Question

Sepsis Case Study Review Scenario: At 12:00 noon, Jose Guerrero, a 17 year old high school student on the soccer team, arrives at the Emergency Department (ED) a few days after cutting his foot at practice. The area on his foot around the wound has progressively gotten red, tender, hot to the touch, and has some drainage. Today it caused pain when walking and he was feeling weak and had a temperature. His only medical history is a mild case of asthma for which he occasionally uses an inhaler. The ED Technician takes Jose’s vital signs. Jose’s vital signs are: • Heart Rate (HR) 98 • Respiratory Rate (RR) 24 • Temperature (T) 38.2° C • Systolic Blood Pressure (SBP) 100 (normal for Jose = 125 – 135) • Level of Consciousness Alert & oriented to time, place and person • Weight 90 kg Using the Sepsis Algorithm, answer the following questions: • Does Jose have 2 or more Systemic Inflammatory Response Syndrome (SIRS) criteria? • If yes, what criteria? • Is there an actual or potential infection? • If so, what is the source? • What should happen next? . Based on Jose’s condition and vital signs, here are the steps the ED staff take: • They place Jose into a bed at 1230 pm. • The nurse starts an intravenous (IV) line in case fluids or IV medications need to be given • The doctor orders the following labs: Lactate, Blood Culture and Complete Blood Count (CBC) (the phlebotomist draws the labs at 1255 pm) • The doctor orders 1 Liter (L) of intravenous fluid [normal saline (NS)] and the nurse gives the fluid starting at 1:20 pm, at the time she hangs the fluid bag the SBP = 88 and the HR = 102 In the meantime, Jose is starting to shiver. Some lab results come back from the lab at 1:40 pm. The lab results are: • Lactate = 4.2 • CBC: White Blood Cell (WBC) count = 15 thousand; Hematocrit (Hct) = 42 • The blood culture is pending The ED technician takes Jose’s vital signs (VS) again at 1:45 pm after the liter of fluid has been given to him. Jose’s vital signs are now: • SBP = 80 • HR = 114 • RR = 28 • T = 39° C • Jose looks very pale Answer the following questions: • Is John’s condition improving? • What do you think needs to happen now? Because Jose’s condition is not improving: • The doctor orders another liter (L) of fluid (NS) and IV antibiotics and asks the nurse to get VS again as soon as the fluid is administered • 1 L fluid is given at 2:10 pm • The antibiotic is started at 2:20 pm and takes 30 min to give • The doctor calls the nurse at 2:25 pm and tells her that he wants to start Early Goal Directed Therapy (EGDT) on Jose The start time for EGDT is 1:40 pm when the lactate result of 4.2 came back from the lab. All interventions related to his care that have time frames associated with them are based on this start time. The liter of fluid has been administered and at 2:30 the nurse checks John’s VS again as the doctor ordered. Jose’s vital signs are: • SBP = 85 • HR = 105 • RR = 25 • T = 38.7° C The sepsis catheter is inserted at 3:05 pm and the nurse starts monitoring the measurements from the catheter that give information that helps guide treatment for Jose. The doctor orders a chest X-ray to make sure the catheter is inserted correctly and makes arrangements to transfer Jose to the Intensive Care Unit (ICU) as soon as possible. Here are the values recorded from the sepsis catheter: Time CVP MAP ScvO2 3:15 pm 4 56 60 3:40 pm 5 57 4:10 pm 5 56 62 4:45 pm 6 59 5:10 pm 8 60 65 5:40 pm 8 59 6:00 pm 10 62 64 6:30 pm 9 64 6:55 pm 9 67 66 7:15 pm 8 68 7:40 pm 9 68 68 8:15 pm 8 70 8:45 pm 10 69 69 9:10 pm 9 68 9:45 pm 9 72 72 The ED staff takes another lactate draw at 7:05 pm. The results from that draw arrive at 7:57 pm and are 2.3. Based on this information, did the ED staff meet the EGDT goals outlined in the Sepsis Algorithm? Which of these were met? • Antibiotics given at the right time? • Sepsis catheter inserted at the right time? • CVP, MAP, ScvO2 targets? • Decreased repeat lactate? Jose slowly improves over the next 2 days while in the ICU. He remains on IV antibiotics and is transferred to the Medical Surgical unit until he is discharged home 2 days later.

Answer 1

Jose has 2 SIRS criteria- hypotension, fever indicating an underlying infection sourcing from the cut foot.

In this condition he should be observed further and

1. his vital signs should be recrdere at 30 min interval.

2. Serum lactate , Total count for presence of leucocytosis should be checked to confirm the presence of infection

3. Blood should be sent for culture and sensitivity test

4. IV antibiotics should be started along with fluid supplement to conterract hypotension and tachycardia

5. Sepsis catheter should be placed to measure mean arterial pressure to maintain normotensive status.