Early Awareness of Critical Illness Case File

Early Awareness of Critical Illness Case File

Eugene C. Toy, MD, Manuel Suarez, MD, FACCP, Terrence H. Liu, MD, MPH

Case 1

Just prior to being discharged from the hospital, a patient on the general medicine ward  began to display abnormal "vital  signs." The patient is a  55-year-old man who was admitted 3 days prior for renal colic and hydronephrosis. His respiratory rate  (RR)  is 25  breaths/minute, blood pressure  (BP)  is 84  mm Hg/46 mm Hg, temperature is 101°Fahrenheit  (F), and heart rate (HR)  is 130 beats/minute with a regular rhythm. His oxygen saturation (02 sat)  is 80% on ambient air (RA) . The patient is confused and answers questions slowly but correctly. A  rapid response team (RRT) is called to initiate goal-directed treatment. 

⯈ What is the most likely diagnosis?

⯈ How would one gauge the severity of the patient's condition? 

⯈ What are the next steps in treatment and what should be done within the first hour of this patient's presentation?

ANSWER TO CASE 1:

Early Awareness of Critical Illness

Summary: A 55-year-old man admitted for renal colic and hydronephrosis is now showing signs of sepsis, and septic shock with multiorgan involvement. The focus of the infection is the urinary tract and that should determine the antibiotic choices. The presence of tachycardia, tachypnea, hypotension, hypoxemia, and low urine output combined with a  decreased mental status are all responses to sepsis. Can­cel discharge, administer a fluid bolus of 20 mL/kg of normal saline, start rapid response team measures, and transfer the patient to the ICU. 

• Most likely diagnosis: The most likely diagnosis is sepsis, with systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction (MOD) likely caused by obstructive pyelonephritis.

• Assessment of severity: An early warning score based on deviations of vital signs is a good objective way to assess severity of potentially critically ill patients. This patient's instability indicates a need for immediate medical attention.

• Next steps in treatment: The first interventions to be considered are addressing the severe hypoxemia, aggressive hydration to restore blood pressure, improve tachycardia, and increase cardiac and urine output.

• Management priority during the first hour: Administer the correct antibiotic(s) with coverage for the most common pathogens. Goal-directed treatment should follow the surviving sepsis guidelines. The obstructed, infected ureter/kidney should be drained. 

ANALYSIS

Objectives

1. To recognize the early signs of   critical illnesses. 
2. To be familiar with the treatment strategies to correct abnormal vital signs and early goal-directed therapy. 

Considerations

The patient described in this  scenario was about to be discharged from the hospital. The nurse called regarding abnormal vital signs, which were dramatically altered from normal. The hypotension, tachycardia, hypoxemia, and confusion are very worrisome. For  instance, the oxygen saturation of 80% likely correlates to an oxygen partial pressure of 45 mm Hg, which is incompatible with life. Thus, the first intervention is oxygen! This hospital has a rapid response team, which is a mul­tidisciplinary team that assesses patients quickly when there are potential critical illnesses. The rapid response team then uses an efficient protocol regarding its objec­tive evaluation of the patient's clinical status. A  delay in assessment, recognition, or therapy could lead to adverse consequences, including death. 

Approach To:

Early  Recognition of Critical Illness 

Early awareness of a critical illness is  crucial in  order to  reduce its  morbidity and mortality. The mortality rate is about 5% among all hospitalized patients but increases to 15% in patients admitted to an intensive care unit (ICU). In cases of sepsis and acute lung injury, the death rate can approach 50%. Critical care is extremely costly and ICU costs represent about 15% of all hospital expenses. The recently developed rapid response teams or medical emergency teams which consist of a group of clinicians and nurses, brings critical care expertise to the bedside. Their early intervention with IV fluids and antibiotics for hospitalized patients who show early signs of sepsis with hemodynamic deterioration, such as tachycardia, low blood pressure, low urine output, fever, and changes in mental status has markedly lowered both morbidity and mortality.

Rapid response teams. Earlier detection of a patient's clinical deterioration pro­vides a great opportunity to prove Ben Frankl   in's adage that "an ounce of preven­tion is worth a pound of cure." Rapid response teams are aimed at intervening as soon as possible before the patient's condition deteriorates and help ensure optimal outcome. Since most patients in this situation require respiratory care, respiratory therapists (RTs) have been considered key team members,  and most hospitals have already implemented these teams with an RT member. In addition, a critical care nurse, a physician, a physician's assistant, and/or pharmacist are all important mem­bers of the team. Their expertise has drastically reduced both the incidence of cardiac arrests and subsequent deaths. It has also decreased the number of days in an ICU, hospital days, and  the number of in-patient deaths. This has resulted in an increase in the number of patients who are discharged in a functional state. 

Scoring systems utilizing routine observations and vital signs taken by the nursing and ancillary staff are used to evaluate the possible deterioration of patients. This dete­rioration is frequently preceded by a further decline in physiological parameters. Fur­thermore, a  failure of the clinical staff to recognize this failure in respiratory or cerebral function will put patients at risk of cardiac arrest. Suboptimal care prior to admission to an ICU leads to increased mortality. Because of resource limitations, the number of patients that can be monitored and treated in an ICU is limited. The selection of patients who might benefit most from critical care is crucial. The early identification of in­patients at risk of deterioration based on measurements of physiological parameters will reduce the number of pre-ICU resuscitations required. 

Early awareness score (EWS). The EWS is a tool for bedside evaluation based on 5  physiological parameters:  systolic  blood pressure (BP), pulse rate (PR), respiratory rate  (RR), temperature, and response of the central nervous system (CNS). The purpose of RRTs is to use protocols, which will recognize deteriorating hemodynamics as quickly as possible. This treatment can be initiated before the MD or intensivist arrives who may then give further individualized orders. 

Precautions to prevent aspiration such as elevation of the   head of the   bed to 30° to 45° should be instituted whenever there is a change in mental status, or increased risk of aspiration, provided the current blood pressure allows this. The patient should 

be transferred to the   ICU for further treatment and provided continuous monitoring and goal-directed therapy based on the surviving sepsis guidelines. Cardiac arrest has been associated with the failure to correct physiological derangement in oxygenation (breathing), hypotension (blood pressure), and mental status (see Table 1-1). These features may be apparent up to 8 hours prior to eventual cardiac arrest. The intro­duction of the rapid response system has accelerated an early referral to the ICU and in   many cases has avoided an ICU admission when the patient has a good early response and reaches clinical stability quickly.

VITAL SIGNS

Respiratory rate. The respiratory rate varies with age, but the normal reference range for an adult is 12 to 20 breaths/minute. The respiratory rate is an indicator of potential respiratory dysfunction. An elevated RR > 25 to 30 breaths/minute is a poor prognostic factor in patients with pneumonia, congestive heart failure (CHF), and other illnesses such as chronic obstructive pulmonary disease (COPD). 

Blood pressure. Blood pressure (BP) is measured by 2 readings; a  high systolic ( ven­tricular contraction) pressure and the lower diastolic (ventricular filling) pressure. A BP (mm Hg) of 120 systolic over 80 diastolic is considered normal. The difference between the systolic and diastolic pressure is called the pulse pressure (PP). A low or narrow PP suggests significant intravascular volume loss. If the pulse pressure is extremely low, <25 mm Hg, the cause may be a decreased low stroke volume as in CHF or shock. A  narrow pulse pressure value is also caused by aortic stenosis and cardiac tamponade. There is no absolute natural or "normal" value for BP, but rather a range of values. When excessively elevated, these values are associated with an increased risk of stroke and heart disease. Blood pressure is usually taken at the arms but may also be taken at the lower level of the legs, this is called seg­mental BP and evaluates blockage or arterial occlusion in a limb. 

Pulse. The pulse is the result of the   physical expansion of the artery. The pulse rate is usually measured at the wrist or at the ankle and is recorded as beats/minute. The pulse is commonly taken at the radial artery. If the pulse cannot be taken at the wrist, it may be taken at the elbow (brachial artery), at the neck against the carotid artery (carotid pulse), behind the knee (popliteal artery), or in the foot (dorsalis pedis or posterior tibial arteries). The pulse rate can also be measured by listening directly to the heartbeat using a  stethoscope. An irregular pulse with regular skips is very suggestive of atrial fibrillation. Rates <60 or rates > 100 are defined as bra­dycardia and tachycardia, respectively. When there is a rapid, regular pulse, sinus tachycardia and supraventricular tachycardia should be considered.

Temperature. An elevated temperature is an important indicator of illness, espe­cially when preceded by chills. Systemic infection or inflammation is indicated by the presence of a fever (temperature >38.5°C or sustained temperature >38°C), or a significant elevation of the temperature above the individual's normal temperature. Fever will increase the heart  rate by 10 beats/minute with every Fahrenheit (F) degree above normal. Temperature depression (hypothermia), <95°F, should also be evaluated since it is an ominous sign for severe disease and is more threatening than hyperthermia. Body temperature is maintained through a balance of the heat produced by the body and the heat lost from the body. Antipyretics should not be withheld. The patient should be made comfortable and fluid repletion should be used to counter the fever induced fluid losses. The absence of fever does not indicate the absence of infection. High spiking fevers in the 104°F to 105°F range are less likely septic and may represent a drug allergy or blood transfusion reaction. Fever and other vital signs are keys to the diagnosis of the  systemic inflammatory response syndrome (SIRS). See Table 1-2.

Sepsis is defined as SIRS in response to a confirmed infectious process. Severe sepsis is defined as sepsis with organ dysfunction, hypoperfusion, or hypotension. Septic shock is defined as sepsis-induced hypotension or  hypoperfusion abnormalities despite adequate fluid resuscitation. 

The fifth vital sign. The phrase "fifth vital sign" usually refers to pain or the oxygen saturation measurement. Pupil size, equality in pupil size, and reactivity to light can also be used as a vital signs. Many emergency medical service (EMS) agencies use pulse oximetry and blood glucose levels as vital signs in addition to pulse rate, respiratory rate, and blood pressure. A pulse oximetry saturation of 90% to 92% represents a PA02 near 60 mm Hg and should be the minimal goal of 02 supplemen­tation. The 90% 02 sat point represents the elbow of the   hemoglobin dissociation curve, whereas below this number there is rapid hemoglobin desaturation; above this number there is little gained in 02 carrying capacity of the  hemoglobin.

Protocol-Based Care

Protocols are decision-making tools in which differential interventions are applied based on explicit directions and regular patient assessments. Whether implemented by physicians, nonphysician providers, or nurses, protocols serve to standardize care practices, reduce unnecessary variation in care, and aid in the implementation of evidence-based therapies. Protocols have been associated with improvements in the quality of critical care. These include protocols for sedation, weaning from mechanical ventilation, lung protective ventilation in acute lung injury, early adequate resuscita­tion in severe sepsis, and moderate glucose control in post-cardiac surgery patients. 

implement protocols successfully. Hospitalists specializing in acute care should be able to provide necessary physician services in the ICU and make minute-to-minute decisions governed by protocols. Protocols are not superior to major decisions made by a qualified intensivist or physician. In settings with optimal physician staffing, protocols have not consistently resulted in improved outcomes; however, few ICUs are staffed with the trained intensivists and multidisciplinary clinicians necessary to provide such optimal care. The evidence suggests that outcomes are improved when routine care decisions are standardized and taken out of the hands of individuals.

There are a myriad of laboratory data that can be obtained quickly to aid in the diagnosis and treatment of patients. Electrocardiography, arterial blood gas, electro­lytes levels, 02 saturation, cardiac enzyme analyses, echocardiography, CT scanning and ultrasound, are all examples of such tests. The proper evaluation of the  patient's physical condition and vital signs will enable a quick and correct application of the proper treatment. The differential diagnosis of a patient's problems should imme­diately identify the most catastrophic but reversible and treatable events. 

The current gold standard for the organization of critical care services is the incorporation of an intensivist in the multidisciplinary care team. The intensiv­ist is responsible for overseeing the multidisciplinary, collaborative team of nurses, clinical pharmacists, respiratory therapists, and nutritionists. Intensivist-led multi­disciplinary care is endorsed as a key to successful evidence-based practice for the management of critically ill patients. 

See also Case 2  (transfer of critically ill patients), Case 3  (scoring systems and patient prognosis), and Case 4 (monitoring). 

CLINICAL CASE CORRELATION

• See also Case 2  (transfer of critically ill patients), Case 3  (scoring systems and patient prognosis), and Case 4 (monitoring).

COMPREHENSION QUESTIONS

1.1 A 71-year-old woman is brought to the ICU from a nursing home because of confusion, fever, and flank pain. On physical examination, her temperature is 38.5°C ( 101.3°F), blood pressure is 82/48 mm Hg, heart rate is 123 beats/minute, and respiration rate is 30 breaths/minute. Dry mucous membranes, costovertebral angle tenderness, poor skin turgor, and an absence of edema are noted on physical examination. The leukocyte count is 15,600/μL; urinalysis shows 50 to 100 leukocytes and many bacteria per high power field. The patient has an anion-gap metabolic acidosis and high lactic acid level. Antibiotic therapy is started. Which of the following is most likely to improve the survival of this patient?

A. Aggressive fluid resuscitation

B. 25% albumin infusion

C. Hemodynamic monitoring with a pulmonary artery catheter

D. Maintaining hemoglobin above 1 2 g/dL

E. Maintaining Pco2 below 50 mm Hg

1.2 A 29-year-old man underwent an elective laparoscopic gall bladder surgery which was uneventful. The evening after surgery, the nurse is alarmed due to the patient's complaint of abdominal pain and a 3 gm/dL drop from his preoperative hemoglobin level, HR of 130 beats/minute, BP of 80/40 mm Hg, and urine output of 120 cc over the past 8 hours.

Which of the following is the most likely diagnosis ?

A. Septic shock

B. Hemorrhagic shock

C. Cardiogenic shock

D. Pulmonary embolism

E. Anaphylactic shock

ANSWERS TO QUESTIONS

1.1 A. Aggressive fluid resuscitation with resolution of lactic acidosis within the first 6 hours has a beneficial effect on the survival of patients with severe sepsis. This patient has severe sepsis presumptively from pyelonephritis. The timing of resuscitation influences survival. Early goal-directed therapy that included interventions delivered within the first 6 hours to maintain a central venous oxygen saturation of > 70% and to effect a resolution of lactic acidosis resulted in higher survival rates than more delayed resuscitation attempts. Crystalloid is given much more frequently than colloid, and there are no data to support routinely using colloid in lieu of crystalloid. Blood transfusions may be part of the resuscitation effort for anemic patients in shock. In stable ICU patients who are not in shock, a transfusion threshold of 7 g/dL of hemoglobin is an acceptable conservative approach, but this does not apply to the treatment of patients with severe sepsis, where having a hematocrit <30% is reason for transfusion.

1.2 B. This patient has hypotension and tachycardia and also oliguria. The urine output is <0.5 cc/kg/h. This constellation of findings in a postoperative patient is most consistent with hemorrhagic shock, or hypovolemic shock. There is likely to be an intra-abdominal vascular injury unless proven otherwise. The first steps in treating this patient should include placement of 2 large bore IVs, infusion of normal saline rapidly, and rapid assessment for intraabdominal hemorrhage and its surgical correction if confirmed.

CLINICAL PEARLS

• Early recognition of changes in the vital signs and the mental status are critical  to the early detection of patient deterioration and the prevention of cardiac arrest. 
• Continuous or bedside spot monitoring of oxygen saturation is now con­sidered the fifth vital sign and provides accurate pulse readings and PAO2 approximation (ABG, Svo2 sat).
• The phrase "fifth vital sign" can refer to pain or 02 saturation as a   vital sign.
• Protocol-driven  rapid response teams have significantly decreased the mortality  and morbidity of in-patients and significantly reduced cardiac arrests in the hospital setting.
• Oxygen saturation via oxymetry of 90% is equivalent to a PAO2 of60 mm Hg, the elbow of the hemoglobin dissociation curve, and the acceptable mini­mum in 02 saturation. 
• Fever  and other vital  signs are  keys to the diagnosis of the systemic inflammatory response syndrome (SIRS) and can be caused by sepsis as well as noninfectious causes.

References

Clifford S, Deutschman MS. Evidence-Based Practice of Critical Care. Philadelphia, PA: Saunders; 2010. 

Loscalzo J. Harrison's Pulmonary and Critical Care Medicine. New York, NY: McGraw-Hill; 2010. 

Rhodes A, Bennett ED. Early goal-directed therapy: an evidence-based review. Crit Care Med. 2004; 32:S448-S450. 

Rubenfeld GO, Caldwell E, Peabody E, et al. Incidence and outcomes of acute lung injury. N Eng!] Med. 2005;353: 1685-1693. 

Toy E, Simon B, Takenaka K, Liu T, Rosh A. Case Files Emergency Medicine. 2nd ed. New York, NY: McGraw-Hill/Lange Medical Books, 2013.

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