1)H&P/Soap Note

H&P Urosepsis

2)Summary of Article

Lactate Clearance Predicts Survival Among Patients in the Emergency Department with Severe Sepsis

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4703153/pdf/wjem-16-1118.pdf

This article is a retrospective dual-centered cross-sectional study that is med lined indexed and published in 2015. It discusses lactate clearance during the emergency department stay of patients diagnosed with severe sepsis/septic shock and how lactate clearance is associated with decreased mortality. Serum lactic acid levels have been long time used as a diagnostic tool for tissue hypoxia and serve in identifying patients with severe sepsis. Increases in initial lactate values have been associated with mortality in sepsis and specifically in ED patients with sepsis. It is now suggested by international sepsis guidelines that routine measurement of lactate be performed among patients with severe sepsis and immediate resuscitation implemented for septic patient whose serum lactate is greater than 4 mmol. Even though the optimal frequency of measuring lactate is unknown, serum lactate is usually followed in patients with sepsis until the lactate value has fallen.

This study attempts to examine the role of lactate clearance (or taking serial lactate measurements to measure decrease in lactate) as a way to understand mortality in patients with severe sepsis or septic shock presenting in the ED. The aim of the study was to evaluate the predictive value of lactate clearance on 28 day in hospital mortality, and also to investigate secondary outcomes like need for particular treatments and interventions. It was predicted that ED patients with severe sepsis or septic shock and have evidence of lactate clearance upon admission to hospital would have lower in-hospital mortality rates than those who did not clear initial lactate levels.

The study included 207 patients from the Yale New Haven Hospital Emergency Medicine registry with severe sepsis/septic shock who had initial lactate levels measured in ED and upon arrival (<24 hours). Sepsis outcome (short-term mortality) and quality measures (lactate measurement, time to antibiotics, resuscitative endpoints) were examined. Lactate clearance was calculated (Initial ED lactate level – Admission ED lactate level)/Initial ED lactate level. A zero or positive number indicated lactate clearance. 171 patients were in the lactate clearance group and 36 patients were in the non-clearance group. 136 patients (65.7%) had severe sepsis and 71 patients (34.3%) had septic shock.

The results of the study showed that 28-day mortality rates were 15.2% in the lactate clearance group and 36.1% in the non-clearance group (p<0.01).Vasopressor support was imitated more often in the non-clearance group (61.1%) than in the clearance group (36.8%, p<0.01) and mechanical ventilation was used in 66.7% of the non-clearance group and 36.3% of the clearance group (p=0.001). Based on these results, patients who do not clear their lactate in the ED have significantly higher mortality than those with decreasing lactate level. Some limitations of this study were that is was a retrospective extraction. It also did include 207 patients in the cohort, but this was among the highest in any study of lactate clearance and sepsis to date at the time of publish.

 

Comments from evaluator-Classic study that moved ER from placing central lines in every sepsis patient – which was previously more commonly done to obtain central venous pressure and gauge pressor/fluid support. Good article in relation to your sepsis patient. Didn’t see the repeat lactate value in the case.

 

3)Site Evaluation: My Summary

During my emergency medicine rotation, I had two site visits. In each, I was able to present a case. The first case was of a patient with pancreatitis.

Case 1:  Mr. O is a 32 y/o M with PMH alcohol abuse presents to emergency room c/o severe epigastric abdominal pain x 1 day associated with nausea, 2 episodes of vomiting and decreased appetite. PT states that he was drinking alcohol when he developed epigastric pain described as sharp, constant, 8/10 in pain, and radiating to the back. He stated that he has been drinking frequently because he recently lost a family member. Denies any other exacerbating factors. Denies fever, chills, chest pain, palpitations, SOB, syncope, headache, dizziness, hematemesis, bloody stools, diarrhea, constipation, dysuria, hematuria, urinary frequency/urgency.

The patient’s vitals were stable except for him being tachycardic with rate 100 bpm. Physical exam was positive for epigastric abdominal tenderness w/o guarding or rebound tenderness. Bowel sounds were present in all 4 quadrants. Abdomen was flat and symmetrical. Urinalysis and finger stick performed were normal. The patient’s WBC was 16.33 and his lipase was elevated at 631 which is specific for pancreatitis. CT scan of abdomen confirmed the diagnosis. Some differentials I considered was cholecystitis, peptic ulcer disease, hepatitis, and appendicitis. The plan was to make the patient NPO, give morphine for pain control, Zofran for nausea, monitor labs and administer IV fluid therapy.

The second case I presented was of a patient with urosepsis. I found this case very interesting

Case 2: It was of an 89 y/o M with PMH Afib, pacemaker HTN, ischemic CVA with left sided residual weakness and hypothyroid. He was brought to ED by his son due to urinary retention and fatigue. PT had a history of BPH/lower urinary tract infection s/p greenlight TURP in 2015 (India). Because of this he had repeated episodes of urinary retention requiring Foley exchange every 6 weeks. PT last saw his urologist on 7/17 and was given 5 days Bactrim for UTI. The urine cx grew proteus mirabilis resistant to Bactrim. PT’s son also reported that pt has had increasing weakness of right extremities x 1 week.

On presentation, the patient was in atrial fibrillation with rate in the 180’s. The patient was administered IV Lopressor 5 mg which brought the rate down to the 110’s. His Foley catheter was not producing urine, so another Foley was placed and 400 ml of turbid yellow purulent urine came out. The patient ended up being diagnosed with urosepsis as he also had on labs lactate of 5.1, urinalysis positive for blood, protein, nitrate and leukocytes. His urine culture was positive for proteus mirabilis. He also had a BUN 59, Cr 2.1. The patient ended up being admitted to the ICU due to urosepsis and acute kidney injury.

I liked presenting these cases because I got to see the full work up of the patient and the end result before the patients were admitted to ICU. While presenting the case, it felt good being able to have a decent understanding of the case and why each test was ordered. In the ER, I noticed there were times when a number of tests/labs were ordered for patients. It was overwhelming at first but also cool attempting to understand the reasoning for each test and how the result related to the patients symptoms. My evaluator was also able to give me constructive feedback and insight regarding the cases which I thought was great.

 

4)Typhon Report

Emergency Medicine 7.27-8.21

 

5)Rotation Reflection

On my first day at Metropolitan Hospital, I had the opportunity to accompany my preceptor and the emergency room director to the internal medicine floor to watch a Mock Code ran by the internal medicine team. The practice case was of an elderly man who suddenly collapsed and went into cardiac arrest. This was a good experience for me because in our ACLS/BLS practice course at York, we got to run a few practice simulations as well, so it was nice to be able to see the medical team also do the same. I got to see the team simulate and practice calling the code and respond by starting CPR, giving oxygen, attaching monitor/defibrillator and interpreting rhythm, and administering meds. I thought this was a great introduction into the rotation for me because it reinforced the importance of practicing and repetition as a medical team in order to be prepared for patients in need of emergency care.

• Exposure to new techniques or treatment strategies – how did that go?

I got the opportunity to practice IV’s a few times but felt I needed to improve more on this. I saw the value in being able to perform IV’s as the providers were called upon to do this when the nurse rarely was unable to do this. I got to observe the doctors and PA’s use ultrasound for various procedures including observing for fluid in a paronychia, looking for good veins for IV and central line access and performing FAST (Focused assessment with sonography in traum) exams, useful for screening for pericardial effusion or any bleeding within the peritoneum in acute situations.

• Types of patients you found challenging in this rotation and what you learned about dealing with them

I found some challenge with getting use to interviewing a patient who spoke a different language. I had to utilize the hospitals translator service in order to gather history from a Spanish speaking patient twice. I thought it was great that the hospital had a translator one call away and found it necessary and important so that the patient is better able to express their symptoms. One of the PA preceptors I worked with even told me she was able to learn some Spanish just by her constantly using the translating service which I thought was pretty cool.

In the ER, the level of acuity is also higher. In so eliciting a history can be challenging sometimes especially when a patient is in a lot of pain or if the patient is agitated, intoxicated or have a mental disorder. I had to realize that it is important to be sensitive to the patients and recognize their uniqueness. Practicing patience is also important in order to effectively gather the history of the patient.

-Interpersonal challenges and how you addressed them

In this rotation, I had to learn how to be more proactive. A few ways I learned to be more proactive is by reading up labs that are to be drawn for a patient and asking the nurses if they can teach me how to perform IV’s. Also, I found it useful to try to read up on UpToDate or Wiki EM the diagnoses and treatment plans on a few cases in order to learn more about the case. Being proactive is a skill that I would want to improve further on as a PA student and future healthcare provider. I was also fortunate to have a former York PA Program student Merin on a couple of shifts with me. She was able to mentor me and give me some more tips about Emergency Medicine.

I had the opportunity to also work with some awesome PA’s.They were very knowledgeable and made me more prouder with my choice of pursing a career as a Physician Assistant.