Next to STEMI and neurologic emergencies such as spontaneous ICH, SAH, and ischemic stroke, one of the most common pathologies we transfer from one facility to another on Air Care is sepsis. However, unlike many of the other patients we transfer, these patient’s are usually being transferred from the ICU of an outlying facility to the ICU of a tertiary referral center that can deliver a higher intensity of care. I sat down and discussed with Dr. Bill Knight, a former flight MD and now Emergency Medicine and Neurocritical care physician, about some of the complexities of caring for these patients. Check out the podcast on iTunes. Without question these patients can be the absolute sickest patient’s to fly in our helicopter and they can have a number of factors complicating our management. As already mentioned, most all of these patients are being transferred from an ICU not able to deliver some service needed by the patient. This means that nearly every patient is certain to have at least 1 or 2 organ systems with significant end organ damage (i.e. might be transferred for dialysis which is often not available at referring hospitals). It also may mean that the source of the patient’s sepsis may not yet be controlled (i.e. a patient thought to have cellulitis actually has necrotizing fasciitis, a patient with urosepsis actually found to have an intraabdominal abscess). Most of these patients will have received some form of resuscitation over a period of usually days which may have included the adequate, inadequate, or overzealous administration of fluid. Most of these patients will be on some form of pressor support (often multiple vasopressors and potentially a vasopressor that you would not necessarily start of with - I’m talking dopamine here). Nearly all these patients will be intubated and, because we are often arriving later in the care of these patients, many will have some degree of pulmonary edema/ARDS.
To manage these patients one must rapidly determine where the patient is in terms of their resuscitation. If they get hypotensive, are they going to need more fluids or adjustment of their pressors? How much volume have they gotten to this point? Where are they on their vent? Do they have oxygenation or ventilation issues? Do you need to make changes to the tidal volume? FiO2? PEEP? How much of a change? How fast?
As you can see there are a lot of decisions that need to be made and they all start with a.) a thorough assessment of the patient on your arrival (physical exam, consideration of using ultrasound for evaluation of IVC, etc) and b.) an efficient, thorough review of the medical records (last ABG, fluids administered, pressor requirements, urine output, CXR findings, electrolyte disturbances, recent vent changes). This podcast provides a brief overview of many of the management considerations in these patients. In the coming weeks, we’ll expand on some of these learning points with posts on PEEP, EtCO2, and pressors.
For some additional reading and some of the articles referenced in the podcast take a look at these resources:
- Surviving Sepsis Campaign - http://www.sccm.org/Documents/SSC-Guidelines.pdf
- Low Tidal Volume Ventilation in ARDS - ARDS Net (2000) Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome. NEJM. 342 (18) 1301-1308.