Septic Pneumonia

[mobey]

I will do this in a call-review style (Grand rounds) cause I am not going to be available for alot of Q&A.

O/A Female 61 y/o patient found semi fowlers in elec bed. Pt in obvious resp distress. No response to verbal. Groans/localizes deep sternal rub. Cyanotic @ lips hands/feet. RR 22 deep, laboured. Snoring/gurgling audible. Vomit dried on sheets and Pt's face. Fresh Vomit on nightgown.

Well kept house in rural adress. 20min from major hospital.

PmHx: Husband states asthma - well controlled w/Spiriva. Pt recived "Transfusion" yesterday, but does not know what. Husband sts "She has no immune system".

That is all that's offered.

HxCc: Pt went to bed w/mild SOB & chest tightness. Husband awoke this AM to find her like this.

Vitals: BP 92/50 HR 134 sinus rythm, No St changes narrow QRS. BGL 6.2 Temp 38.7C. Pupils ERL @3mm.

Meds unknown (can't find them.) Husband sts, just asthma inhaler, pain med for arthritis, and a stomach pill for indegestion.

Exam findings: Pt obeise. UnCx. Responce to pain only. A/E = coarse crackles throughout all lung fields, bases sound more like rhonchi, not much air movement down there. Other than that, no real physical exam findings.

Tx: (Simplified) I.V. attempt X3 failed. I.O. established R tibia infusing NaCl. Intubate using 250mcg Fentanyl 7.0 tube. Redose w/ Fentanyl prn.

Vitals post intubation: HR 110 reg. BP 88/- Radials palpable. RR20 (pt still breathing on own) Temp 38.8C

So..... How do we correct the BP, the choices are

Fluid

Dopamine

Epi infusion

Remember 2 key things.

There is NO IV access. Only 1 I.O. (but we do have another IO needle if you like)

See Resp A/E sounds

[Aussieaid]

Start with a fluid bolus on a pressure infusor through the IO. Repeat as tolerated. I would probably give a couple of liters of fluid (multiple repeat boluses reassessing for response) before I went for an inotrope.

If you have to start pressors and the fluid has not tanked her up enough to get an IV then I would put in a second IO for the pressor.

Insert an NG tube if you have it.

Start cooling measures.

If her respiratory status starts to deteriorate with the fluids add PEEP.

Just for starters.

[HellsBells]

An interesting dilemma, clearly this women is dehydrated. I'd say that even with the pneumonia, she needs some fluid. The good thing about the IO is that the fluid needs to be pressure infused and make an accidental over bolus less likely.

I'd try a small bolus of NaCl @ about 250ml. Assess her after that. If the transport is 20 mins or longer dopamine would probably be indicated, if her pressure remained low. I couldn't see myself going with an Epi drip on this women, unless her condition rapidly deteriorated enroute.

[mobey]

Sorry..... I realize I did not explain Resp status very well.

Course crackles and decreased sounds in the bases. Loud crackles in the apicies. We were suctioning about every 5-8min and pulled over 200ml out of the tube during the entire call. It was vomit/mucus.

Just to throw out my idea since you cannot see the pt, I was working off one DD of ARDS secondary to aspiration, with the underlying illness being pneumonia/sepsis.

I will wait for a few more responces then I will post my ideas on fluids, Dopamine, Peep, and hopefully learn a thang or two from ya'll!

[Aussieaid]

Sorry..... I realize I did not explain Resp status very well.

Course crackles and decreased sounds in the bases. Loud crackles in the apicies. We were suctioning about every 5-8min and pulled over 200ml out of the tube during the entire call. It was vomit/mucus.

Just to throw out my idea since you cannot see the pt, I was working off one DD of ARDS secondary to aspiration, with the underlying illness being pneumonia/sepsis.

I will wait for a few more responces then I will post my ideas on fluids, Dopamine, Peep, and hopefully learn a thang or two from ya'll!

Agree with your pneumonia/sepsis possible diagnosis with aspiration on top of it. She is still dehydrated and needs the fluids but if she isn't responding well enough to just fluids she will need inotropes.

Respiratory wise sounds like she could benefit from about 10 of PEEP right off the bat and use recruitment maneuvers when possible especially after suctioning. Try to minimize suctioning but it was obviously needed a lot.

I will try to stop responding and let others give their thoughts.....

Edited February 25, 2010 by Aussieaid

[DartmouthDave]

Hello,

Thank you for a new case study.

I think pneumonia/sepsis is a solid dx. Throw in a little post intubation hypotension as well. Give a fluid bolus (1L). Odds are that should almost be in by the time you arrive at the ED. Maybe, with luck, get an IV in.

If it is pneumonia/dehydration. Fluids will sort that out as well to a certain extent.

Besides, if the ED is switched on, this lady would get a central line (CVP + meds) and an arterial line as well. Get her on a vent (AC with PEEP), do a gas, and hang some sedation. Snap a CXR. Foley. More fluids. Labs. Find out more of her history. The usual.

If it is smaller center. Grab a coffee and wait for the call for the transfer to the local university hospital... LOL

Cheers

Edited February 25, 2010 by DartmouthDave

[Kiwiology]

Fluids, maybe ceftriaxone?

Not too sure on the dopamine or adrenaline

[ccmedoc]

Fluids, maybe ceftriaxone?

Not too sure on the dopamine or adrenaline

Yeah, I would want to hold off on vasoactives until we see what PPV and fluids do.. probably go with dopamine if thats the choices we have..after the fluid challenge..

Wait on the ABX until others are sorted..no use adding to the soup at this time..

I like the CVP and A-line..mandatory in my opinion..

If only IO then look for EJ, IJ, or subclavian...I dont like double IO.

[VentMedic]

Respiratory wise sounds like she could benefit from about 10 of PEEP right off the bat and use recruitment maneuvers when possible especially after suctioning. Try to minimize suctioning but it was obviously needed a lot.

Considering the vomit around her and the rhonchi, aggressive sucitoning is probably what she needs. This is something some Paramedics seem to be rather shy about doing and will often bring the patient in with scrambled eggs buried in the airways from using high level of PEEP or CPAP trying to force the O2 through the food and vomit. A 7.5 ET tube would also be nicer if she needs a bronch later to clean out airways, hopefully when more stabilized.

Ventilation that is too aggressive that might cause a drop the BP MAP will be detrimental in the front resuscitation phase especially prehospital where you may be very limited to the necessary pressors, management capabilities (see IV gtt thread) and monitoring to know if you are running too lean or over the top.

PNA will also not always need PEEP in the rescue phase and may not need it until CXR confirmation of ARDS or oxygenation is a problem. If this patient also has an asthma hx, one would have to be concerned about over distending her FRC to cause further hemodynamic compromise.

Clear the airway before and after ETI, 100% O2 if you have enough oxygen in your tank to support it and worry more about increasing your BP MAP rather than your airway MAP. Once you BP MAP improves, the SpO2 should follow. Unless you are concerned about CHF and the need for fluid distribution pressure factors or oxygenation is still a concern after BP MAP is stabilized, then PEEP might be considered as a treatment.

A central line would be a "must have" for ScvO2 monitoring as well as CVP to where the BP MAP can be ramped to increase the ScvO2. A foley catheter would be a big factor for monitoring a suspected sepsis during a fluid resuscitation since renal failure from the dehydration would be an issue.

You are also not going to be able to do an "ARDS" ventilation protocol in the field and doing just parts of it without full access to all the buffers and medicaton protocols for low volume high PEEP dump the BP and pH. If your volumes are too low when you back off on the PEEP, you will set the patient up for atelectasis which decreases the ability to oxygenate/ventilate and then re-expansion trauma later if the opening pressures are high. An iSTAT would also be nice to know where your pH is before you try to manage a ventilator for "ARDS". You may have to run THAM (preferred) or NaHCO2 but then her Na+ might be high or the metabolic condition may not warrant it as a buffering agent. THAM is more useful for the permissive hypercapnia.

Understand the whole consequence and benefit sequence for any ventilation maneuver since every knob turn affects more than just that one setting.

This is a sample sepsis protocol if you are in the ED, ICU or on an aggressive/progressive CCT team.

http://www.survivingsepsis.org/SiteCollectionDocuments/2008%20Pocket%20Guides.pdf

Edited February 25, 2010 by VentMedic

[VentMedic]

Just to throw out my idea since you cannot see the pt, I was working off one DD of ARDS secondary to aspiration, with the underlying illness being pneumonia/sepsis.

How did you come up with the diagnosis of ARDS and what protocols to you have for field management?

ARDS is often an overused and misused term like "hyperventilation" or the statement "all COPD patients are CO2 retainers". Just like CO2 retainers, ARDS is a diagnosis that is not made very often. Managing a badass PNA can be difficult but it usually responds fairly quickly to treatment once antibiotics are initiated and doesn't always require much out of the ordinary for ventilation/oxygenation stategy once on a higher level ventilator that is not considered an "ATV". ARDS on the hand wants you to try everything you've got including ECMO at times. It can make the best ICU technology and practitioners work hard for their money with even the priciest ventilators groaning. The best we can do sometimes is supportive care with pressors, maybe corticosteroids, maybe Nitric Oxide, maybe serious diuretics or not and maybe dialysis of various types. An elderly patient with septsis PNA, ARDS patient with a pre-existing "no immune" system will have a very high incidence of death. An elderly septic patient with PNA and even a compromised immune system has a much better chance of survival although not great.

We will not initiate an ARDS protocol until we have radiographic evidence and then the ABG and metabolic panel will dictate which direction. Too much damage which is difficult to reverse can be done by just doing a few bits and pieces of a protocol by buzz words such as "recruitment maneuvers" or "PEEP 'em" or "low tidal volumes" if you do not have an adequate way to monitor pressures (hemodynamic and airway such as plateau pressure) and CVP.

Edited February 25, 2010 by VentMedic