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    Septic Shock Student Case Study

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    Jenn Galloway
    A 74-year-old man arrived at the ER unconscious with stab wounds to his abdomen and chest. He was hypotensive and tachycardic. He underwent surgery which revealed lacerations to his liver and duodenum. Over the next few days in the ICU, his condition deteriorated as he developed signs of infection, hypotension, and multi-organ dysfunction. Blood cultures grew gram-negative bacilli and antibiotics were started. However, his condition continued to worsen and he became septic and hypotensive, with mottled skin and abdominal distension. Lab results showed worsening acidosis, electrolyte imbalances and organ dysfunction. Despite aggressive treatment, he continued to decompensate and died from

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    Septic Shock Student Case Study

    Uploaded by

    Jenn Galloway
    549 views6 pages
    A 74-year-old man arrived at the ER unconscious with stab wounds to his abdomen and chest. He was hypotensive and tachycardic. He underwent surgery which revealed lacerations to his liver and duodenum. Over the next few days in the ICU, his condition deteriorated as he developed signs of infection, hypotension, and multi-organ dysfunction. Blood cultures grew gram-negative bacilli and antibiotics were started. However, his condition continued to worsen and he became septic and hypotensive, with mottled skin and abdominal distension. Lab results showed worsening acidosis, electrolyte imbalances and organ dysfunction. Despite aggressive treatment, he continued to decompensate and died from

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    Septic Shock case study

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    A 74-year-old man arrived at the ER unconscious with stab wounds to his abdomen and chest. He was hypotensive and tachycardic. He underwent surgery which revealed lacerations to his liver and duodenum. Over the next few days in the ICU, his condition deteriorated as he developed signs of infection, hypotension, and multi-organ dysfunction. Blood cultures grew gram-negative bacilli and antibiotics were started. However, his condition continued to worsen and he became septic and hypotensive, with mottled skin and abdominal distension. Lab results showed worsening acidosis, electrolyte imbalances and organ dysfunction. Despite aggressive treatment, he continued to decompensate and died from

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    549 views6 pages

    Septic Shock Student Case Study

    Uploaded by

    Jenn Galloway
    A 74-year-old man arrived at the ER unconscious with stab wounds to his abdomen and chest. He was hypotensive and tachycardic. He underwent surgery which revealed lacerations to his liver and duodenum. Over the next few days in the ICU, his condition deteriorated as he developed signs of infection, hypotension, and multi-organ dysfunction. Blood cultures grew gram-negative bacilli and antibiotics were started. However, his condition continued to worsen and he became septic and hypotensive, with mottled skin and abdominal distension. Lab results showed worsening acidosis, electrolyte imbalances and organ dysfunction. Despite aggressive treatment, he continued to decompensate and died from

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    © All Rights Reserved
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    of 6

    Septic Shock

    Case: Joseph Bender, a 74-year-old make arrived in the ER unconscious, with stab
    wounds to the right upper abdomen and lower-right chest which he sustained after
    being confronted with an intruder in his home. When paramedics arrived, they
    started 2 large-bore IVs and infused lactated ringers wide open. An ET tube was
    inserted and ventilations with 100% oxygen was started. He arrives in the ER and
    two chest tubes are immediately inserted. 500 ml of red drainage was returned
    from the lower chest tube.
    Vitals are as follows: BP 70/50 mm HG; HR 125bpm; R 30 breaths/min; Temp 37C
    (98.6F). Weight 165 lb (74kg)
    1. What is your priority nursing assessment at this time? Checking patients
    respiratory status and function. Auscultating lungs, assessing oxygenationperfusion (lips, fingers, etc).
    2. What additional interventions should be done? Position HOB in Semi-Fowlers
    position; check ventilator function (mode, rate, tidal volume); start 2 new large
    bore IVs not in antecubital vein; ensure closed-tube drainage system is working
    properly (tidaling, bubbling, etc); ensure dressing around tube is intact and
    protecting tube (Vaseline gauze & ABD pad-tape to skin to protect from bacteria)
    3. How is endotracheal tube, how is placement verified?
    Answer: Confirm the placement of the ET tube while the patient is manually
    ventilated using the Ambu bag with 100% O 2. A chest x-ray can be used to confirm
    placement; other methods include using an end-tidal CO 2 detector to note the
    presence of exhaled CO2 from the lungs and listening for equal bilateral breath
    sounds while observing equal bilateral chest expansion. In addition, SpO 2 should be
    stable or improved.

    A urinary catheter is inserted with a return of 400 ml clear, dark yellow urine. He
    received 2L of LR and was sent to the OR still hypotensive.
    OR procedure revealed a lacerated liver and duodenum. Extensive hemorrhage and
    leaking of intestinal contents were apparent after opening the peritoneum. Injuries
    were repaired, peritoneal cavity was irrigated with antibiotic solution and incisional
    drains were placed in the duodenum. During the 4 hour surgery, Mr. Bender
    received 6 U of blood and 3 L LR. PA catheter and arterial line was inserted.
    4. Why were these lines necessary to Mr. Benders care? Impaired gas exchange
    related to trauma; to ensure adequate venous return and help monitor and provide

    care. Arterial line may be placed for blood sampling and BP monitoring. PA cath
    may be used for fluids and antibiotic therapy by IV.

    5. Knowing what you do at this point, what is he especially at risk for and why?
    Infection! He had intestinal content leakage. It also puts him at risk for peritonitis.

    He is admitted to the SICU on the following vent settings:


    Mode: Assist control (A/C)-he can start his initial breath but the machine helps
    expand his lungs to fill tidal volume
    Rate: 12- this ensures that at least this amount of breaths are given but he is able
    to breathe his own additional breaths
    Fi02 60%- this is the fraction of inspired oxygen delivered to the patient by the
    ventilator
    Tidal volume 800 ml- amount of air delivered with each patient breath
    Peep 5+ -this is being used to help improve the patients oxygenation and maintain
    the set parameters prescribed by the physician
    6. Describe each of R.B.'s ventilator settings and the rationale for the selection of
    each.
    See above.
    7. You obtain a set of hemodynamic monitoring values. Interpret these results:
    BP 92/52 mm Hg, HR 114 bpm,
    PAOP 6 mmHg

    CVP 4

    RR 12 breaths/min T 36.2C (97.2 F)

    SVR 1040

    CO 5.0 L/min

    CI 2.9 L/min/m 2

    Labs: Normal ABGs, Hgb 10g/dl, WBC 13.6


    BP has increased from baseline due to fluid and blood restoration. HR may be
    elevated related to blood loss that he sustained during trauma and surgery. RR is
    WNL. Temperature is decreased possibly as a s/e of anesthesia from surgery. PAOP,
    CVP, SVR, CO, & CI are WNL perhaps due to fluid loss being maintained through
    fluids and blood volume resuscitation. Hemoglobin may be decreased due to blood
    loss. WBC elevation could be related to possible infection and/or inflammation.

    ICU POD 1 he remains drowsy and is ventilated. Pain controlled with Morphine IV
    and Fentanyl. NG draining large amounts of green fluid. Duodenal drains with large
    amount soft greenish brown fluid. Dressings dry. Breath sounds diminished to right
    side but clear on left. Urine output 40-60 ml/hr. Abdomen slightly firm, no bowel
    sounds.
    POD 2 he became less responsive and difficult to arouse but could follow
    commands. Skin warm, dry, flushed. U/O decreased to 20ml/hr.
    Vitals and hemodynamics:
    BP 80/50 mm Hg, HR 134 bpm,
    PAOP 4 mmHg

    CVP 2

    RR 28 breaths/min T 36.2C (97.2 F)

    SVR 560

    CO 8.0 L/min

    CI 4.7 L/min/m 2

    Labs: WBC 22,000. Glucose 270.


    8. Interpret these findings.
    BP is fallen because of the bodys response to external fluid loss through
    tubes/drains, may also be a compensatory response. RR & HR are elevated maybe
    in response to infection and/or compensation of the body (fluid loss). Temperature
    may be fluctuating in response to infection. HR is tachy in response to body trying
    to compensate for change in status & perfusion. PAOP is decreased due to possible
    hypovolemia. SVR is decreased perhaps due to inflammatory mediators causing
    vasodilation. CI & CO is elevated as the heart is pumping out more (compensation
    from being in a hypermetabolic state). Increased WBC indicate infection and/or
    inflammatory response to pathogens. Glucose is elevated as a hypermetabolic
    response and resistance to insulin. We want to keep these in control to decrease
    the rate of infectious complications.
    9. What should be ordered at this time? Blood culture for accuracy in identifying
    pathogen. Antibiotic therapy depending on what organism has been identified as
    the causative agent. Fluid resuscitation to try and elevate that BP and
    oxygenation/perfusion balance. We may need to get a vasopressor ordered
    depending on patients response to fluid administration and antibiotic therapy
    response. The vasopressor will be used to help elevate the BP. Insulin drip to
    decrease the rate of infectious complications and lower the blood sugar to
    acceptable level.

    Lab: Culture and sensitivity from wound drainage shows gram-negative bacilli.
    LR increased to 150ml/hr.

    Dopamine started at 5 ug/kg/min. TPN started.

    10. Describe the purpose of Dopamine. Is this an appropriate dose? Why or why
    not?
    Dopamine is used to increase contractility and maintain adequate BP & perfusion.
    We want the BP to be back in normal range and have adequate perfusion. In order
    for this medication to work appropriately (vasoconstrict), the dosage needs to be
    higher (>10mcg/kg/min).
    Mr. Bender continued to deteriorate over the next couple of days. BP remained low.
    Norepinephrine (Levophed) 4mg/250 ml started at 6ug/min.
    11. Why is this medication chosen? Could Neosynephrine be used instead? Why or
    why not?
    This medication is more potent than Dopamine. It causes direct venous and arterial
    constriction. Neosynephrine could be used but Norepinephrine is typically the first
    choice because it directly works on Beta receptors. NE doesnt cause tachycardia
    like dopamine can. It also doesnt worsen end0organ ischemia.

    By POD 6 skin was cool, mottled and moist. Sclera yellow. Unresponsive to stimuli.
    Monitor showing the following rhythm.
    12. Interpret: PVC

    What medication could be added at this time and why? Lidocaine to


    decrease irritability of the myocardium (ventricles less likely to fibrillate)
    and amiodarone which also controls the rate

    Lungs with crackles throughout. U/O 3-5 ml/hr and grossly bloody. Abdomen
    distended and firm. Suture lines dehisced. NG drainage red.
    13. You obtain a set of vitals and hemodynamic monitoring values. Interpret these
    results.

    BP 70/50 mm Hg, HR 140 bpm,


    PAOP 24 mmHg

    CVP 8

    RR 14 breaths/min, T 35.8C (96.4F)

    SVR 2000

    CO 2.0 L/min

    CI 1.1L/min/m 2

    BP-patient is hypotensive. Temperature is decreasing in response to possibly being


    in shock. PAOP is now increased because of possible fluid overload. CVP may be
    elevated in response to an increased volume due to infusion of fluid into system.
    SVR may be elevated due to vasoconstriction from medications. CO & CI has
    decreased because the heart is not pumping effectively due to fluid overload.
    14. Interpret the ABGs.
    pH 7.14,

    PCO2 49.1 mmHg,

    PO2 46%

    HCO3 12 mmol/L Sa02 85

    Patient is now in combined respiratory and metabolic acidosis. His levels are
    decreased because there is no perfusion and oxygenation going on.

    Labs:

    WBCs 13.9mm3

    Na 152 mmol/L

    Glucose 117mg/dl

    K+ 5.9 mmol/L

    Cl- 103mmol/L

    Creatinine 3.4mg/dl

    ALT 100 U/L


    FDP 39
    PT 22sec
    Amylase 290 U/L

    AST 82U/L
    Platelets 75,000
    PTT 98.5 sec
    Lipase 3.9 U/L

    15. Discuss the significance of Mr. Benders clinical changes on day 6.


    Rapid deterioration through decompensation from infection.
    Metabolically, his levels have shifted due to organ dysfunction. There is
    still an elevated WBC count indicative of infection. Sodium is elevated
    because the kidneys arent functioning and are retaining water and
    sodium. Potassium may be elevated due to dysrhythmias. Platelets
    counts are decreased due to bleeding. Creatinine levels are elevated in
    response to the organs starting to shut down. The kidneys arent
    functioning therefore the level continues to rise. PT and PTT could be
    elevated in response to bleeding and decreased platelet counts and
    inability to coagulate properly.

    16. Why are the renal, liver, and pancreatic labs abnormal? Kidneys cant
    filter the acid from the body. There has been profound ischemia to organs
    due to inadequate perfusion and oxygenation

    17. How do elderly patients manifest symptoms of sepsis? Altered mental


    status, delirium, weakness, anorexia, fluid loss while maintaining temp
    until it suddenly bottoms out; febrile, hypothermic, shaking, chills, racing
    heart- which may be symptomatic of small infections that providers should
    be aware of.

    Final events
    Despite all efforts, Mr. Bender went into the following cardiac rhythm:

    Interpret: ventricular fibrillation

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