Sepsis Under Fire

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This is our 2nd of 2 cases exploring the care of patients with sepsis in the Emergency Department.  Similar to our "Out on a Limb" case series, the case presented is followed by a series of questions, with a discussion in the comment section facilitated by the post authors.  In approximately 1 month (November 11th), the authors of the post will conduct a combined simulation/small group session reinforcing the learning points from the posts during Grand Rounds.  Around this time, they will also curate the comments from the discussion and publish a post highlighting these learning points.  Looking forward to a great discussion!

Walking past 3 parked EMS squads in the bay and into the ED to start your single-coverage overnight shift, you have the sense its going to be a busy one.  You take sign-out on 13 patients while 4 patients sign in through the front door.  You head to see one of the patient's just dropped off by EMS.  

Lucy, a 79 yo female, sent from her skilled nursing facility for evaluation of “fever” and “altered mental status”.  EMS states she has not been herself for the past day or so.  She is moved to a room and triage vitals are a temp of 100.8, HR 106, BP 86/44, R 18, and SpO2 93%.  You order Tylenol, a liter of LR, and your usual AMS work-up and move on to the other patients needing to be seen. 

Her labs return with a WBC of 14, Lactate of 3.6, and a UA, which is nitrite positive with >100 WBCs and many bacteria.  Repeat BP is 84/40and you give a second liter of fluids, send cultures, order antibiotics, and place a call to the Hospitalist for “urosepsis” and admission to the MICU. 

Meanwhile, you stay busy with all of your other patients. 

Your nurse comes to you and lets you know that the second liter is in and repeat vital signs are a T 99.6, HR 103, BP 86/42 (MAP 56), RR16, and SpO2 94% on 2L NC…  

Please respond to a single question and note in the discussion section which question you are responding by beginning your post with Q1, Q2, etc.

Q1 - Do you think it is the responsibility of the ED physician to reassess volume status on this patient or is that the responsibility of the admitting physician at this point?  If so, what method would you choose and why?

 

Q2 - In addition to administering fluids, at what point do you consider adding on a vasopressor, which do you choose, what MAP do you target, and why?

 

Q3 - If it is required, do you think it is appropriate and safe to start a low dose vasopressor through a large bore IV peripherally to increase venous return and admit the patient to the ICU or is this “poor form”/bad medicine?

 

Q4 - What is your threshold for placing a central line and in this case do you feel that it is the responsibility of the ED physician to place that line or should it be placed by the admitting physician in this case?  How about an arterial line?