Septic shock is a life-threatening complication associated with sepsis, which is the dysregulated host response to severe infection (Cecconi, Evans, Levy, & Rhodes, 2018, p. 75) The condition sepsis occurs when the body’s immune system turns on itself and causes inflammation in the body. Septic shock is the late stage of sepsis where cells and tissues are hypoperfused secondary to persisting hypotension. World Health Organization [WHO] (2018, p.) has stated that globally, each year, an estimated six million patients die from sepsis.
In this case scenario, Jedda Merindah, a 33-year-old male of Indigenous heritage has been admitted after a post-medical emergency for hypotension. He was receiving induction phase chemotherapy for his Acute Myeloid Leukemia (AML). According to Merindah’s self-monitoring, he reported that he was afebrile. Blood culture taken 1 week ago did not grow any pathogen. His past medical history indicates Acute Rheumatic Fever during childhood with no structural heart abnormalities, mild left ventricle dilation, and normal ejection fraction based on the previous echocardiogram. Other past medical history includes depression and hypercholesterolemia. which he is taking Citalopram 10mg daily and Atorvastatin 40mg respectively. In addition, Merindah attempted suicide in 2003 via drug overdose. On assessment, his sign and symptoms are heart rate 118 beats/min with atrial fibrillation, Blood pressure 92/65mmHg, febrile 38.8°C, Hb 89, WBC 3.4, creatinine 138, BGL 9.6mmol, tachypneic 28 breaths per minute, using accessory muscles, anxiety and restless, diaphoretic, decreased nutritional intake and decreased urinary output. This paper will discuss the identification of the presented case-patient deterioration due to septic shock and the evidence-based practice of clinical interventions that can be put in place to ensure the patient is regaining good health.
The early recognition of the clinical deterioration gives room for the health care providers to look for the best means possible to adequate and evidence-based interventions to the patient (Fisher & King, 2013, pp. 2378-2381). Therefore, Registered Nurses must possess knowledge on physiological changes that occur during septic shock and the possible interventions that can help the patient.
Sign and symptoms: Decreased BP, Increased respiratory rate and effort, decreased WBC and platelets
The patient blood pressure is 92 mmHg Systolic which according to definition is not considered hypotensive shock (Dellinger, 2013, p. 583). However, the increase in HR shows the body’s attempt to increase the cardiac output to preserve the oxygen delivery to cells and tissues (CO = HR X SV). This was possibly caused by the release of adrenaline which is another attempt to increase the BP to preserve the organ perfusion. Another assessment data which confirms this assumption is the cold peripheries secondary to peripheral vasoconstriction caused by the release of angiotensinogen which is part of the renin-angiotensin -aldosterone system (RAAS) (CorrĂŞa, Takala, & Jakob, 2015).
In addition, the blood test confirmed the potential hypotension perfusion of the kidneys because the creatine level was 138 and urea is 11.2 which both are about the reference ranges. The cause for the suspected infective reaction is likely viral-induced septic shock as the blood culture when negative however a septic screen is recommended to identify the potential source of infection, in particular, because the patient is febrile and diaphoretic. According to the blood test result, the white cell count was below the reference range which increases the susceptibility of the patient to infection. However, the hemoglobin and platelet are also decreased. This is likely caused by chemotherapy which affects all myeloid lineage cells, resulting in pancytopenia. This increases the risk of coagulopathy, indicated by deranged APTT and INR.
Priority: Kidney Perfusion
Based on the information above, the highest priority is to support the body’s attempt to compensate for the decreased blood pressure and to improve organ perfusion, particularly in the kidneys (Benedict, 2015, p. 140). The inability of the body to compensate can lead to a multiorgan failure. This is caused by cell hypoxia, leading to anaerobic respiration and later lactic acidosis and decreasing blood pH, which consequently increases mortality rates (Benedict, 2015, p. 141). It has been shown that lactic acid is a rather strong vasodilative agent that would further decrease blood pressure. The Surviving Sepsis Campaign identifies a lactic acid level of more than 4 mmol/L as potentially dangerous for the entire metabolism.
Collaborative Intervention: Fluid Resuscitation
The Registered nurse has to assess the IV access for patency and signs of infection before connecting the infusion. Also, the regular assessment of the IV access is recommended to recognize a potential tissuing of the fluid, which might cause pain and discomfort to the patient. Most of the current guideline recommends an initial fluid resuscitation with isotonic crystalloids and the fluid of choice is mostly the 0.9%NaCl (Bark, Persson, & Grände, 2013, p. 862; Winters, Sherwin, Vilke, & Wardi, 2017, p. 593). The reason for this choice is the fact that it is cheap, available, and well-tolerated. A volume of 2 liters is adequate in a young and healthy patient; however, the patient in this case study has a medical history of mild ventricular dilatation, and during fluid over-resuscitation, the inability of the left ventricle to contract might cause further dilatation, fluid overload in the respiratory system, and heart failure (Rochwerg et al., 2014, p. 349).
Also, the patient has a mild renal impairment; therefore, a 2-liter fluid resuscitation might be contraindicated. According to Rhodes et al. (2017), the volume of fluid directly depends on the patient’s arterial pressure (AP) (p. 492). The increased volume is likely to lead to the raised cardiac index, while the urinary flow remains unchanged. The above authors demonstrated that the change of AP from the target 65 mm Hg to 85 mm Hg is a sign of significantly decreased risk of mortality (Lira & Pinsky, 2014, p. 47).
Dellinger et al. (2013) recommend that after the initial fluid resuscitation, the volume of further infusion therapy should be re-estimated based on a repeated assessment of the hemodynamic status of a patient (p. 584). It is also suggested by Rhodes et al. (2017) to use an initial target mean arterial pressure of 65 mm Hg (p. 492). The above authors propose to consider increasing the level of serum lactate as a marker of kidney tissue hyperperfusion syndrome. It is assumed that its normalization determines the effectiveness of intensive therapy (Rhodes et al., 2017, p. 310). However, the condition of the patient may change fast, and the nurse should report on any expected or unexpected situation.
To assess the success of fluid resuscitation, ScvO2 (the target value is ≥ 70%) and lactate clearance (10-20%) may be used (Venkataraman & Kellum, 2013, p. 11). In this regard, the risk of pulmonary edema can be controlled by optimizing the preload. Kumar, Kumar, and Lata (2013) conclude that albumin infusion is likely to contribute to extracellular fluid overload, while hypovolemia in patients with sepsis tends to be unchanged (p. 454). This means that fluid may return to intravascular space, leading to an increase in BP and a reduction in HR.
The modern guidelines for fluid resuscitation explain the fact that large volumes of liquid (5-10 liters) are often introduced in the early stages of sepsis. However, there is little evidence that fluid infusion (> 30 ml/kg), significantly exceeding the daily physiological demand for water, reliably improves blood pressure and organ perfusion (Silversides et al., 2017, p. 159). From a pathophysiological point of view, fluid resuscitation using large volumes in patients with sepsis may worsen existing hemodynamic disorders. Even in patients with septic shock, who respond to the introduction of fluid increased cardiac output, vasodilation with a decrease in the vascular tone of systemic and vascular resistance may be observed.
Pharmacological Intervention: Noradrenaline (NA) Infusion
In case the given patient shows resistance to the aggressive fluid resuscitation, vasopressor or inotropic therapy may be applied as a part of the Surviving Sepsis Campaign (Pollard, Edwin, & Alaniz, 2015, p. 445). In particular, it has been demonstrated that noradrenaline is the key agent to increase vasoconstriction using stimulating α-adrenergic and β-adrenergic receptors (Rhodes et al., 2017, p. 493). If hypotension persists, patients with septic shock can be assigned norepinephrine in addition to vasopressin (0.03 units/min) to increase the mean arterial pressure (MAP) to at least 65 mm Hg (Rhodes et al., 2017, p. 492). To preserve kidney tissue perfusion, the efficacy of titration of norepinephrine before reaching a mean of 65 mm Hg was demonstrated (Leone, Asfar, Radermacher, Vincent, & Martin, 2015, p. 106). Such indicators as blood pressure are important to supplement the study of global perfusion, for example, by determining the concentration of blood lactate and diuresis. In case of the failure of achieving the desired effect with the administration of Noradrenaline, the physician can add other agents such as Adrenaline and Dobutamine (Rhodes et al., 2017, p. 504).
One of the most significant side-effects of Noradrenaline is the release of glucose from the liver and muscle cells, which occur due to the activation of the Noradrenaline receptors causing a similar reaction from the release of endogenous Noradrenaline. The nurses must assess the blood sugar level more frequently to monitor the state of patients, as proposed by Damiani et al. (2015) in their systematic review study (p. 7). About kidney perfusion management, a nurse’s responsibilities include management and administration of NA to patients. Vasopressor administration is characterized by central venous access or a central line as a possibility to reduce the risks of extravasation (Plum & Moukhachen, 2015, p. 583). The above evidence demonstrates that peripheral NA administration should be avoided. Instead, it is recommended to use a CV line for such infusion. Therefore, nurses have to monitor their patients and check their BP continuously to recognize early infection or other complications.
In sum, if nurses and pharmacists follow the plan established by the therapist and monitor all the changes, it is possible to avoid negative outcomes of the chosen therapy. The patient’s condition is not stable, and her past suicidal attempts caused by drugs have to be taken into consideration when a pharmacological approach is offered. Noradrenalin infusion along with fluid resuscitation is the effective solution in this case.
Nursing Initiated Interventions
The task of a nurse is not only to control the condition of this person but also to take the necessary steps and control fever. Considering that the patient’s temperature is 38.8oC, it should be controlled during the therapy. Suzuki et al. (2015) recommend paracetamol as one of the best and less harmful analgesic and antipyretic drugs for the patients in the intensive care unit or other critical patients (p. 167). Nasogastric tube, rectal, or oral administration of paracetamol may be selected depending on the patient’s state and related therapies (Chiumello, Gotti, & Vergani, 2017, p. 249). In this case, a nurse can follow an oral administration with its standard dose of 4 g/day during the next 2-3 weeks (Young et al., 2015, p. 2220). Instead of searching for some anti-inflammatory options for the patient, a nurse should select paracetamol as a strong pain killer due to its analgesic qualities. Though it does not aim to reduce the level of inflammation in the body, it will cope with inflammation complications.
Compared to other analgesic and anti-inflammatory agents, the effectiveness of paracetamol is explained by fewer side effects. For example, the antipyretic effect of paracetamol has a positive outcome as it lowers metabolic demand (Chiumello et al., 2017, p. 250). However, fever may be a sign of infection in the body, and the role of a nurse is to observe the condition of the patient to clarify if fever is a sign or an outcome of another dangerous condition. The patient should feel comfortable, and the nurse is the person who should take enough time and effort to note changes and improvements. Sepsis has several hidden causes and outcomes in addition to fever. Though antibiotics can stabilize the condition of the patient by adjusting the blood flow (Kleinpell, Aitken, & Schorr, 2013, p. 216; Vaughan & Parry, 2016, p. 1199), this approach is not recommended in this case. In others words, paracetamol should be regarded as the preferred option.
In general, the intervention based on paracetamol administration is identified as the option that is less harmful to critically ill patients. Its analgesic and antipyretic impacts provide a nurse with an opportunity to make a final decision and increase the dose. However, the toxic dose of paracetamol is variable and depends on patients’ age, condition, and other therapies (Young et al., 2015, p. 2220). Therefore, communication with the patient and the recognition of additional factors and changes cannot be ignored in the course of the intervention implementation.
Conclusion
To conclude, several options may be selected to manage the patient’s kidney perfusion, including fluid resuscitation, noradrenaline infusion, and nursing initiatives. It is revealed that fluid volume depends on AP and cardiac output, and resuscitation effectiveness is proved by recent studies. In addition to the infusion therapy, inotropic support plays an important role in the stabilization of hemodynamic parameters, providing an adequate level of tissue perfusion along with the coping of hemodynamic disorders. Noradrenaline causes vasoconstriction, increased BP without worsening cardiac output, and reduced mesenteric blood flow. Ultimately, the clinical application of nursing-related interventions focuses on proper patient evaluation, administration of agents, as well as the control of the key indicators.
References
Bark, B. P., Persson, J., & Grände, P. O. (2013). Importance of the infusion rate for the plasma expanding effect of 5% albumin, 6% HES 130/0.4, 4% gelatin, and 0.9% NaCl in the septic rat. Critical Care Medicine, 41(3), 857-866.
Benedict, L. (2015). Surviving sepsis in the critical care environment. Critical Care Nursing Quarterly, 38(2), 137-142.
Chiumello, D., Gotti, M., & Vergani, G. (2017). Paracetamol in fever in critically ill patients—An update. Journal of Critical Care, 38, 245-252.
Damiani, E., Donati, A., Serafini, G., Rinaldi, L., Adrario, E., Pelaia, P.,… Girardis, M. (2015). Effect of performance improvement programs on compliance with sepsis bundles and mortality: A systematic review and meta-analysis of observational studies. PLoS One, 10(5), 1-12.
Dellinger, R. P., Levy, M. M., Rhodes, A., Annane, D., Gerlach, H., Opal, S. M.,… Osborn, T. M. (2013). Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock: 2012. Intensive Care Medicine, 39(2), 165-228.
Kleinpell, R., Aitken, L., & Schorr, C. A. (2013). Implications of the new international sepsis guidelines for nursing care. American Journal of Critical Care, 22(3), 212-222.
Kumar, R., Kumar, S., & Lata, S. (2013). Albumin infusion may deleteriously promote extracellular fluid overload without improving circulating hypovolemia in patients of advanced cirrhosis with diabetes mellitus and sepsis. Medical Hypotheses, 80(4), 452-455.
Leone, M., Asfar, P., Radermacher, P., Vincent, J. L., & Martin, C. (2015). Optimizing mean arterial pressure in septic shock: A critical reappraisal of the literature. Critical Care, 19(1), 101-108.
Lira, A., & Pinsky, M. R. (2014). Choices in fluid type and volume during resuscitation: Impact on patient outcomes. Annals of Intensive Care, 4(1), 38-51.
Plum, M., & Moukhachen, O. (2017). Alternative pharmacological management of vasopressor extravasation in the absence of phentolamine. Pharmacy and Therapeutics, 42(9), 581-585.
Pollard, S., Edwin, S. B., & Alaniz, C. (2015). Vasopressor and inotropic management of patients with septic shock. Pharmacy and Therapeutics, 40(7), 438-450.
Rhodes, A., Evans, L. E., Alhazzani, W., Levy, M. M., Antonelli, M., Ferrer, R.,… Rochwerg, B. (2017). Surviving sepsis campaign: International guidelines for management of sepsis and septic shock: 2016. Intensive Care Medicine, 43(3), 304-377.
Rochwerg, B., Alhazzani, W., Sindi, A., Heels-Ansdell, D., Thabane, L., Fox-Robichaud, A.,… Ip, W. C. (2014). Fluid resuscitation in sepsis: A systematic review and network meta-analysis. Annals of Internal Medicine, 161(5), 347-355.
Sherwin, R., Winters, M. E., Vilke, G. M., & Wardi, G. (2017). Does early and appropriate antibiotic administration improve mortality in emergency department patients with severe sepsis or septic shock? The Journal of Emergency Medicine, 53(4), 588-595.
Silversides, J. A., Major, E., Ferguson, A. J., Mann, E. E., McAuley, D. F., Marshall, J. C.,… Fan, E. (2017). Conservative fluid management or deresuscitation for patients with sepsis or acute respiratory distress syndrome following the resuscitation phase of critical illness: A systematic review and meta-analysis. Intensive Care Medicine, 43(2), 155-170.
Suzuki, S., Eastwood, G. M., Bailey, M., Gattas, D., Kruger, P., Saxena, M.,… Bellomo, R. (2015). Paracetamol therapy and outcome of critically ill patients: A multicenter retrospective observational study. Critical Care, 19(1), 162-171.
Vaughan, J., & Parry, A. (2016). Assessment and management of the septic patient: Part 2. British Journal of Nursing, 25(21), 1196-1200.
Venkataraman, R., & Kellum, J. A. (2013). Sepsis: Update in the management. Advances in Chronic Kidney Disease, 20(1), 6-13.
Williams, L. M. (2014). Take aim at acute kidney injury with RIFLE criteria. Nursing2018, 44(7), 50-55.
Young, P., Saxena, M., Bellomo, R., Freebairn, R., Hammond, N., van Haren, F.,… McGuinness, S. (2015). Acetaminophen for fever in critically ill patients with suspected infection. New England Journal of Medicine, 373(23), 2215-2224.