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Clinical Case 087: Sepsis Kimberley-style (for ACEM)

This is not just another Clinical Case that I am sharing with you all today.  This case is going to form the basis of the Broome Docs team presentation at the ACEM Winter Symposium here in Broome on the 15th June 2013.

So this is your chance to get involved – and share your opinions with the audience at ACEM in a few weeks.  So have a read of this case and contemplate the decision points I have selected.  Let me know how you would manage this case and if you have any new (or old) evidence to support our decisions.  One of the beauties of Social Media in Medical Education is that we can “crowdsource” expertise, opinion and know-how.  So here we go – let us know how you would proceed.  Here is the case…

Emily is a 42 yo. woman from Billiluna (Mindi Bungu) in the East Kimberley not far from Wolfe Creek crater. She has been living in Broome for a few months.  She was sent in by the clinic for a Surgical review of her diabetic foot ulcers a while back – but has been ‘living rough’ in town ever since.  Currently residing in a 2 bedroom unit with 10 other adults and their children.

Emily has been seen in ED a few times recently with minor injuries resulting from assaults.  Her foot ulcers have never really healed and she has intermittently been seen in the dressing clinic for ongoing dressings.  Emily doesn’t wear (or own) shoes.

In terms of PMHx, there are a lot of unknowns.  We know that Emily has been diabetic for at least 10 years and has had significant hypertension and proteinuria for at least 5 years.  She was seen by the visiting Ophthalmology team in Billiluna last year – they diagnosed moderate non-prolifertive retinopathy.  There is not much more information – she has moved around a lot with her family so there is no “complete” medical record.

Emily’s current medications according to the Billiluna clinic’s fax – usually supplied a Webster pack with the following meds.  Last dispensed 3 months ago.

metformin 2000 mg slow-release daily, ramipril 10 mg daily, amlodipine 10 mg daily, irbesartan 150 mg daily, aspirin 100 mg. She has an Implanon device in situ.

OK that is all the background you have when the Ambos roll in the door with Emily on the trolley.  One of her housemates called them as Emily was complaining of being “short winded” with some fevers.

On arrival her obs are:- pulse 120 sinus tachy, BP 100/50, RR is 25/min SpO2 95% on 6 l via HM, her temp is 39.1 (102 F for the Americans),  a finger prick BSL = 24mmol/l ( 432 mg/dL in the USof A)

Emily is shivering and looks uncomfortable.  She is sitting forward and coughing intermittently.  She is alert, looks anxious / scared.  There is an unpleasant smell emanating from the dressing on her left foot.

Q1:  OK here is my first point for contemplation.  What further history do you want to know in the next 10 minutes?  

As you are getting in a few lines and taking a history the nurse has run a VBG on the ED POC machine.  Here are the numbers:

pH = 7.15

PO2 = 31

pCO2= 29

BE = -7

HCO3 = 15

Lactate = 5.1

Q2:  Contemplation point #2:  What is the significance of a lactate = 5.1 mmol in this context?

OK, she’s sick.  Looks infected and has a high lactate.  Her BP is lowish – but recall this is a woman who is prescribed 3 different antihypertensives to control her BP.

Lets start a bit of fluid resuscitation – I think we can all agree she is going to need it!  We have a few big IVCs  and a radial art. line in place.  There are only 2 questions really – but they are not without their controversies.

Q3a:  Which fluid will you use initially for your resuscitation?

    3b:  How much will you give empirically?

    3c:  How will you decide that you have given enough?

We need to localise the source of her sepsis.  Her foot looks nasty, purulent exudate and you suspect a collection adjacent to that ulcer.  Now – where else could it be coming from?

Physical examination reveals:  bilateral chest crackles, an aortic flow murmur (very tachy though), no obvious skin sores elsewhere, urinalysis shows 4+ protein but no leuks or nitrites.  She denies any headache currently.

Q4: Which empirical investigations or studies will you order to find the potential sources of infection?  What time frame do you want to achieve this within?

Now I would like to fast forward this case about 12 hours.  Emily has been resuscitated, worked up and admitted to the HDU [Staffed by a single RN and variably experienced Docs.  Despite a trial of peripheral IV phenylepherine her BP and urine output have been lagging overnight, so the night MO inserted a CVC into her (R)IJ and commenced inotropes.

Q5:  What is your first line agent for sepsis?  Tougher question – why?

After a smidge of X [insert your answer to Q5] her numbers look a bit better, but….

The CXR from this morning reveals a right lower lobe pneumonia and it looks like there is a bit of patchy changes around the left heart border as well – they were not there last PM

She is getting more short of breathe, her sats are cruising in the low 90s on a high flow face mask.  RR and work of breathing certainly worse overnight.  She remains alert but looks tired.  The arterial gases have showed a slow drift into deepening acidosis – both lactic / metabolic, but now with a creeping pCO2 – up to 46 mmHg.  She is going to need some help.  Her family are a bedside – so you decide to have a chat about the plan for the coming hours.

She is looking like she might need an ICU at some point.  And if you are in Broome – this means a flight and a long one – 2000 km to our “local ICU”.  Being a patient-friendly Doc, you mention this to her.  You think she should be transferred as it is possible that she will get worse.  You start to explain how this would mean being placed on a ventilator and an induced coma for days – possibly weeks…..

Emily stops you right there!  She refuses to be transferred out of Broome. Full stop.  When you ask why?  She has recently lost a number of family members to illness – and they all left Broome on the plane and never came back.  For Emily this is an unacceptable outcome.  Dying “out of the Kimberley” out of her country is unacceptable.  She wants to stay, she wants you to do all you can to keep her here.

Right.  Tough one.  The Nurse Manager is calling you into her office – there are 2 x “Trop negative Chest pains” awaiting admission to HDU and the surgeons are mid-way through a hemicolectomy on an 80 year old chap.  She cannot possibly staff the HDU when all this arrives.  Her position is: “Send her out ASAP”  We are out of resources.

As you leave the Manager’s office you start wondering….   Emily is doing OK from a haemodynamic POV – she is requiring only the tiniest dose of inotrope.  Her oxygenation and ventilation are the main issues right now.  Sure – intubation would help that – but she has expressed a strong desire to avoid that option.  And we know that intubation carries its own set of risks down stream.   You know that there is NO way the retrieval team would take her ‘unintubated’ – just too risky.  So what about a trial of NIV?

Q6:  Would you trial a period of non-invasive ventilation in this case?  If so, what end-points are you looking to achieve ?  Or how do you decide if it is failing?

OK, lets fast-forward again 3 hours.  Emily has tolerated the NIV well.  Her respiratory rate has fallen and her gases are improving a bit – she is not hypoxic and her CO2 has come down to normal range.  Just as you are suggesting a break from the mask the phone rings….

The RFDS are inbound with another sick patient who will likely need HDU level care.  The Nurse Manager is not looking pleased!  The RFDS say they have enough hours to scoop Emily to Perth if you think she needs… BUT…. she cannot go without a tube and all the works.  But you have to decide in the next 30 minutes.

So here we are… decision time.  Emily is looking better, sure she might get worse, but right now she is “Broome-worthy”.  There are a heap of “non-Emily” reasons to transfer her.  So how do you balance these?

Q7:  Final decision – does she stay or does she go?  

Your call (remember you are in Broome), you are going to have deal with the consequences and once this bird has flown, it won’t be coming back anytime soon!

Comments

  1. 2. classically severe sepsis (lactate>4) but I don’t know about the validation for VBGs, especially from peripheral jabs, as opposed to ABGs or from big veins without tourniquet.
    3. I like Hartmann’s.
    4. CXR, UA, and a whole body CT.
    5. A knife. Why does she still have a left foot?
    7. Do you have surgeons locally?

    • I can think of a one old fellow with diabetes who finally had a below knee amputation after 2 years of debridements, dressings, antibiotics and at least one episode of sepsis. It took that long to convince him. Six months down the track having almost mastered his new leg he finally admitted he should have had the operation much earlier.

      Emily has still go her presumed focus of infection because no one has been able to convince of her of the merits of removing it. Without her and possibly her family’s consent it would be an assault to remove despite how right it might seem to in our mind.

  2. Minh Le Cong says

    welcome to rural medicine Oz style!

    Didint i send you my paper on NIPPV in aeromedical retrieval?

    This patient sounds like a great candidate! Why is there an insistence for her to be intubated for aeromedical retrieval? Because of the concern of altitude related hypoxia? Deterioration in flight?
    I dont think that is an issue given what is laid out here. It can be done and there is no good reason why it should not be. In fact if it is offered to her for her retrieval it may well convince her to agree to going to Perth!

    I just did a NIPPV aeromedical retrieval recently out of remote community. Art line in and gases not dissimilar to what you have stated here. Patient did fine. Initially refused to leave community but accepted NIPPV, felt better and then agreed.
    You need to suit the patient not dogma.

    But I dont understand why you insist on flying the patient to Perth if she refuses to go? if she is competent to give consent then it would be assault to intubate her and fly her to Perth, even if that might mean saving her life. Dying off country is a big deal for many Indigenous Australians. medical community in Australia need to understand that
    as to bed management issues, well no magical solutions here. Fly someone else out! Can a closer regional hospital help share the load and take some of the extra patients ?

    you will cope at Broome. what if due to weather no flights were possible for next 24 hrs? you would have to cope anyway!

    And just because you can, does not mean you have to. Patients have a right to refuse life saving treatment. People die, thats life.

    • Hi Minh.
      Good points. Though – I am not insisting on flying her, just saying it might be a good option to do earlier rather than wait for her to deteriorate if her disease is progressing. We need to be realistic about our capacity to deal with this type of scenario over 1, 2 … days.

      I read your paper. And I think we agree that the trend prior to flying is important. IF she were getting worse despite NIPPV then your audit showed a high rate of “cardio respiratory arrest” in transit – which seems like a bad thing.
      So this is a scenario where the ground team and the retrieval team need to communicate well and ensure that she is in fact improving on NIV. If not then I think it is cavalier to put her in a plane without a tube / stabilised dynamics etc.

      The crux of the argument is this: should we intubate purely for transfer if she is plateau-ing, or is it better to decline transfer and watch / wait if that is her preference? And is this truly and informed choice on her part – or one based on a single bad experience / exrapolated beliefs? Hard to get consent from a scared sick patient

      Is it better to have a dead patient or a cranky live one that will make a complaint.
      What trumps what – patient safety or autonomy?
      No clear answer or preference from my end – just asking the questions…. C

  3. I am going to jump to the end point

    She stays. Parient autonomy and all that. She has made her decision clear, has testamentary capacity.

    So I’d have to make some hard decisions on the others. But she stays in Broome…

    • Gareth Taverner says

      We treat the patient first, not the blood results and not the logistical demands from the nurse manager, (although I do not envy her role).

      If Emily is of sound mind, we respect her wishes.

      I agree that she may remain in country, with one leg or two.

  4. http://www.kimberleycalling.net/Listen-Call-Law-index.php

    from your neck of the woods ,Casey!

    Read the paragraphs by Deborah Bird Rose and Sally Morgan.

    What suits the patient, not what suits us

  5. this is another good article describing death and dying issues for Indigenous Australians.
    Replace the word “palliative ” with “intensive” in the article title.
    https://www.mja.com.au/journal/2003/179/6/issues-palliative-care-indigenous-communities

  6. Emily stops you right there! ……… Working in Nhulunbuy this is an issue I have faced. Sometimes it is a struggle to get someone in from a peripheral community. This is were we have to temper our physiology, pharmacolology and therapeutics with culture. It is not a problem unique to Aboriginal culture. I know of a woman with lupus who chose not to have a blood transfusion which hastened her demise. For her it was her religious belief. I recently cared for a man with advanced squamous cancer of his neck who had decided he had had enough radiotherapy, chemotherapy and surgery. He died peacefully with family and friends on Island.

    For Emily you can enlist the aid of significant family members to try to explain your motives. Is her English sufficient to explain your concerns. I know my Yolngu never reached that level of sophistication.

    Of course you are not going to guarantee she will make it home. You would loose the trust of her remaining family if you did and she died away from family. A significant family member could travel with her as a medical escort but that places a big responsibility on their shoulders should Emily die.

    What would I do.

    Fluid resuscitate with Hartman’s

    Maybe inotropes (with a little advise from somewhere else)

    Control glucose

    Cultures – blood, urine, sputum

    CXR, xray the foot to see if how much ostiomyelitis there is

    NPPV

    Antibiotics to cover diabetic foot – Pipercillin & tazobactam would be start. In Arnhemland I would have to keep melioid in mind but I think regimen covers that

    Clean the wound to get rid of the pus and gangrene under a foot block – they work well in diabetes – something to do with the fact the nerves don’t work well in the first place. Failing that maggot will do a good job. If the wound is open there may be some there already.

    Nurse bureaucrats … well at the end of the day I believe patient autonomy is more important and I would argue strongly on Emily’s behalf if she has decided to stay.

    • Hi Mark.
      My favourite comment so far – do a foot/ leg US-guided regional block and debride / explore the foot wound / ulcer.

      If there is a collection it needs draining ASAP and you can “diagnose” osteomyelitis if you can probe down onto the bone – so this will help steer longer term therapy options. We do a lot of amputations in Broome for this indication and often under a popliteal or spinal block (maybe not a SAB for her today!) This is a great pearl – it highlights the benefit of generalist care as we are the same docs in ED as in Anaesthesia and the ward – so a popliteal block is easily done and can sort out the foot in rapid time.

      The 2012 Surviving Sepsis guidelines are very clear on early, minimally invasive source control – this is a good example.

      Also – agree with family meeting. Needs to be open / transparent. Explore the concerns and beliefs around transfer – it might be that there is a falsehood or myth that you can correct to decrease anxiety around transfer. After all her prognosis is not too grim at this point.
      C

  7. Great Top End case. Familiar for those of us used to the demographic, scary for those not.
    Several questions:
    1) What’s her creatinine? Is she making urine? Highly likely to have CRF +/- be a known dialysis patient who’s gone walkabout with her known diabetic complications. Crucial info to know. If missed dialysis, what’s her ideal dry weight? As this will guide fluid replacement, and potential need for filtration.
    2) What were her ketones and osmolality on arrival? Is she just hyperglycaemic, DKA, or hyperosmolar?
    2) Can anyone in town do a formal echo? Be good to know about Rheumatic heart disease, the cause of the murmur (has she got aortic stenosis?) and her LV systolic function. Oh, and I’d also want to know if there’s a pericardial effusion – from her CRF, TB, or other bugs… Would be very useful to know given she’s needing inotropes.
    3) As to the source of her sepsis, I can’t believe no-one’s mentioned it yet: MELIOIDOSIS! Can occur even in dry season. She’s an absolute sitting duck. Needs the specific swabs and specific ABx
    4) Should she be transferred? Tough call – capacity assessment may be hard. I’d enlist family and make a group decision, with her opinion being paramount.
    5) If she goes, should she be intubated for flight? Well, NIV is not a treatment for pneumonia. If we’re presuming that’s the cause of her hypoxia and she’s deteriorating – I’d tube.
    6) Lastly, although she clearly appears septic, in this population don’t forget about occult trauma as a cause of unresponsive shock. Have had a couple of similar cases, poor historians, slight temps, deteriorating haemodynamics with no apparent source and clinically soft abdomens, with known chronic liver disease from alcohol (and therefore known ascites, so FAST +ve), who on CT had solid organ injuries and bellies full of blood – both adamantly denied any trauma.
    Great case!

    • Thanks Andy
      Great pearls – the occult trauma thing is one we see not infrequently and really requires a very cynical and “experienced” clinician – but it happens – so keep it on the cards.

      Yep – Rheumatic HD is common – so infective endocarditis needs to be in the differential and I think covered with initial therapy.

      I was a surprised like you – nobody mentioned Melioidosis earlier. It is uncommon, but htis is the patient in whom you would cover and aim to isolate it.

      She has “normal” renal function for the purposes of this exercise – but yes HD patients are scary in this context. Though the decision to fly them is much easier as thye are already involved in remote care from a big hospital and the Renal Docs would shoot me if I did not send her down stat!

      See you next week. Casey

  8. …BTW, has her lactate ‘cleared’? (I’m trailing a coat here…)

  9. Thought so, do report back…

    I’ll still be trying to “get the lactate down”..by effective resus

    So…did you sip her out on the blue cigar? Or NIPPV per Minh? Or respect her wishes and ‘crack on’ in Broome?

    the trop neg chest pains will be fine…

    • Can’t tell you the end of story – still to be “plated out” at the ACEM meeting next week.
      We are doing a live debate as part of the Broome Docs presentation.

      Its a “booked argument” – love that Python sketch 😉
      C

  10. In spirit of flipped classroom…how did the lecture/ debate go at ACEM? Im guessing there’ll be a pod or vodcast on sepsis on a shoestring?

    • Tim
      I think it went really well. Very proud of my RMOs
      Stellar performance under pressure

      There is a lactate debate up already then the individual RMOs will present a vodcast of their PKs on the blog in coming weeks
      Casey

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