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Morbidity Rounds

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

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Morbidity Rounds

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  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

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