Morbidity Rounds

1. Phil Ukrainetz Thursday, May 7, 2009 Morbidity Rounds

2. Objective • Are we adequately identifying septic patients in the ED? • Are we optimally managing septic patients in the ED? • How can we better manage the septic patient in the ED? • What are our next steps if any?

3. “Straight forward patient” • Hx: 76 F, sent from Cardiac Function Clinic, precarious CHF, new bilateral leg cellulitis with heel ulcers • PMHx: Aortic Valve Replacement, CHF, bilateral leg DVT’s, DDR pacemaker, RA, hypothyroid, Afib • Meds: ASA, Amiodarone, Candesartan, Lasix, Imdur, Nitro patch, Losec, Coumadin, K-Dur, Metoprolol, Prednisone, Adalimumab • Jehovah Witness – No blood products

4. And by the way… • BP 80/50 (normal as per pt SBP 90), P 78, T 37.1, Sat 94% on 3L NP • Already juicy and Cr rising as per function clinic – so please avoid saline infusions • Over next 2 hrs – SBP’s as low as 58/38 • Positive urine

5. Patient c/o: • Little “dizzy” • Swollen warm legs • No chest pain, no SOB on 3L NP – 92% • NAD

6. EP Mngmt: • Foley • Antibiotics • 250 NS boluses • Dopamine after 750 NS • Central line and then norepi • MTU/ICU/CCU consults

7. Patient outcome – did fine admit to CCU • Mentated throughout 20 hr stay – vague, nonclinically helpful complaints • Vitals of approx SBP 80/50 and Sats of 92% maintained throughout • ICU 5 hrs to assess – gave fluid/norepi/?ccu • CCU 5 hrs to assess- chf/minor infection - admit

8. Non-Fatal Harm Morbidity Case • Patient was felt by CCU to be more CHF then sepsis • Worried about excessive fluids given • Couldn’t get off pressor – never changed urine output or oxygenation with mngmt • Admitted

9. Long and short of it • Pt given 3L fluids/20 hrs but never had incr O2 needs • Patient did well • Most of us would manage similarly • Lets learn from this difficult case

10. Sepsis Priorities • Identify sepsis early • Early antibiotics • Early “liberal” fluids • Monitor frequently, accurately and “fly ahead of the plane”

11. Sepsis Management • EGDT – Emmanuel Rivers 2001 • U/S?? • Arterial Line Tracing Interpretation?? • Early Sepsis Hotline??

12. EGDT – Hard to Deny • “Golden hours” means ED must be involved • Who is best suited to do CVP placement monitoring? Detroit Model?? • Will it aid and abet longer ED stays? • What if it were your mom?

13. Ultrasound CVP Equivalent? • Looks promising – train our own • Non-invasive – don’t add to nurse burden • Longer ED stays? • Do we see enough to be true experts?

14. Arterial Line Tracing Interpretation • RTs are now putting in arterial lines • Promising but promotes long ED stays?? • Will we truly have the expertise?

15. Sepsis Hotline • We identify the patient • Stroke team like “swoop down” – glorious! • If central line/CVP needed patient is fast-tracked • No beds then CVP placed/ICU manages in ED or in ICU depending on bedspace

16. Objective • Are we adequately identifying septic patients in the ED? - yes • Are we optimally managing septic patients in the ED? – no – CVP’s should be utilized • How can we better manage the septic patient in the ED? – open dialogue with ICU • What are our next steps if any? -who else is doing ED CVPs in Alberta or Canada? what does ICU think of EGDT team? identify a champion/Jason for the cause

17. Thanks • Shawn Dowling • Jason Lord • Rob Hall • Gavin Greenfield • Tom Rich • My mom