Line Sepsis in ESRD

[waterski232002]

Do you guys admit all cases of suspected line sepsis in ESRD patients who's only symptom is fever during dialysis? Or do you discharge them and have them continue to receive vanc/gent at dialysis pending culture results?

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[Jeff698]

Strange, I had a very similar patient the other day. 60-something HD patient who came in with a fever but was otherwise fine. No other complaints. Her last dialysis was the day before. She had an elevated WBC but her other labs were peachy. I drew cultures and gave her Vanc. While that was going I spoke with our nephrologists.

They asked that I add on Gent and send her home to follow up with them at dialysis the next day.

Take care,
Jeff

 

[docB]

Feel free to call me a nit picker on this one but I do admit all cases of line sepsis. Now I expect them to be tachy, hypotensive and generally decompensated to fit that diagnosis. If they just have a suspected catheter infection I will start abx and talk to their PMD/Nephro.

 

[Jeff698]

Nit picker.

Take care,
Jeff

 

[waterski232002]

Feel free to call me a nit picker on this one but I do admit all cases of line sepsis. Now I expect them to be tachy, hypotensive and generally decompensated to fit that diagnosis. If they just have a suspected catheter infection I will start abx and talk to their PMD/Nephro.

To be REALLY nit picky... Hypotension would fall into the category of severe sepsis or septic shock (not plain sepsis). Sepsis is just SIRS + documented infectious source.

So... a patient with a fever > 38 and WBC > 12, and a line infection technically has "line sepsis"... if he also had a BP 80/40 which responded to 2L NS bolus, it would be considered "severe sepsis"... however, if that same patient remainded hypotensive despite adequate fluid rescusitation it would be considered "septic shock".

 

[docB]

To be REALLY nit picky... Hypotension would fall into the category of severe sepsis or septic shock (not plain sepsis). Sepsis is just SIRS + documented infectious source.

So... a patient with a fever > 38 and WBC > 12, and a line infection technically has "line sepsis"... if he also had a BP 80/40 which responded to 2L NS bolus, it would be considered "severe sepsis"... however, if that same patient remainded hypotensive despite adequate fluid rescusitation it would be considered "septic shock".

Touche! So, back to your original question, if I had a guy with a documented bacteremia (off cultures at the PMD or dialysis) I'd admit him. The fact is that dialysis patients in my area fall through the cracks a lot and trying to turf one back to a PMD who will have to send him to a CT surgeon (they're the ones around here who place dialysis catheters) which will take at least two weeks is not good.

 

[waterski232002]

I am fortunate that the patient is well plugged in with his nephrologist who will follow up on his blood cultures. If they turn positive or he continues to spike fevers I assume they'll admit him and pull the catheter out. But I can totally understand admiting this guy too... The complications of line sepsis are pretty bad...

 

[DrQuinn]

I tend to admit these patients. Here in the DC area we treat predominantly african american patients... and a lot of them don't go see a doctor until they are ESRD... in fact, we have some of the highest percentages of ESRD patients in the US. I usually see 3-4 ESRD patients a day (in a shift of about 15-20 patients). Our ESRD like to admit them, and our ED staff has agreed to probably admit these guys. We even have a ton of ESRD homeless guys as well, as a lot of these people fall through teh cracks, so we tend to admit.

Q

 

[icu RN]

I agree!

 

[EM2BE]

I agree!

Are you really interested in sepsis, or is it just coincidental you posted your 2 posts in 2 forums covering the topic?

 

[Painter1]

This should be a homerun admission for various reasons: These patients are immunocompromised and though you may send them off on vanco and gent, they can decompensate too quickly with devastating consequences even while waiting to see they nephrologist the next day. Secondly, why even risk it? Lastly, I can't imagine anyone putting up a fight refusing to have the patient admitted.

In short, do yourself a favor and if you have to, paint the picture toward the worst when admitting these patients so no one will try to be brave enough to recommend discharging them.

 

[EctopicFetus]

Touche! So, back to your original question, if I had a guy with a documented bacteremia (off cultures at the PMD or dialysis) I'd admit him. The fact is that dialysis patients in my area fall through the cracks a lot and trying to turf one back to a PMD who will have to send him to a CT surgeon (they're the ones around here who place dialysis catheters) which will take at least two weeks is not good.

Had this same pt yest. Admit.. too many people can fall thru the cracks.

 

[DeLaughterDO]

I usually try to get them admitted - if the admitting medicine team sees the patient, speaks with nephrology (after I already have) and wants to discharge them (like they usually do), it's their name on the discharge, not mine.

I'll be sure to tell the patient that if ANYTHING (and I mean anything) changes, or they get worse, to come back immediately for admission. I usually push hard for admission if they would be going "home" alone, as there would be noone else there to see if anything gets worse.

The little battles we have every day with admitting teams are "fun."

 

[roja]

Admit. Based mostly on lack of followup, etc.

I think if they look peachy, aren't in septic shock, have a great doctor, are reliable, then I would consider dosing them in leave.


In 5 years, no one has met these requirements.

 

[n2b8me]