why not antibiotics

[telenurse]

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I have a pt scenario I have some concerns about, I'd post this on allnurses...but I want to hear from doctors not nurses. I'm always willing to be educated.

I had a pt, 7 days s/p L lobectomy.
BP trends over 5 days went from 140 sbp 70dbp to 100sbp 50dbp.
Pt went into SVT on day 6, was on cardizem gtt at 10mg/hr in SR at 80-90's.

This is where I took care of this pt...and noted that His WBC were trending up, from 13.1 on post op day 2 to 23.2 on post op day 7. Gran# were 18.33 on postop day 7, gran % 79, lymph % 10, with toxic grans noted.
He had been cultured previously blood, sputum and urine, cultures pending...he was not on antiobiotics. Also noted his BUN was trending up, was 24 post up now 30, cr was 1.4, now 2.4, urine output WNL, but trending down and dark yellow.
Pt had crackles to base of R Lung, SPo2 94% on 4L, productive cough, frothy yellow/white. Encouraged pulmonary toilet, neb tx.
Temp was 97.1 orally...heart rate trending to 95-105 and BP trending to 90/50 manually for me.... pt with intractable n/v refractory to zofran and phenergan. Resident notified x2, reminded of WBC count, updated on condition, not concerned, reordered antiemetics.
I was checking VS on this guy every 2 hours, digging through his chart...etc. Tried talking to the resident, he didn't really want to talk to a nurse.

So teach me...
What would be a valid reason this guy is not on antibiotics?? Because I can't think of one, and I just really feel like I didn't advocate for this guy enough.

 

[Pir8DeacDoc]

was his O2 requirement an uptrend or had he been on O's the entire time?

No documented fever?

On any steroids?

COPD?

 

[telenurse]

quote=Pir8DeacDoc;5864773]was his O2 requirement an uptrend or had he been on O's the entire time?

No documented fever?

On any steroids?

COPD?[/quote]
O2 was 3-4 liters the whole time...but per looking at assessments and speaking with RT, his lung sounds were more coarse, sputum production increased.

No fever, temp was decreasing... from documented 98 range to low of 97.1 orally.

No oral or IV steriods, albuterol nebs only q4-6.

NO hx of copd before th ca dx..

 

[Pir8DeacDoc]

Often times the thought process is this..


What does it take to diagnose a pneumonia?
I know there is a fancy chart somewhere that I learned in medical school but here is what pops to mind for me.

Things arguing against a PNA:
1. afebrile
2. no change in his O2 requirement
3. ? no change in mental status
4. ? no change in his CXR
5. Negative cultures

Things arguing for a PNA:
1. Pressures are softening
2. HR is trending upward
3. WBC is up
4. Sputum production increased
5. Physical exam worsening


Honestly, much of his pressure and heart rate issues could be related to a wide variety of causes including preexisting disease. WBC uptrending is very non-specific. Sputum could be a result of a previous smoker who is clearing many of the secretions/sputum as his ciliar recover function. Physical exam almost never seems to help.


If I am a resident and start this guy on ABX the first thing my uppers are gonna ask me is "what are you treating?" If you don't have a culture to validate an infection with a known organism and the patient clinically isn't deteriorating to the point that they need an escalation in care, then you wait. If it is a PNA then it will declare itself.

Others please feel free to correct me. I am very new in my training but feel like the above would be my thought process. Hope this helps!

 

[Blade28]

If I am a resident and start this guy on ABX the first thing my uppers are gonna ask me is "what are you treating?" If you don't have a culture to validate an infection with a known organism and the patient clinically isn't deteriorating to the point that they need an escalation in care, then you wait. If it is a PNA then it will declare itself.

That'd be my thought process as well. What exactly would you be throwing the antibiotics at? We don't have any positive cultures, nor do we have a fever yet. I'd watch the lung exam and follow the white count.

BTW, to the OP - just for clarification, this is a left lung lobectomy, right? (Just assuming it's not the brain/liver/etc.). Which lobe? Open or VATS? Does the patient have a chest tube?

If there's a chest tube, you can also follow the daily CXR.

 

[Faebinder]

No fever and not immunosuppressed (Steroids or post chemo) or immunodeficient (HIV)? Then ABX are no good probably, WBCs do go up in non-infectious conditions you know. I would culture though cause elderly sometime dont mount fevers.

 

[jennyboo]

I have a pt scenario I have some concerns about, I'd post this on allnurses...but I want to hear from doctors not nurses. I'm always willing to be educated.

I had a pt, 7 days s/p L lobectomy.
BP trends over 5 days went from 140 sbp 70dbp to 100sbp 50dbp.
Pt went into SVT on day 6, was on cardizem gtt at 10mg/hr in SR at 80-90's.

This is where I took care of this pt...and noted that His WBC were trending up, from 13.1 on post op day 2 to 23.2 on post op day 7. Gran# were 18.33 on postop day 7, gran % 79, lymph % 10, with toxic grans noted.
He had been cultured previously blood, sputum and urine, cultures pending...he was not on antiobiotics. Also noted his BUN was trending up, was 24 post up now 30, cr was 1.4, now 2.4, urine output WNL, but trending down and dark yellow.
Pt had crackles to base of R Lung, SPo2 94% on 4L, productive cough, frothy yellow/white. Encouraged pulmonary toilet, neb tx.
Temp was 97.1 orally...heart rate trending to 95-105 and BP trending to 90/50 manually for me.... pt with intractable n/v refractory to zofran and phenergan. Resident notified x2, reminded of WBC count, updated on condition, not concerned, reordered antiemetics.
I was checking VS on this guy every 2 hours, digging through his chart...etc. Tried talking to the resident, he didn't really want to talk to a nurse.

So teach me...
What would be a valid reason this guy is not on antibiotics?? Because I can't think of one, and I just really feel like I didn't advocate for this guy enough.

Lung crackles don't necessarily mean pneumonia, it could also be something else like CHF.

Eventually if it becomes obvious that the patient is getting septic, then yes, even without a positive culture the patient will and should get antibiotics. The tricky part is where is the infection, and what antibiotics to use (this depends on where the infection is, since different antibiotics target different flora and different parts of the body have different bacteria). I would definitely get a chest x-ray as well. If the chest x-ray looked like pneumonia, then I would consider treating empirically for a pneumonia after cultures were sent. If you have absolutely no clue where the infection is, it's sensible to either not order antibiotics unnecessarily (patient is stable), or order broad spectrum coverage empirically (patient is unstable).

It sounds like your patient was at least halfway down that road since an infectious workup had already begun with cultures -- which is appropriate. Hopefully they also did a chest x-ray which should be part of the infectious work-up. Not being part of the specific situation, maybe the timing of their decisions was appropriate and maybe they were slow, no one reading about it online can really fairly say.

It seems to me the main problem is probably provider miscommunication rather than patient mismanagement. I know that if I were the resident cross-covering someone else's patient at night, and the patient had a temp at 2am but was otherwise stable, I'd culture the patient but I would definitely not start antibiotics until the patient's real docs came back at 7am. You can always give a drug, but once given you can't take it back (for antibiotics, you might ruin your cultures). If the resident you talked to was one of the primary people taking care of the patient, who knows what the reasoning was -- but I guess the reasons should have been elicited and communicated at the time all of this was unfolding. Unfortunately, we all screw up this part of 'communication' all the time.

What was the patient's outcome?

 

[NotAProgDirector]

Creatinine's up from 1.4 to 2.4, urine output is WNL, suggests an ongoing renal problem also. Although his renal insuff could be due to relative hypotension (especially if he has underlying renal artery stenosis, an ACE/ARB on board, or some other predisposing factor), usually if the ARF is pressure related the urine output drops to zero. Hence, it's more likely that he has an ongoing interstitial nephritis or similar. Most likely cause would be meds, Abx are at the top of that list. Likely he got Abx for 24 hrs post op, so all of this could be a drug reaction to the abx he got -- a great reason for not giving him more abx.

Problem with cases like this is it's really hard to know what's going on without seeing the patient and reviewing all the data. We don't know why he had a lobectomy, other PMH, all of his meds, problems in the OR, etc.

"Curbside" consults used to be common in my hospital -- almost everyone insists on a full consult now.

 

[telenurse]

Thanks for the replies.
The pt was 68 male, and it was a open left upper and lower lobectomy, no chest tubes, had a portable CXR 12 hours prior to my shift, PA/LA next am scheduled.

Not immunosuppressed.

The resident was assigned to that surgical service, not crosscover.

Looking at the guy, I felt like he was teetering and was practically begging the charge nurse to give the pt to a good RN not an LPN for the dayshift.

Remembering also...feet and legs were much colder than rest of him, DP and PT palpable just cold, if you can't tell, this pt really worried me...

 

[SexPanther]

Thanks for the replies.
The pt was 68 male, and it was a open left upper and lower lobectomy, no chest tubes, had a portable CXR 12 hours prior to my shift, PA/LA next am scheduled.

Not immunosuppressed.

The resident was assigned to that surgical service, not crosscover.

Looking at the guy, I felt like he was teetering and was practically begging the charge nurse to give the pt to a good RN not an LPN for the dayshift.

Remembering also...feet and legs were much colder than rest of him, DP and PT palpable just cold, if you can't tell, this pt really worried me...

Although not 100% reliable, peripheral pulses can help differentiate types of shock. Septic shock is classically a vasodilatory shock in which you get warm extremities often with bounding pulses. Your description of his extremities makes me lean less towards sepsis (and thus Abx).

 

[Blade28]

The pt was 68 male, and it was a open left upper and lower lobectomy, no chest tubes, had a portable CXR 12 hours prior to my shift, PA/LA next am scheduled.

😕 Doesn't that mean the patient had a left pneumonectomy? With no chest tubes placed?

 

[Tn Family MD]

😕 Doesn't that mean the patient had a left pneumonectomy? With no chest tubes placed?

Exactly what I was thinking. No chest tubes?

 

[Smurfette]

Exactly what I was thinking. No chest tubes?

Why would a patient 7 days out from a pneumonectomy have chest tubes? No chance of ptx if no left lung (thus no indication for suction). If chest tube is placed, it's for output monitoring, and most advocate removal in 24hrs.

Then again, Blade, I am sure you are far more well-read in CT stuff than I am since that is what you want to do....maybe I will look this up later...

 

[Blade28]

Why would a patient 7 days out from a pneumonectomy have chest tubes? No chance of ptx if no left lung (thus no indication for suction). If chest tube is placed, it's for output monitoring, and most advocate removal in 24hrs.

Chest tubes for post-pneumonectomy patients aren't for pneumothorax, they're usually for monitoring blood loss and equalizing pressure changes in the thorax. There may also be a temporarily accumulation of fluid in the space previous occupied by the left lung.

But my attendings have always warned me about the possibility of massive subcutaneous emphysema due to mediastinum shifts after pneumonectomy. We routinely place two chest tubes in these patients regardless of disease process (i.e. malignancy vs. trauma).

BTW, Smurfette, we're the same year...so this is possibly just institution-dependent. I doubt I'm more well-read in anything. 🙂

 

[Hernandez]

Pt went into SVT on day 6, was on cardizem gtt at 10mg/hr in SR at 80-90's.

cr was 1.4, now 2.4, urine output WNL, but trending down and dark yellow.

I'd be curious what his bp's were on the Cardizem, the increased Cr could be iatragenic from that.

heart rate trending to 95-105 .......reminded of WBC count,

At this point, even though I'm not a surgeon, I'm going to agree with the nurse on this one. Post op and in SIRS, they're infected until proven otherwise (or if there is something else going on that we're not aware of in this situation) in my book.

If we look at the data about SIRS, 30% progress to sepsis, 20% to sepsis with MODS and 7% to overt septic shock. And retrospective analysis have shown that people who develop sepsis in the hospital, half of them were in SIRS for at least 1.5 days prior to developing recognized sepsis.

It could just be me, but I've seen far too many surgeon interns and even worse surgeon residents write in their assessment 1) leuckocytosis...will follow 2) febrile, will add tylenol....all while the pts got something cooking in their surgical site.

so what else about this pt are we not hearing?

oh and this is unofficial, and not to be used on your pt and should not be construed as medical advice.

 

[Hernandez]

Remembering also...feet and legs were much colder than rest of him, DP and PT palpable just cold, if you can't tell, this pt really worried me...

you're describing my wife 360 days out of the year

 

[telenurse]

He had CT sutures...not sure when chest tubes were pulled...it was my first time with the pt...and I had 5 other pts, 2 post open hearts, 2post wedge resection, and 1 post MI with PTCA 2 stents who spiked a temp of 102...

I go back to work tonight...so I'll be able to give an update...unless I get floated...

 

[yaah]

Problem with cases like this is it's really hard to know what's going on without seeing the patient and reviewing all the data. We don't know why he had a lobectomy, other PMH, all of his meds, problems in the OR, etc.

I think that's the main issue. If you have concerns, you should talk to the MDs treating the patient. People here only have the information you post plus their own biases (from experience or more importantly, INexperience).

 

[Smurfette]

Chest tubes for post-pneumonectomy patients aren't for pneumothorax, they're usually for monitoring blood loss and equalizing pressure changes in the thorax. There may also be a temporarily accumulation of fluid in the space previous occupied by the left lung.

But my attendings have always warned me about the possibility of massive subcutaneous emphysema due to mediastinum shifts after pneumonectomy. We routinely place two chest tubes in these patients regardless of disease process (i.e. malignancy vs. trauma).

BTW, Smurfette, we're the same year...so this is possibly just institution-dependent. I doubt I'm more well-read in anything. 🙂

Actually, I have heard the medistinal fluid shift thing before...just forgot. But I still would think that that is more of an initial post-op problem rather than something a week out.?? Is the risk of massive subq emphysema derived from an airleak from the bronchial stump then? Just curious. Our CT service(s) where I am are pretty minimal in the thoracic component and heavy in the cardiac....haven't taken care of many pneumonectomies.

 

[elwademd]

I have a pt scenario I have some concerns about, I'd post this on allnurses...but I want to hear from doctors not nurses. I'm always willing to be educated.

I had a pt, 7 days s/p L lobectomy.
BP trends over 5 days went from 140 sbp 70dbp to 100sbp 50dbp.
Pt went into SVT on day 6, was on cardizem gtt at 10mg/hr in SR at 80-90's.

This is where I took care of this pt...and noted that His WBC were trending up, from 13.1 on post op day 2 to 23.2 on post op day 7. Gran# were 18.33 on postop day 7, gran % 79, lymph % 10, with toxic grans noted.
He had been cultured previously blood, sputum and urine, cultures pending...he was not on antiobiotics. Also noted his BUN was trending up, was 24 post up now 30, cr was 1.4, now 2.4, urine output WNL, but trending down and dark yellow.
Pt had crackles to base of R Lung, SPo2 94% on 4L, productive cough, frothy yellow/white. Encouraged pulmonary toilet, neb tx.
Temp was 97.1 orally...heart rate trending to 95-105 and BP trending to 90/50 manually for me.... pt with intractable n/v refractory to zofran and phenergan. Resident notified x2, reminded of WBC count, updated on condition, not concerned, reordered antiemetics.
I was checking VS on this guy every 2 hours, digging through his chart...etc. Tried talking to the resident, he didn't really want to talk to a nurse.

So teach me...
What would be a valid reason this guy is not on antibiotics?? Because I can't think of one, and I just really feel like I didn't advocate for this guy enough.

you presume that his white count is a result of his infection, and thus his entire condition is a result of his infection. but an elevated white blood cell count does not necessarily mean infection (reactive leukocytosis, myelproliferative disorder, leukemia to name a few). as others have stated, if it is an infection, you'd need to know what the likely/potential source is, in order to start the appropriate antibiotics.

with all of that said, there's plenty of other potential causes for the patient's condition besides infection... a glaring part that's left out of the history is the reason for the lobectomy in the first place! infarcted tissue from a pulmonary embolus? lung cancer (stage 1 or 2)? an emphysematous bullae? or something else?

 

[telenurse]

Sorry about late follow up...I went back to work Friday in the middle of a killer migraine, census was low and I was sent home. Saturday I finally took enough meds to knock myself out, today after 22 hours straight sleep I woke up to my spouse taking my vitals "to be sure you're still alive", still am postdromal...

The brief update I was able to obtain on the pt...was that at approx 1000am that day he started desatting and his BP went throught the toilet...was successfully bolussed, and placed on Bipap...was started on cipro, zosyn, fluconazole. BP stabilized, pt remained on my floor. Cultures came back, (I think it was g+rods, don't quote me...this was a BAD migraine) It was a UTI after all, but pt was "showing signs of sepsis syndrome" per resident's notes.

 

[Hernandez]

It was a UTI after all, but pt was "showing signs of sepsis syndrome" per resident's notes.

This is me acting shocked. This is one thing which should be watched very closely and we should be extremely aggressive with, IMHO. Just as my med students how much I harp on SIRS and sepsis. I guaran-damn-tee my students will have this memorized before they finish a round on service with me.

 

[Blade28]

Cipro and Zosyn? That's a weird combo.

 

[andros]

Cipro and Zosyn? That's a weird combo.

Double coverage for pseudomonas?

 

[Blade28]

But how about Gram-positive coverage?

 

[Pir8DeacDoc]

Zosyn covers Gram (+).

 

[RTrain]

Meh, Zosyn ain't bad for gram positives. It's not the best thing, but if you're covering enterics too you get good bang for your buck. Only thing not getting any whipping is MRSA.

 

[Faebinder]

Meh, Zosyn ain't bad for gram positives. It's not the best thing, but if you're covering enterics too you get good bang for your buck. Only thing not getting any whipping is MRSA.

Or the new name for it... "ZRSA". 😀

 

[Blade28]

Yeah, it's OK...guess it ended up being decent for the aforementioned Gram-positive rods, just wouldn't have been first-line choice for the big Gram-positive cocci.