!Sepsis care conflicts --- agk's diary 7 December 2022 @ 07:13 UTC --- written on GPD Win 1 via PowerShell OpenSSH in back bedroom with selzer --- 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.