretically see him having a normal wbc if it was super early but was it a cbc with diff? Any bands? No lactic acid? I work on a stepdown floor so I see sepsis or the beginning of it fairly regularly and all the clinical markers are in line with that diagnosis, with the exception of the labs.

[Virgo_RN, BSN, RN]

It certainly sounds like sepsis.

[talaxandra]

Sounds more like sepsis than a PE to me, too.

[Virgo_RN, BSN, RN]

So, since the WBC count was normal, I'd expect to see a left shift, or an elevated lactate.....

[morte, LPN, LVN]

this may come under the heading of "zebra", but perhaps he has an underlying blood cell forming issue, therefore has low WBC count....

[fakebee]

How do you have a pH of 7.28 with a bicarb of 24 and a CO2 of 36?