Everything RTs need to know about Sepsis

This post was originally published on January 29, 2008. It is part of the classics of the RT Cave collection. While some of this is outdated, most of it is not.

So, in our quest to become more well rounded therapists, we must now look into another common condition, a condition that is the leading cause of death in critical care units.

For starters, we need to know that is is the leading cause of death in critical care units. Of the 750,000 patients it effects every year, 250,000 will die. These statistics cannot, and are not, being ignored. Hospitals continue to work overtime to create guidelines to help caregivers both recognize and diagnose sepsis so those who have it can get the treatment they need. Likewise, efforts can be made to recognize who is at risk for developing sepsis so it can be prevented.

These statistics have gone pretty much unchanged since the early 1980s. So, even with modern knowledge and technology, hospitals have been unable to break this trend. Yet they are, as noted above, working overtime to do just that.

But there is another side of sepsis that we must look at, and this is the financial side. While the experts will tell you and me that they are working overtime to make changes that improve lives, the bottom line is usually money. And this is the case here as well. For instance, according to the MUST protocol (which is now outdated, and the link is outdated as well), cost estimates nationwide tend to scale into the $17 billion category. I'm not sure what the data is for each individual hospital, but I imagine it's a lot of money, most of which hospitals eat.

So, sepsis is expensive. Actually, we can probably go deeper than this, and say that Medicare probably forced hospitals to look at this. Now, many hospitals had already begun their own research into it, but the government seemed to force their hands, so to speak. I'm not blaming government here, I'm just saying, sepsis kills, it costs a lot of money, and efforts are ongoing to improve upon them.

So, with the hope that hospitals would create sepsis protocols (many are now well beyond a gamut of committee) of their own, the MUST protocol was created to be used as a guideline protocol. According to the protocol itself, most hospitals have not adapted it (although this has changed since the original publication of this article). but I do know that many hospitals are looking into creating their own sepsis protocols (most already have).

So, what is sepsis. It's caused by an injury. Your body is infected by a pathogen, most likely a bacteria. Your immune system recognizes this. T-cells identify them as harmful, and initiates an all out immune response. This ultimately causes cells in the infected area to leak their fluid, and this causes inflammation. This response is necessary to trap pathogens.

Inflammatory mediators are released into the blood stream and sent to the area of infection to cause inflammation. Ironically, sepsis is a pathological process caused by the widespread release of these inflammatory markers into the bloodstream, with or without an initiating infection. When these get to organs, they can injure them, even cause them to fail, resulting in death.

There's a little more to it that what I just described, although it's all a respiratory therapist needs to know.  The basic theory here is early recognition and early treatment can greatly diminish injury, and reduce the death rate from sepsis. This, in turn, can reduce healthcare costs.

(Although, ironically, the costs to individual hospitals rises considerably. This is especially true as they do many procedures automatically on anyone who meets criteria for the sepsis protocol. Medicare will usually be the only one who saves money,and that's usually all that matters.  But I digress.)

Here are the early signs of Sepsis:

A. Suspected Infection

B. Two of the following: Meeting two of these should trigger the sepsis protocol (editors note: This may have changed slightly since then).

1. Temperature greater than 100.4, <96 .8="" li="">
2. Fast heart rate, or greater than 90 beats per minute
3. Fast respiratory rate, or greater than 20 breaths per minute, or a PaCO2 that is elevated above a person's baseline (for this reason, an ABG is usually included in the sepsis protocol. Likewise, a pH that is acidotic can be an early sign of organ failure)
4. <32>High white blood cell count (greater than 12,000 or <4000>10% bands)

C. Systemic blood pressure <90>

D. Lactate greater than 4.0 or elevated LDH

E. Decreased platelets (watch for DIC)

F. Decreased PaO2, or a PaO2 below normal for that patient

G. Altered mental status not due to drugs may signify organ failure.

Here are the signs of Severe Sepsis:

A. Patient receiving antibiotics & needs Vasopressor (this is a dangerous sign).

B. Pt showing signs of organ failure in 2 + systems for <= 24 hrs.
<90>
C. Patient showing signs of Adult Respiratory Distress Syndrome, DIC, or Multi System Organ Failure.

There, that's pretty much all you need to know. These are all things you can learn from a quick assessment, which may entail talking to the patient or family members, talking with doctors and nurses, or simply by looking into the patient's chart. We at the RT Cave think it's always a good idea to look a the patient's laboratory results anyway, if time allows.

From there doctors and nurses use their magic potions to fix the patient. This may entail Activated Protein C, the only drug to show any efficacy in sepsis. It may also entail antibiotics and steroids. It may also include vasopressors to control blood pressure.

Central Venous Catheter administration may be indicated to adjust vasopressors, to monitor fluids, and to determine if a blood transfusion is indicated. These and other therapies may be prescribed just in case it might do something, which is often the issue with administering albuberol for sepsis and heart failure. So, you never know, albuterol might also be indicated for sepsis.

It's nice to know all this, although it comes secondary to whatever our job is at the time. The hardest part about treating patients is getting to the bottom of what's causing their symptoms, and you and I both know a breathing treatment with albuterol is often a top-line option. So, while you're standing there waiting for the treatment to get done, you can do some investigating for the true cause of that shortness of breath, or whatever symptoms you are treating.

Still, I have had times when the true diagnosis eludes even the best nurses and doctors, and in these cases it's nice to have a well rounded RT come into the scene and say, "Hey, maybe this is what the true cause is!"

Edited on July 5, 2016, by John Bottrell 

Everything RTs need to know about Sepsis

This post was originally published on January 29, 2008. It is part of the classics of the RT Cave collection. While some of this is outdated, most of it is not.

So, in our quest to become more well rounded therapists, we must now look into another common condition, a condition that is the leading cause of death in critical care units.

For starters, we need to know that is is the leading cause of death in critical care units. Of the 750,000 patients it effects every year, 250,000 will die. These statistics cannot, and are not, being ignored. Hospitals continue to work overtime to create guidelines to help caregivers both recognize and diagnose sepsis so those who have it can get the treatment they need. Likewise, efforts can be made to recognize who is at risk for developing sepsis so it can be prevented.

These statistics have gone pretty much unchanged since the early 1980s. So, even with modern knowledge and technology, hospitals have been unable to break this trend. Yet they are, as noted above, working overtime to do just that.

But there is another side of sepsis that we must look at, and this is the financial side. While the experts will tell you and me that they are working overtime to make changes that improve lives, the bottom line is usually money. And this is the case here as well. For instance, according to the MUST protocol (which is now outdated, and the link is outdated as well), cost estimates nationwide tend to scale into the $17 billion category. I'm not sure what the data is for each individual hospital, but I imagine it's a lot of money, most of which hospitals eat.

So, sepsis is expensive. Actually, we can probably go deeper than this, and say that Medicare probably forced hospitals to look at this. Now, many hospitals had already begun their own research into it, but the government seemed to force their hands, so to speak. I'm not blaming government here, I'm just saying, sepsis kills, it costs a lot of money, and efforts are ongoing to improve upon them.

So, with the hope that hospitals would create sepsis protocols (many are now well beyond a gamut of committee) of their own, the MUST protocol was created to be used as a guideline protocol. According to the protocol itself, most hospitals have not adapted it (although this has changed since the original publication of this article). but I do know that many hospitals are looking into creating their own sepsis protocols (most already have).

So, what is sepsis. It's caused by an injury. Your body is infected by a pathogen, most likely a bacteria. Your immune system recognizes this. T-cells identify them as harmful, and initiates an all out immune response. This ultimately causes cells in the infected area to leak their fluid, and this causes inflammation. This response is necessary to trap pathogens.

Inflammatory mediators are released into the blood stream and sent to the area of infection to cause inflammation. Ironically, sepsis is a pathological process caused by the widespread release of these inflammatory markers into the bloodstream, with or without an initiating infection. When these get to organs, they can injure them, even cause them to fail, resulting in death.

There's a little more to it that what I just described, although it's all a respiratory therapist needs to know.  The basic theory here is early recognition and early treatment can greatly diminish injury, and reduce the death rate from sepsis. This, in turn, can reduce healthcare costs.

(Although, ironically, the costs to individual hospitals rises considerably. This is especially true as they do many procedures automatically on anyone who meets criteria for the sepsis protocol. Medicare will usually be the only one who saves money,and that's usually all that matters.  But I digress.)

Here are the early signs of Sepsis:

A. Suspected Infection

B. Two of the following: Meeting two of these should trigger the sepsis protocol (editors note: This may have changed slightly since then).

1. Temperature greater than 100.4, <96 .8="" li="">
2. Fast heart rate, or greater than 90 beats per minute
3. Fast respiratory rate, or greater than 20 breaths per minute, or a PaCO2 that is elevated above a person's baseline (for this reason, an ABG is usually included in the sepsis protocol. Likewise, a pH that is acidotic can be an early sign of organ failure)
4. <32>High white blood cell count (greater than 12,000 or <4000>10% bands)

C. Systemic blood pressure <90>

D. Lactate greater than 4.0 or elevated LDH

E. Decreased platelets (watch for DIC)

F. Decreased PaO2, or a PaO2 below normal for that patient

G. Altered mental status not due to drugs may signify organ failure.

Here are the signs of Severe Sepsis:

A. Patient receiving antibiotics & needs Vasopressor (this is a dangerous sign).

B. Pt showing signs of organ failure in 2 + systems for <= 24 hrs.
<90>
C. Patient showing signs of Adult Respiratory Distress Syndrome, DIC, or Multi System Organ Failure.

There, that's pretty much all you need to know. These are all things you can learn from a quick assessment, which may entail talking to the patient or family members, talking with doctors and nurses, or simply by looking into the patient's chart. We at the RT Cave think it's always a good idea to look a the patient's laboratory results anyway, if time allows.

From there doctors and nurses use their magic potions to fix the patient. This may entail Activated Protein C, the only drug to show any efficacy in sepsis. It may also entail antibiotics and steroids. It may also include vasopressors to control blood pressure.

Central Venous Catheter administration may be indicated to adjust vasopressors, to monitor fluids, and to determine if a blood transfusion is indicated. These and other therapies may be prescribed just in case it might do something, which is often the issue with administering albuberol for sepsis and heart failure. So, you never know, albuterol might also be indicated for sepsis.

It's nice to know all this, although it comes secondary to whatever our job is at the time. The hardest part about treating patients is getting to the bottom of what's causing their symptoms, and you and I both know a breathing treatment with albuterol is often a top-line option. So, while you're standing there waiting for the treatment to get done, you can do some investigating for the true cause of that shortness of breath, or whatever symptoms you are treating.

Still, I have had times when the true diagnosis eludes even the best nurses and doctors, and in these cases it's nice to have a well rounded RT come into the scene and say, "Hey, maybe this is what the true cause is!"

Edited on July 5, 2016, by John Bottrell 

What is Disseminated Intravascular Coagulation (DIC)?

Classics of the RT Cave. This post was originally published March 18, 2008.

First off, I worked a bunch of years in the hospital setting before I had a clue what DIC was. I had observed the symptoms many times. I remember many patients, most of them on ventilators, who seemed to be seeping fluid from their pores. Yet I heeded this condition little attention, mainly because I was a newer RT who was intently focused on getting my own work done.

Then one day I remember one of our senior therapists told me in report she told the nurses to keep a particular close watch on this trauma patient because he was at high risk for DIC and ARDS. It later turned out she was right, and the patient developed both ARDS and DIC. So, it did not pass me by how this senior was correct in her prediction. I was curious to know what she knew.

So I asked her, and she said, "Do some research on DIC, and then get back to me. Do a Google search." She paused, then added, "I think that all therapists coming out of school should focus on doing their jobs and doing them well. However, there comes a time when you should take a look at the other aspects of the healthcare industry, and in this way become well rounded therapists. I say this because well rounded therapists are better team players. While nurses are busy looking in one direction, you can say, "Hey, look here!"

So, that said, here is what I learned about DIC. Here is how you can predict what patients might develop DIC.

First of all, DIC is an acronym for Disseminated Intravascular Coagulation. It is almost always a secondary disease, or a consequence of other diseases, disease conditions, or circumstances. In our patient, it was secondary to trauma.

DIC is a condition, more so than a disease. It is a process that occurs when the proteins in the bloodstream that normally cause clotting in an injured area overreact, form tiny clots all over the body. Then, clotting factors now exhausted, this causes the patient to bleed abnormally. Bleeding occurs from nearly every orifice, including skin pores, the anus, etc. It just leaks out. It's kind of gross. You better wear gloves when you touch such a person (well, you should always wear gloves, but int his case you'll definitely want to).

When you do an ABG, for example, you might hold the site for the recommended five minutes and the patient still doesn't stop bleeding. Usually, when this happens, the RN will have to wrap gauze around the puncture site and bind tape around the patients arm to act like a tourniquet. I've seen this done on many occasions.

Technically speaking, on these patients, a doctor will want to limit the number of blood draws (ABGs included), because of the complications of bleeding. Another thing for us therapists to remember is to be very careful when suctioning. Ideally (and I think this should be standard procedure anyway), the catheter should not be advanced all the way to the corina so as not to puncture it and cause it to bleed.

In severe cases, the patient will seep ooze right out of the pores on his skin. This can be quite disgusting. This is what I described above. But I've seen it quite a few times already. I will probably see it more times in the future. If you work in the critical care or emergency settings, you will see it too.

DIC can also cause sudden bruising, clotting, and, as I described, bleeding from multiple parts of the body, and can lead to severe bleeding, stroke, and lack of blood flow to arms, legs and organs. So, it's not good.

That said, how do you know who is at risk. Here is a list of who to watch.

1. Infection in blood (Sepsis)
2. Severe tissue injury, as in burns, trauma (particularly trauma to the head and brain)
3. Recent surgery or anesthesia
4. Reaction to transfusions
5. Labor and delivery problems
6. Liver disease

Trauma patients not only are at risk for getting DIC, but also ARDS and Sepsis. And sepsis in itself is primary cause of DIC in the hospital setting. And, if that wasn't enough, DIC may lead to acute renal failure and, ultimately, to multiple organ failure -- including the lungs.

It was about this time I started to understand the point my senior therapist was trying to make about being a well rounded therapist. This is why it's a good idea to go through and review the charts of all your patients, particularly the laboratory results. Yes, we can learn a lot from lab results. The following are some lab results that might show DIC:

1. PTT: Again, I'm no expert here. However, according to Medline Plus, this is a test to determine how long it takes for the blood to clot. If a patient is on a blood thinner like Coumadin, the PTT may be therapeutically high. A high PTT is anything greater than 33, and greater than 60 is considered critical, and may be indicative of DIC.
2. PT: Same as PTT, except for the high value is greater than 12.7 and greater than 40 is critical
3. D-Dimer: Greater than 500 may be indicative of acute bleed, but can also indicative of pulmonary embolism and DVT.
4. Platelets: A normal platelet count is 150,000 to 400,000. This is what is needed in order for normal clotting to occur. A low value will be 150,000, meaning abnormal bleeding may occur, and below 50,000 can mean a simple bump can cause bleeding. <80>
5. INR: Greater than 1.2 is considered high, but greater than 6 is critical. This is indicative of DIC or acute bleed.

Now, keep in mind these critical values will vary from hospital to hospital, but at least this gives you an idea of what critical is, and what the labs of a patient in DIC might look like.

Also, you should know that there is a lot more involved in the DIC process than what I describe here, but this is pretty much all that a well rounded respiratory therapist needs to know.  Now, see if you can put this wisdom to good use and impress someone the next time you find one of these patients.

Edited on July 5, 2016, by John Bottrell

Accidental Extubation and spontaneous ARDS

I was having a wonderful conversation with one of my favorite patients when my beeper sounded: "We need you stat in ER."

"Shit!" I said ruefully, "You're breathing okay right now, right?" She looked fine, but I had to be sure.

"Yes, you go right ahead." She was such a great patient and, unlike some patients, I trusted her judgement.

I stopped the treatment and rushed to ER. I busted through the double doors, a strong horrible stench hit me, and Bee the nurse shouted from across the room:

"They need you in Cat Scan!"

"Cat Scan?"

"Yes. Cat Scan. A lady is coding."

"Oh, shit!" Not knowing for sure an airway box was in CT, I grabbed one and busted back through the double doors and started walking fast. Ahead, a skinny man in surgery scrubs burst from the CT room.

"Oh, RT, get me a size 8," he shouts. "Now!" I realize now it's Bob the acerbic anesthesiologist.

"Okay, just a minute."

"No, I need it now!"

"Hugh!" I busted open the box and started shuffling through it looking for the tube while still walking. This is ridiculous, I thought. "You'll have to wait till I get in there."

"No we need it now."

"What's going on here," I said as I enter the room with Dr. Bob breathing down my neck. He was standing beside me now like a little kid, panting for his ETT. I handed it to him.

"We extubated her," one of the surgery nurses said. She was bagging. What in the hell? I thought. How could somebody be extubated in CT when I didn't even know there was an intubated patient. Hello, I'm the lone RT working, I'm supposed to know this kind of stuff. And there's no code, as Bee told me.

Bob crouches by the head of the patient on the CT table, shouts for the nurse to stop bagging, and easily slides the tube in.

I secure the ETT with an ETT holder. "So, what happened again."

"We brought her from surgery. She started wriggling, seizing, and, well, you know."

Then it clicked. I thought this was an ER patient. I thought this was a patient they were working on and didn't tell me about for some inexplicable reason. Why an intubated patient from surgery would need a CT I had no clue. I did not inquire. Then I noticed the old gooey ETT lying askew on the side of the patients head: it had tape on it. Aha.

"So, Bob, maybe next time you'll put one of these in before you transport your patient," I joked, pointing at the ETT holder. To my amazement he smiled.

The excitement was over, and I was starving. I had lunch on my mind. The beeper went off: "Need you in ER."

"Shit!"

I stumbled through the ER doors, grabbed my sheet, grabbed my EKG machine, and headed for my patient. On the way, however, I was overcome again my a horrible stench. I looked into a room and saw a thin, scraggly bearded man sitting up on his bed. He literally looked like something that was scraped off the street. Turned out he was.

I pray to God I don't have to do an EKG on that guy, I thought, and proceeded to my patient. I did a quick EKG and, back at the nurses station, hand it to the doctor. He reads it. "Hey, Rick, could you do an EKG in room four?" He said, kindly, and with a smile.

"Oh sure." I grab the machine and start for room four when it hits me: it's that guy. Why is it every time there's a gross patient they always seem to find a way to get RT involved. I suppose if he's homeless he could be malnourished. His electrolytes could be off, which equals indication for EKG.

"Could you tell me about this patient?" I ask the nurse out of range of the patient.

"Well, we just plucked maggots off him," she whispers.

"Maggots?"

"Yeah, he had poor circulation in his legs. About two or three months ago he went to a doctor and the doctor had his feet wrapped. When he came in, he had garbage bags wrapped over the bandages," she made as though she were going to puke, "It was awful."

"I'd hate to have your job."

"So did I." She smiled.

"So now you want me to get involved." I took a deep breath, and proceeded to do the EKG.

An hour later I was upstairs because Dr. Young ordered a STAT BATH. I reluctantly volunteered. Mickey, a former EMT of 30 plus years and who was now an ER assistant, also volunteered. He had a good idea that we place a sheet in the tub so we could use it to get him out and into the wheel chair. It turned out to be a great idea. It was a horrible job, but a great idea.

I digress though. I was off the next week. When I came back, almost immediately after I received report, I was called stat to room 208.

"What's going on?" The patient was in low fowlers, obtunded and appeared to be laboring. He was gray. I checked his sat, it wouldn't pick up. Of course this was before the rapid response team was in effect. "Does he have a pulse? Have you checked a pulse."

"Yes," the nurse assured me. "His pulse in 90 and his BP is 120/80."

"Does he always look this way, obtunded I mean."

"No. He was fine my last check." Mental note: acute mental change.

"Okay, well that's a good start. But he sure don't look good. Is he a DNR? Did you call the doctor?"

"He's not a DNR. We did call the doctor." I look at the patient again. Now I realize this was the guy with the maggots. I thought about asking if they checked his sugar, but second guessed myself. This would later come back to haunt me.

The patient looked like shit, so we all conclusively decided that I should place the patient on an NRB and do an EKG and a blood gas. What's the old saying, better to do now and apologize later. The patient bled so bad I had blood dripping on the floor. After holding it 5 minutes I gave the job to the nursing supervisor.

The ABG said: ph 6.98, PO2 45 (before NRB), CO2 35 and ? bicarb. The machine did not pick up the bacard, probably because it was so low. My initial conclusion, although I'm not the doctor I usually try to make an educated guess, was this man was in respiratory failure secondary to sepsis. Because he was leaking so bad I'm certain he's in DIC.

By now Dr. Young, our surgeon, was in the room. He's one of those quiet little guys with poor bedside manners. "That's a venous blood."

"No, it came out pretty good."

"It's venous blood. Look at that pH. It's venous blood."

"I'm quite sure it's not venous blood."

"It's venous blood." He looks at the patient. "Why did you call me? He's fine."

"He's not fine. He's labored," the RN says.

"He's fine. Why do you call me for this."

Now the Internist on call enters the room. He looks at the ABGs, "Those are venous."

No they are not, I think but do not say. "Look, even if it is venous blood the pH will still be similar to arterial blood. Look, this guy is in failure."

"He's fine." Both Doctors leave the room. Fine, the only reason they don't want to come in here is because this guy is homeless and he's gross, and they don't want to be bothered.

I never leave the room. The nursing supervisor and I discuss the patient, and we both agree something is obviously wrong. And, five minutes later, the patient codes. Both doctors come back into the room. And, guess who comes in to intubate? Dr. Bob.

He slides the ETT in easily and, before I have a chance to secure the ETT, the head nurse said, "We need to boost him down the bed: one, two, three...

"WAIT!" I shout as they scoot the patient away from me, as my hands and the ETT stay in the same place. The patient is now extubated.

"What the fuck!" Dr. Bob yells. He reintubates the patient in a swift moment. He holds the ETT while I secure it with an ETT holder. "Next time you intubate a patient, be sure to secure the ETT with one of these before you move him," he said, pointing at ETT holder.

He smiles and exits the room. He got me back.

I redrew the ABG. By the time I got back the patient was dead.

The second pH was 7.00. I was right. And, after reading the autopsy a few days later, I learned I was also right about the sepsis. The autopsy also identified ARDS. Oh, and his glucose was 18 which, I learned, if a patient is not on insulen means liver failure.

This was one of those cases I couldn't get out of my mind. What did we do wrong? I wished I had asked about the sugar check. I thought about labs. I checked, and the patient didn't have any labs ordered the day before, nor sugar checks, both of which would have set off alarms.

A week later I ran into Dr. Peterson, an Internist who came into the cave to read EKGs. After I explained the situation to him he said:

"Patients do not go into spontaneous DIC or ARDS. It simply does not happen. And this would never have happened with one of my patients. You don't simply send someone to the floor and not order any tests, regardless of who the patient is."

I never did get into trouble for drawing ABGs without an order. Perhaps because those two doctors knew I was right.