!Sepsis care conflicts
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agk's diary
7 December 2022 @ 07:13 UTC
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written on GPD Win 1 via PowerShell OpenSSH
in back bedroom with selzer
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Hi my name's Anna. Today I'll talk about the con-
flict between curative and palliative care when
sepsis resists treatment.
Hospital
--------
These observations are from the University of **
***** Hospital, a major regional academic medical
center on the border between US South & Midwest.
The hospital's nationally respected for medical &
nursing care. It has 17 operating suites, 100 ICU
beds, the only Level I Trauma Center for 130km one
way & 280km another. >21,000 people get inpatient
care there every year, many transferred from other
hospitals.
Unit
----
The hospital's 9th floor is 4 pulmonary/internal
medicine units. 28 beds are on 2 ICUs. These obser-
vations are from the 38 progressive beds.
Many progressive care patients are monitored with
continuous telemetry. Each progressive nurse cares
for 3-4 patients. Each nurse aide cares for 8-10.
Sepsis
-------
Sepsis's a profound systemic response to infection.
It develops in 1 in 3 patients in my country whose
hospitalization ends in death.
Over the last 50 years sepsis continually increased
in frequency and lethality in my country, probably
due to our aging population, increased immunosuppr-
ession, and multidrug-resistant infections. Better
detection before death also increased known cases
and fatalities.
Some characteristics of sepsis: systemic inflamma-
tion, activation of fibrinolytic and coagulation
systems, disruption of tissue oxygenation by vaso-
dilatory shock, coagulopathy, & lesions of the
microvasculature.
Sepsis directly injures mitochondria, activates
multiple cell death pathways, and dilates blood
vessels, causing severe hypotension. These mechan-
isms decrease functional capillaries, cause inter-
stitial & pulmonary edema, acute kidney failure,
encephalopathy, and failure of other organs.
Signs & tx
----------
The hospital system's Advanced Nursing Protocol for
Adult Sepsis is for emergency dept patients not yet
evaluated by a provider. Use of the protocol's ind-
icated by sepsis signs. A mnemonic---TIME:
- Temperature (hypothermia or fever >38C);
- Infection (a source of infection, particularly in
skin, urinary tract, lungs, or bowels/viscera);
- Mental decline (encephalopathy);
- Extreme illness (signs of hypotension: tachy-
cardia, tachypnea, decreased capillary refill,
mottling, "I feel like I might die").
Emergency assessment of patients with sepsis signs:
- get vital signs & finger-stick blood glucose,
- monitor intake & output,
- put on cardiac & pulse-oximeter telemetry,
- collect blood & urine cultures to identify organ-
isms to be targeted by antibiotic therapy,
- watch complete blood count & coagulation labs,
C-reactive protein or procalcitonin for inflamm-
ation, lactate, blood gases.
Nursing interventions in emergency setting:
- get IV access,
- run a liter of Lactated Ringer's as a bolus,
- start antibiotics based on blood culture results,
- take other steps to prevent & manage tissue
ischemia & organ failure.
Complications
-------------
A case shows the progression of treatment-resistant
sepsis as a patient moved through the hospital: Mrs
X, 85 years old with do not resuscitate/do not in-
tubate orders. She was admitted from a long-term
care facility for encephalopathy w/ altered mental
status, urinary catheter-acquired urinary tract
infection, pneumonia, and sepsis.
In the ICU she was intubated to support ventilation
& oxygenation; received pressors to constrict blown
blood vessels (to support tissue perfusion). After
she was extubated, a month after admission, she was
transferred to the progressive care unit.
Mrs X's medical history included multiple chronic
illnesses: right ventricular & left atrial heart
failure, acute decompensated chronic kidney dis-
ease, acute decompensated cirrhosis, Parkinson's.
She'd been severely ill in various hospitals for a
year.
On the progressive unit nursing staff closely
monitored lactic acid & temperatures, drew blood to
culture, gave glucagon. She was burrito-wrapped in
a mylar warming blanket & hospital blankets. Her
illness acuity rose & fell every 3-5 days, never
trending decisively toward recovery.
She had persistent hypothermia with temps generally
below 35C. Her most recent was 34.4C after a 2-day
decline. Her lactate was 6.7 mmol/L, sharply incr-
eased overnight by lactic acidosis caused by
anerobic metabolism by ischemic tissue. Nucleation
of her red blood cells indicated profound stress
and hypoxia.
Labs showed severe coagulopathy. Her prothrombin
time was >6 seconds, INR 4.9. Her platelets, hemo-
globin, hematocrit, red & white blood cell count
were low, trended down. Thin skin was covered with
scattered bruises. Blood oozed through unwounded
skin to be found on her sheets at turns and baths.
She had atrial fibrillation with a rhythm in the
90s & premature ventricular contractions due to a
septal infarct. She tolerated only a few pureed
spoonfuls at meals. Each bite caused tachycardia.
Secondary to heart failure & coagulopathy, she had
pleural effusions. She was restless, nonverbal, too
weak to draw liquids up a straw to drink.
Mrs X's local daughter understood the severity and
treatment-resistence of her mom's condition. She
wanted heroic care to end, palliative to plan for
Mrs X's comfort. Mrs X's overseas daughter hoped a
cure would bring her back. This family discord
compelled nursing to pursue incoherent care. With
no palliative plan, we alternated aggressive treat-
ment (as if she'd recover) with basic comfort care
(as if she'd soon die).
Palliative care
---------------
Mrs X's sepsis was marked by risks for fatal ill-
ness. She deteriorated despite optimal care. Her
condition was complicated by disseminated intra-
vascular coagulation (DIC), which significantly
increases risk of sepsis mortality. DIC involves
extensive clotting throughout the microvasculature,
which obstructs oxygen extraction and perfusion
while consuming platelets and clotting factors.
She was bedbound with a stubbornly lowered level of
consciousness. One daughter asked to stop treatment
and focus on comfort.
Palliative care was consulted. Their goal is to
improve quality of life for seriously ill patients
and families. They work alongside primary provid-
ers focused on curative treatment, or take over
primary care.
Conclusion
----------
Sepsis was a common presenting condition for prog-
ressive patients on the 9th floor. It presents as
decreased alveolar ventilation and decreased oxygen
extraction at the tissues, hypotension, and fever
or hypothermia.
Management is directed at effective antibiotic
therapy, preventing tissue ischemia & organ failure
and managing the effects of tissue ischemia & organ
failure. In serious and prolonged illness, comfort
should be considered.
At the end of life, comfort of the patient & family
should guide all care. To make this transition the
patient or surrogates should understand the condit-
ion & prognosis, and the goals of palliative and
hospice care.
References
----------
Thank you to the College of Nursing and my clinical
site on the 9th floor of the hospital. Most of my
references came from UpToDate. The advanced nursing
protocol I cited came from the hospital's CareWeb.
