#SimBlog: Pneumonia, Secondary to Sepsis

““A 75-year-old man presents with a 4-day history of a productive cough and is now feeling quite short of breath.””

— He is usually fairly fit and totally independent, living alone with no carers.

Observations

A – RR 21

B – Sats 94%

C – HR 93

D – BP 110/86 (usually 140/90)

E – Temperature 38°C

Clinical Findings

• Hypertension

• Currently on Ramipril

• NKDA

Why We Simulated?

This simulation was designed to highlight the subtleties of both recognising sepsis and it’s management (according to UHL sepsis guidance). The patient has presented with a productive cough and mildly deranged observations. He is scoring for sepsis, but not red flag at this stage.

The bloods are done and VBG shows a lactate of 3.6. Antibiotics and fluids are commenced. A CXR is performed which shows a right-basal consolidation. After the patient has received treatment and the fluid bolus has gone through, a repeat VBG is performed, which shows the lactate has dropped to 2.6. At this stage the BP drops to 90/60.

According to the UHL guidelines, if the lactate has not dropped below 2 following adequate fluid resuscitation, Critical Care should be involved.

Further Reading:

• NICE: Sepsis – recognition, diagnosis and early management

Learning Outcomes

1. Always remember to take a full social history from the patient. If at a later time you need to refer on, especially to critical care this will be vital information.

2. If the patient does not have any history of heart failure, give a full volume of fluid resuscitation, not just one bag.

3. Think ahead past informing your senior, if they are not immediately available you need to have a plan.

4. Know your sepsis guideline and local escalation policy.

Positive Feedback

• Good use of team members, with clear delegation and instructions.

• Good history of presenting complaint.

• Sepsis recognised early and antibiotics administered very quickly, well within the hour target.

Edit & Peer review by Damian Roland & Darren Whitelaw