**Sepsis Case Study Review**
**Scenario:**
At 12:00 noon, Jose Guerrero, a 17-year-old high school student on the soccer team, arrives at the Emergency Department (ED) a few days after cutting his foot at practice. The area on his foot around the wound has progressively gotten red, tender, hot to the touch, and has some drainage. Today, it caused pain when walking, and he was feeling weak and had a temperature. His only medical history is a mild case of asthma, for which he occasionally uses an inhaler.
The ED Technician takes Jose’s vital signs:
- Heart Rate (HR): 98
- Respiratory Rate (RR): 24
- Temperature (T): 38.2° C
- Systolic Blood Pressure (SBP): 100 (normal for Jose = 125 – 135)
- Level of Consciousness: Alert & oriented to time, place, and person
- Weight: 90 kg
**Questions:**
1. Does Jose have 2 or more Systemic Inflammatory Response Syndrome (SIRS) criteria?
2. If yes, what criteria?
3. Is there an actual or potential infection?
4. If so, what is the source?
5. What should happen next?
**Interventions:**
- Jose is placed into a bed at 12:30 pm.
- The nurse starts an intravenous (IV) line for potential fluids or IV medications.
- The doctor orders the following labs: Lactate, Blood Culture, and Complete Blood Count (CBC). The phlebotomist draws the labs at 12:55 pm.
- The doctor orders 1 Liter (L) of intravenous fluid [normal saline (NS)], and the nurse administers the fluid starting at 1:20 pm. At this time, SBP = 88, and HR = 102.
Meanwhile, Jose begins to shiver. Some lab results return at 1:40 pm:
- Lactate: 4.2
- CBC: White Blood Cell (WBC) count = 15 thousand; Hematocrit (Hct) = 42
- The blood culture is pending.
The ED technician takes Jose’s vital signs (VS) again at 1:45 pm after the liter of fluid is given:
- SBP = 80
- HR = 114
- RR = 28
- T = 39° C
- Jose looks very pale.
**Questions:**
1. Is Jose’s condition improving?
2. What do you think needs to happen now?
**Further Interventions:**
- Because Jose’s condition is not improving, the doctor orders another liter (L) of fluid (NS) and IV antibiotics and asks the nurse to get VS again as soon as the fluid is administered.
- 1 L of fluid is given at 2:10 pm.
- The antibiotic is started at 2:20 pm and takes 30 minutes to administer.
- The doctor calls the nurse at 2:25 pm and tells her that he wants to start Early Goal Directed Therapy (EGDT) on Jose.
The start time for EGDT is 1:40 pm when the lactate result of 4.2 returned from the lab. All interventions related to his care that have time frames are based on this start time.
- The liter of fluid has been administered, and at 2:30, the nurse checks Jose’s VS again as the doctor ordered:
- SBP = 85
- HR = 105
- RR = 25
- T = 38.7° C
The sepsis catheter is inserted at 3:05 pm, and the nurse starts monitoring the measurements from the catheter, which help guide treatment for Jose. The doctor orders a chest X-ray to ensure the catheter is inserted correctly and makes arrangements to transfer Jose to the Intensive Care Unit (ICU) as soon as possible.
**Sepsis Catheter Values:**
- 3:15 pm: CVP 4, MAP 56, ScvO2 60
- 3:40 pm: CVP 5, MAP 57
- 4:10 pm: CVP 5, MAP 56, ScvO2 62
- 4:45 pm: CVP 6, MAP 59
- 5:10 pm: CVP 8, MAP 60, ScvO2 65
- 5:40 pm: CVP 8, MAP 59
- 6:00 pm: CVP 10, MAP 62, ScvO2 64
- 6:30 pm: CVP 9, MAP 64
- 6:55 pm: CVP 9, MAP 67, ScvO2 66
- 7:15 pm: CVP 8, MAP 68
- 7:40 pm: CVP 9, MAP 68, ScvO2 68
- 8:15 pm: CVP 8, MAP 70
- 8:45 pm: CVP 10, MAP 69, ScvO2 69
- 9:10 pm: CVP 9, MAP 68
- 9:45 pm: CVP 9, MAP 72, ScvO2 72
The ED staff takes another lactate draw at 7:05 pm. The results arrive at 7:57 pm, showing a lactate of 2.3.
**Questions:**
1. Based on this information, did the ED staff meet the EGDT goals outlined in the Sepsis Algorithm?
2. Which of these were met?
- Antibiotics given at the right time?
- Sepsis catheter inserted at the right time?
- CVP, MAP, ScvO2 targets?
- Decreased repeat lactate?
Jose slowly improves over the next 2 days while in the ICU. He remains on IV antibiotics and is transferred to the Medical Surgical unit until he is discharged home 2 days later.
