Blood poisoning cases on rise: Ask these questions
Patients can deteriorate quickly into septic shock
A 74-year-old woman presents with slight fever, weakness and confusion. Would you suspect septicemia?
"During the first hour in the ED she was hypotensive, tachycardic, and was developing tachypnea," recalls Linda Young, RN, MSN, faculty at Montana University College of Nursing-Missoula Campus. "Her chest X-ray showed a small right lower lobe pneumonia."
During the patient's stay in the ED, her blood pressure and oxygen saturation continued to fall and her breathing continued to worsen, so she was admitted to the intensive care unit.
Patients with septicemia, a potentially deadly bacterial infection of the bloodstream also known as blood poisoning, can deteriorate quickly if the condition progresses into sepsis, says Young. "It can be unusually quick and in some cases virulent," she says. "If antibiotics and fluid resuscitation are started early, it may be helpful in halting progression into septic shock."
The number of septicemia cases increased from 666,000 cases in 1993 to more than 1 million cases in 2003, according to statistics from the Agency for Healthcare Research and Quality. In 2003, almost 75%, of all admissions to the hospital for septicemia came through the ED (290,000 cases).
"In our ED, it isn't uncommon to see septicemia one to two times a month," says Ken Lanphear, RN, an ED nurse at Borgess Medical Center in Kalamazoo, MI. "Considering all the problems with antibiotic resistant organisms that are now so prevalent, it's safe to assume that the number is already increasing, or in the near future it will be."
Sepsis can result from local dissemination of infection, via lymph or septicemia, which is widespread dissemination by way of the blood stream, explains Young. "Delay in treatment is associated with a higher mortality rate, so it should be started immediately," she says. "Development of sepsis in a person who has undergone chemotherapy and has a very low white blood cell count is an extremely serious matter and can lead to death."
Although specific risk factors should be identified, sometimes it's more of an overall "look" to the patient that is a red flag, says Lanphear. "They just look 'sick,' — pale and weak," he says. Vital signs may be an indicator, but not always, Lanphear says. The usual questions about fever and chills need to be asked," he says. "But you also need to look for a potential source that would explain why this patient doesn't feel well."
Look for a prior infective process, such as a patient reporting a cold a week or so prior, respiratory infections, skin lesions, a recent urinary tract infection, open skin wounds, recent use of an antibiotic, or use of an immunosuppressant. "Usually, there isn't one thing as so much as a combination of factors," says Lanphear.
In addition, patients don't always present with the classic signs of septicemia, says Young. "Fever, tachypnea and hypotension may not always be present at first," she says. "A person may come in feeling 'sick,' with low-grade or even subnormal temperature. Diagnosis may be difficult until lab work is drawn."
Ask the following questions, recommends Young:
- Have you had any recent infections of any kind, whether treated or not?
- Have you had any recent trauma, lacerations, or severe bruising?
- Do you have any indwelling lines?
- Are you taking any medications that may lower the immune response such as chemotherapy or radiation treatments, use of corticosteroids, or use of immunosuppressants for transplant, rheumatoid arthritis, or multiple sclerosis?
- Do you have any history of intravenous drug use? "This is becoming more prevalent, as persons will wait until the site is abscessed and are sick from it before they will go to the ED," says Young.
Elderly patients often present with nonspecific symptoms, says Young. Many times the families will bring in their elderly family members and are concerned that they have had a stroke, she says. "This is because confusion is a hallmark sign, especially in an otherwise healthy, oriented person," says Young.
Any elderly person who has been doing well who develops confusion and weakness, after stroke is ruled out, should be worked up for possible sepsis, says Young. "Much of the time a urinary tract infection is the culprit," she says. "Patients may present with low-grade fever, with weakness and confusion the only symptoms."
ED nurses should make sure that all labs are done in a timely fashion, says Lanphear. "I draw cultures when I draw other labs and hold them until I receive the order if I suspect septicemia on my initial assessment," he says. "Antibiotics should be started in the ED, before the patient goes to their assigned bed in the hospital."
As soon as the initial complete blood count comes back with an elevated white blood cell count, cultures are drawn if not already done, and a broad spectrum antibiotic usually is ordered and administered, says Lanphear.
Antibiotics should be started even before cultures are drawn, if necessary, emphasizes Young. "Broad-spectrum antibiotics are usually started until blood cultures identify specific organisms," she says. "IV fluids and antibiotics should be started in the ED for certain, especially in the person with neutropenia."
At Edward Hospital in Naperville, IL, antibiotics are started in the ED after cultures are drawn for admitted patients. "We've found that giving antibiotics in the ED vs. the floor prevents a tremendous delay," reports Sharron Chivari, RN, APN-CNS, clinical leader for the ED. "The process of admitting patients has become lengthier due to volume, and administering antibiotics in the ED can save up to a four-hour delay."
Sources
For more information on septicemia, contact:
- Sharron Chivari, RN, APN-CNS, Clinical Leader, Emergency Department, Edward Hospital, 801 S. Washington St., Naperville, IL 60540. Telephone: (630) 527-5259. Fax: (630) 527-5018. E-mail: [email protected].
- Ken Lanphear, RN, BSN, Emergency Department, Borgess Medical Center, 1521 Gull Road, Kalamazoo, MI 49048. Telephone: (269) 383-8232. E-mail: [email protected].
- Linda Young, RN, MSN, Montana State University, College of Nursing, Missoula Campus, 32 Campus Drive, No. 7416, Missoula, MT 59812-7416. Telephone: (406) 243-2623. E-mail: [email protected].
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