Sepsis. It is a word that sends shivers down my spine each time I hear it in passing or as a possible diagnosis. When I worked in a busy surgical ICU at a large academic medical center, we often received patients from outside institutions who had exhausted all of their resources and needed help to work through the medical mystery.
When I was about seven months pregnant and quite large, “on-call” time was offered so I snatched it up because who knew when it would make its way around to me again. I recall being at home that morning, resting with my 2-year-old, when my phone rang and it was my beloved charge nurse. As I answered, I was praying that she was going to give me the rest of the day off. However, that was not the case on this beautiful October day. Instead, she asked me very sweetly if I could come in to admit a patient with a suspected sepsis diagnosis who was arriving from an outside hospital as a direct admit. Of course, I agreed that I would be there as soon as I dropped off my daughter at daycare. So much for enjoying the elusive on-call opportunity!
Assessing the Patient
As I waddled down the hallway toward my pod I could see a flurry of action outside my room, which we know is the worst way to arrive on shift! I quickly gowned up and went into action. I knew I would receive a report once the patient was stabilized, so I focused on what to do at that moment, which was getting her settled and performing a quick assessment to prioritize interventions with the medical team. Her family arrived and needed an update, so I briefly stepped out of her room to introduce myself and have our unit clerk show them to the waiting room. I promised that the physician would update them as soon as he could.
After gowning up to walk back into the room, I overheard that dreadful word. They were worried she was in septic shock and we would lose her if we didn’t act quickly. I rerouted myself to the med station to withdraw multiple liter bags of fluid, grab extra lab tubes and make my mental to-do list of impending workups that would be performed over the next several hours.
In report, I learned that she was a 16yo female who had given birth to a healthy baby within the last six months. Her family reported that she had recent complaints of tooth abscess, vomiting over several days, lower back pain, and vaginal bleeding with purulent discharge and odor. On the morning of admission, she presented to her local emergency department with a fever of 102 degrees and self-reported that she had taken leftover antibiotics from her mom’s friend, went swimming in a local lake in the days prior to admission and recently received multiple non-professional tattoos.
I reminded myself to breathe as I learned more and more about her history. My heart was crumbling for this girl lying in a hospital bed on complete life-support to maintain hemodynamic stability and respiratory needs at such a young age. Throughout my shift, we drew more labs than I had ever drawn before; some for tests that I had no idea even existed or understood why we were doing them. Knowing how quickly she was deteriorating, we had to think fast. It almost felt like an episode of “House,” as we raced to save her life.
Managing the Patient With TSS
As we cleaned her up and did the one turn of the day, I recognized a rash was forming on her backside, and she was starting to ooze blood from every orifice. As the protocol for any new finding, I let the resident and fellow know about the new puzzle pieces. Our attending physician on shift started researching and began to suspect toxic shock syndrome (TSS), a disease I had learned about as a young female but always wondered if it really exists. I knew it could develop if a tampon was left in too long, but I had no idea there were other ways to contract this debilitating disease.
TSS is a rare, life-threatening complication of certain types of bacterial infections, often a result of Staphylococcus aureus or toxins produced by group A streptococcus. The rash was the first indication that pointed toward the source of her septic nature coupled with her sudden high fever, low blood pressure, confusion and muscle aches. While a definitive test does not exist, a combination of testing blood and urine cultures is used to look for the presence of staph or strep infections, and swabs from the vagina, cervix and throat may be sent to the lab. Considering what her family had shared about the days leading up to her hospitalization, we knew we needed to act quickly. She had numerous points of entry from swimming in the lake, recent childbirth and a localized infection site.
After working up her infectious protocol of sending off more labs, swabs and cultures, we started her on prophylactic IVIG therapy, in addition to vasopressors, antibiotics and blood products to treat her INR of 1.9 and rising fibrinogen levels. An article by Ross and Shouff tells us “intravenous immunoglobulin (IVIG) is thought to work by neutralizing the activity of the toxins produced and can be considered for shock refractory to fluids and vasopressors.” While the dosing has not been fully established, we started her at 2 g/kg and saw rapid improvement in her declining state. After 24 hours, she slowly started to come around, was weaned off medications, and started to wake up from her fragile state.
To learn more about TSS and sepsis, refer to these resources:
- Johns Hopkins Medicine
- “An Overlooked Cause of Septic Shock: Staphylococcal Toxic Shock Syndrome”
- Cleveland Clinic
- Sepsis Alliance
For the latest evidence-based practice guidelines on the management of patients with sepsis, see the Society of Critical Care Medicine’s Surviving Sepsis Campaign. An update to these guidelines is anticipated in fall 2021.
During Sepsis Awareness Month each September, my thoughts inevitably return to some of my patients with sepsis and the nurses I’ve educated about recognizing sepsis and managing these patients. Don’t forget your lactates!
How have you helped increase understanding of the care of these complex patients or increased public awareness of sepsis?
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