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