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| == Discussion 2 - Resolved April 26, 2010==
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| *What should I record as first low BP in this case.--Marylou
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| **Final answer: First low BP April 16th at 17:26--[[User:TOstryzniuk|TOstryzniuk]] 12:54, 28 April 2010 (CDT)
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| *Here is another scenario:
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| *'''Apr 16 @ 1148 hrs''' - '''to ER''': with hematemesis and confusion, rhabdo and ARI. '''BP ok'''. '''Temp N''', WBC 10.6, '''Hgb 124''', '''Lactate 8.7''', Creatinine 244 (elevated for this pt), and elevated INR, '''HR 110''', '''RR 60'''. Treatment included iv rate 200cc/hr with bicarb. 1.5 l n/s bolus
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| **1610 - CT shows no surgical issues
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| **1625 - intubated for increased WOB (work of breathing)
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| **'''1726'''- '''First drop in BP 81/57''' and '''started on dopamine'''
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| **1750 '''- To ICU'''. '''Hgb now 80''' and given 2 units blood. '''CVP 13-17''' prior to blood.
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| *'''1930''' Dr. wrote in the chart that '''septic shock could not be ruled out''' so '''pip-taz''' was '''orderd empirically'''
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| **'''2100''' '''- First antibiotic (pip-taz) given empirically'''
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| **2150 - scoped and found esophagitis and old blood in stomach but no new bleeding.
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| *'''Apr 17''' @ '''0100 hrs:''' Hbg now 104. '''CVP 18-20''' and still on '''levo (switched from dopamine)'''
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| **0635 - '''another drop in BP 82/53'''. '''CVP 11''' treated with fluid and FFP
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| **0730 - Temp now 38
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| **1130 - Temp 38.3
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| *My question is this: '''Is the FIRST low BP related to sepsis on Apr 16th at 1726 or Apr 17th at 0625? The first BP drop could have been related to hypovolemia from bleeding'''?
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| **does the pt meets the criteria for septic shock '''after''' he was intubated and his BP first dropped on April 16 @ 1726 hrs?
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| **I am not sure because his Hgb was 80 so the hypotension could be related to a bleed not noticed on the scope although his CVP was 13-17?
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| *By April 17th @ 0100 hrs, his hgb is 104 and has had alot of fluid. The '''next drop in BP is at 0625'''. He is well hydrated now although his CVP is down to 11 and his temp begins to rise shortly after this. --[[User:MWaschuk|MWaschuk]], 20 April 2010 (CDT)
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| ***Did the doctors make a diagnosis? To me the lactate of 8.7 is certainly a red flag and usually means that there is ischemia somewhere like the gut. If this is the case, it is obviously a septic source and antibiotics should be started in my opinion. I would definitely use the first drop in BP on April 16 as the time of septic shock if pressors were started as well as if the other septic shock criteria were evident. The drop in BP is not related to bleeding according to your data. --[[User:LKolesar|LKolesar]] 11:45, 21 April 2010 (CDT)
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| *******A few questions for point of clarification:
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| #What is the admitting and working diagnosis?
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| #Please quantify BP parameters.
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| #What antibiotic was ordered April 16th at 2100h? Thanks--Brenda Kline, April 21.10 1012 hrs.
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| -Reply to Brenda's question above-
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| *at '''admission''' on '''April 16 at 1715'''- The '''working diagnosis''' was: '''upper GI bleed''', '''lactate acidosis NYD''' and '''shock due to hypovolemia'''.
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| **Surgery had assessed pt twice prior to admission to ICU and the pt did not have an acute abd. **Entrance complaint: severe adb pain and leg pain.
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| **The pt's lipase was 2000 but surgery was not convinced he had acute pancreatitis because CT was unremarkable except for a 6cm AAA (non-leaking).
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| **The leg mottling was thought to be due to hypoperfusion secondary to shock as opposed to a thrombis.
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| *'''Apr 16th at 1726''' was the first drop in '''BP 81/57'''
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| *'''April 16th @ 1930''' Dr. wrote in the chart that '''septic shock could not be ruled out''' so '''pip-taz''' was '''orderd empirically''' and was '''given at 2100 hrs'''.
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| *'''Apr 17th at 0635''' a second significant drop in '''BP 82/53''' (pt was on levophed at the time).
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| *'''Apr 18 at 1500''', 46 hrs after admission to ICU, the pt was '''transferred''' to '''HSC MICU''' with the '''working dx''' of '''metabolic acidosis secondary to hypovolemia shock''' and '''hypoperfusion plus or minus septic shock'''.--[[User:MWaschuk|MWaschuk]], 21 April 2010 (CDT)
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| *Thanks for the update. This is a good example because of the multiple potential septic sources and standard practice of addressing hypovolemic shock. After reading Laura's response, she validated my initial thoughts, but I wanted that wee bit more info, which was provided. Thus, I agree with the first drop in BP as the start of septic shock (may be in combo with hypovolemic). HOWEVER, I do want to discuss further with Kendiss, or she may respond before I get a chance. I am impressed with the critical thinking that is going on around some of your cases. Thank you!--[[User:Bkline|Bkline]] 12:04, 22 April 2010 (CDT)
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| *Link with updated information sent over the Kendiss. Stay tuned.........--[[User:TOstryzniuk|TOstryzniuk]] 19:14, 22 April 2010 (CDT)
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| This case is challenging…..
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| *This patient had 2 things going on resulting in shock; GI bleed and non-GI bleed –cause, likely sepsis. Was an actual septic source ever identified in this man?
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| *I think his initial blood pressure drop on April 16, 17:26 was at least partially (or all) due to GI bleed. He had a significant drop in haemoglobin with some blood seen on EGD. By the next day, his shock was definitely not due to GI bleeding as his CVP is up and his haemoglobin is stable.
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| *I think you could make an argument for 2 times:
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| #April 16th at 17:26; This patient’s CVP is not low and therefore there is a real good possibility that GI bleeding is not the only reason for shock at this point. The doctor’s notes also put sepsis in the differential at this point.
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| #April 17th at 1 am. The patient has been well resuscitated and his CVP is now 18-20. He remains hypotensive and is switched to levophed. It is clear now that GI bleed is no longer the cause of his hypotension and he is likely septic.
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| *I would favour listing the time of septic shock onset as April 16th at 17:26, however as stated above one could also make the argument for April 17th 1 am.-Kendiss
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| **Marylou, have you resolved?--[[User:TOstryzniuk|TOstryzniuk]] 13:03, 29 April 2010 (CDT)
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| ***April 29.10 - Yes I have. I sent the file in the last batch. The pt was transfered to St B. and they had septic shock and hypovolemic shock as their admits so '''I opted to go with the second drop in BP as the first drop related to septic shock'''. Kendiss wrote that I would have an argument with either BP but seeing as they were treating the GI bleed first I chose the second drop for the study. [[User:MWaschuk|MWaschuk]]
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| [[Category: Data Integrity Rules]] | | [[Category: Data Integrity Rules]] |
| [[Category:Diagnosis Coding]] | | [[Category:Diagnosis Coding]] |