Septic Shock and MODS Case Study A

Septic Shock and MODS Case Study A 72-year-old male client arrived in the emergency department unconscious, with stab wounds to the upper-right abdomen and lower-right chest sustained in his home fighting off an attacker. EMS providers secured two large bore intravenous lines in his right and left antecubital spaces and infused a lactated ringer bolus. An endotracheal tube was inserted and ventilation with a resuscitation bag was initiated. Pressure dressings to both wounds were secured. A five-centimeter stab wound to his right lower chest and a 7-centimeter stab wound to his right upper abdomen were inspected. Chest tubes were inserted, and 500 mL of sanguineous immediately returned via the lower chest tube. The client’s heart rate was 125 beats per minute, sinus tachycardia without ectopy. His blood pressure was 70/50 mmHg (57). Inserting a Foley catheter resulted in drainage of 400 mL of clear, dark yellow urine. Upon arrival, he went straight to the operating room. 1. What is suspected in the above scenario and what do you think the priority treatments are? During surgery, a right thoracotomy and right abdominal laparotomy were performed. The right upper chest wound was explored, and a lacerated intercostal artery was ligated. Exploration of the upper right abdominal wound revealed more extensive damage. The liver and duodenum were lacerated. Extensive hemorrhage and leaking of intestinal contents were apparent after opening the peritoneal cavity. His injuries were repaired, the peritoneal cavity was irrigated with antibiotic solution, and incisional drains were placed in the duodenum. During the four-hour surgery, he received six units of packed red blood cells and an additional three liters of lactated ringers. A pulmonary artery catheter and right radial arterial line were inserted. Vital signs and hemodynamic parameters after surgery were as follows: BP: 92/52 (65) mm Hg HR: 114 beats/minute Respirations: 12 breaths/minute Temperature: 36.2 C (97.2 F) PAP: 20/8 mm Hg PCWP: 6 mmg Hg CVP: 4 mm Hg CO: 5 L/min CI: 2.9 L/min/m2 SVR: 1040 dynes/sec/cm-5 Except for a white blood cell count of 13.6 mm3 and a hemoglobin of 10 g/dL, his other lab values are within normal parameters. He remained drowsy and received ventilator support for 24 hours. His pain was controlled by morphine. The nasogastric tube continued to drain large amounts of green fluid and the incisional drains drained large amounts of greenish brown fluid. His chest and abdominal dressings remained dry. Breath sounds were diminished on the right side but clear on the left. His chest tubes continued to drain small amounts of serosanguinous fluid. Urine output was 40 to 60 mL/hour. His abdomen was slightly distended and firm, and he had no bowel sounds. His condition remained stable until his second postoperative day. He became difficult to arouse but did respond to commands. His respirations were 28 breaths/minute, shallow, and labored. His urine output dropped to 20 mL/hour. His skin became warm, dry, and flushed. His vital sign and hemodynamic parameters were as follows: BP: 80/48 (58) mmHg HR: 132 beats/minute WBCs: 28,000/mm3 Temperature: 36.2 C (97.2 F) PAP: 14/7 mm Hg PCWP: 4 mmg Hg CVP: 2 mm Hg CO: 8 L/min CI: 4.7 L/min/m2 SVR: 560 dynes/sec/cm-5 2. What is suspected in the above scenario and what do you think the priority treatments are? Culture and sensitivity reports from wound drainage indicated gram-negative bacilli. Appropriate intravenous antibiotics were administered. TPN was started. A fluid bolus was given, and an infusion of lactated ringers was increased to 150 mL/hour. Levophed was started at 0.02 mcg/kg/minute and titrated to maintain a mean pressure > 65 mmHg. By the sixth postoperative day, his condition had deteriorated rapidly. His skin was cool, mottled, and moist. His sclerae were yellow tinged. He no longer responded to stimuli. His monitor showed sinus tachycardia with short runs of ventricular tachycardia, ST-segment elevation, and T-wave inversion. His breath sounds revealed crackles throughout his chest. Urine output was only 3-5 mL/hour and bloody. His abdomen was enlarged and firm. His abdominal sutures had dehisced and the peritoneum could be seen. The duodenal drains and NGT drainage turned bloody. All arterial and venous puncture sites started to ooze. 3. What is suspected in the above scenario and what do you think the priority treatments are? 4. What lab values would be important at this time and why? 5. What do you think his vital signs and hemodynamic parameters would look like? Why? 6. What would account for the EKG changes described above? Further clinical data included: BP: 70/50 (56) mmHg HR: 140 beats/minute WBCs: 28,000/mm3 Temperature: 35.8 C (96.4 F) PAP: 44/26 mm Hg PCWP: 24 mm Hg CVP: 8 mm Hg CO: 2 L/min CI: 1.1 L/min/m2 SVR: 2000 dynes/sec/cm-5 pH 7.14, PCO2 49 mmHg, PO2 46 mmHg, SaO2 85% HCO3- 12 mmol/L, Lactic acid 3.0 mEq/L, Na+ 152 mmol/L, K+ 5.9 mmol/L Creatinine 3.4 mg/dL, Amylase 290 U/L, Lipase 3.9 U/L, ALT 100 U/L AST 82 U/L, Platelets 75,000/mm3, PT 22 seconds, PTT 98.5 sec, Fibrinogen 130 mg/dL, CK 640 U/L, Troponin >50 7. What is suspected based upon these lab results and why? How would these abnormalities present clinically? Despite attempts to increase contractility with dobutamine, his hemodynamic status failed even further. He went into acute renal failure, liver failure, and respiratory failure. When his cardiac rhythm deteriorated into ventricular fibrillation, resuscitation efforts were unsuccessful. An autopsy revealed several lung abscesses, acute hepatic failure, acute renal failure, multiple hemorrhagic areas, and an acute myocardial infarction. 8. Discuss the risk factors for infection and development of septic shock in this scenario. 9. What pathophysiologic process occur with septic shock? What are the effects of these processes on his tank, plumbing, and pump? What symptoms could you identify that correlate with these processes? 10. Describe the pathophysiologic basis for the development in MODS and identify the clues of progression in this scenario.

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