Topic 15-16 D

Q-1

Course Objectives

The objectives of this teaching module is the learners to gain knowledge on bowel obstruction (BO), understands the etiology of the disease, signs/symptoms, underlying pathophysiological process and management, concepts and principles of hemodynamic management of the patient for close monitoring which aid in better management to reduce complication and mortality.

Etiology

Blockage of the lumen of the intestine that impedes passage of gas and contents through the bowel. Causes includes adhesions post radiation therapy, post multiple abdominal surgeries, hernia common in middle adult age group, volvulus common in children, Tumors such as colorectal cancer, fecal impaction in elderly, ileus due to functional obstruction.

Incidence

BO is an important cause of morbidity and mortality accounting for nearly 30,000 deaths and more than $ 3 billion per year in direct medical costs (Barkley, 2021). Approximately 15% of the hospital admissions for acute abdominal pain in the USA and around 20% of cases needing acute surgical care (Barkley, 2021).

Pathophysiology

BO caused either by a mechanical obstruction or extrinsic compression or adynamic ileus and colonic pseudo-obstructions due to lack of enteric propulsion from drugs, trauma, post-operative period, metabolic disturbances, and other different causes. In BO there is increase in motility to overcome obstruction causes colicky abdominal pain and later reduced peristalsis and dilatation and perforation. Peritoneal signs such as abdominal distension and guarding and rigidity are associated with ischemia and /or perforation. Severe obstruction can cause hypovolemia and shock due to fluid shift due to septic shock causing tachycardia, tachypnea, cool extremities, mottling or cyanotic skin, decreased capillary refill, and oliguria.

Signs/Symptoms

Cramping periumbilical pain initially and later becomes constant and diffuse, vomiting with pain abdomen early in proximal obstruction and in two hours in distal obstruction, minimal or no fever, minimal to pronounced abdominal distension, mild tenderness, high pitched twinkling bowel sounds, unable to pass stool/gas (Barkley, 2021).

Laboratory/Diagnostic Tests

1. CBC shows elevated WBCs and values matches with degree of dehydration.BMP to evaluate the fluid status and electrolyte balance.

2. Plane x-ray abdomen shows dilated loops of bowel and air-filled levels. Horizontal pattern in small bowel obstruction and Frame pattern in large bowel obstruction.

3. A small bowel follow-through using water soluble contrast in small bowel obstruction non-operative management may cause aspiration pneumonia, pulmonary edema and exacerbate dehydration and shock like state in children and elderly (Catena, De Simone, Coccolini, Di Saverio, Sartelli, & Ansaloni, 2019).

4. Abdominal CT with contrast is superior to that of conventional abdominal radiography and ultrasound in providing information about etiological causes and alternative diagnosis, ischemia, and infarction state (Catena, De Simone, Coccolini, Di Saverio, Sartelli, & Ansaloni, 2019).

5. Colonoscopy to exclude other causes for obstruction and need biopsy in case of malignancy and to place an endoscopic stent (Catena, De Simone, Coccolini, Di Saverio, Sartelli, & Ansaloni, 2019).

Management

Nurses at bedside is to be able to monitor patient continuously act timely and report the changes to the provider and to administer the treatment ordered without delay to prevent mortality and morbidity. Management strategies were:

1. Fluid resuscitation.

2. NGT suction to decompress stomach

3. Close monitoring hemodynamic status.

4. Surgical intervention in all cases of complete obstruction.

5. Conservative medical treatment in partial obstruction.

6. Education and counselling patient on disease process, diagnostic tests, management, monitoring, post-operative complications, importance of mobility, deep breathing exercises, pain management, and wound care post-operatively.

Key Principle in Non-invasive Hemodynamic Monitoring

An ideal non-invasive monitoring system will provide accurate and reproducible measurements of clinically relevant variables which enables clinicians to guide therapy accordingly. The monitoring should be easy to use, rapid, readily available at bedside, operator-independent, cost-effective, and minimal risk, and side effects to patients. Recently several non-invasive technologies to monitor hemodynamics in the hospital settings were introduced which are suprasternal doppler ultrasound, modifies windkessel function, pulse wave transmit time, radial artery tonometry, thoracic bioimpedance, endotracheal bioimpedance, bioreactance, and partial CO2 rebreathing been tested for monitoring cardiac output and stroke volume (Pestel, Fukui, Higashi, Schmidtmann, & Werner, 2018). Photoelectric finger blood volume clamp technique and respiratory variation of the plethysmography curve have been assessed for fluid volume responsiveness (Pestel, Fukui, Higashi, Schmidtmann, & Werner, 2018). Every technology of non-invasive monitoring come with advantages and its own limitations. In our facility we use EV1000 vigeleo monitor which has a finger probe attached to a monitor uses laser detection of capillary blood to measure cardiac output, cardiac index, stroke volume and stroke volume variation, CVP values.

Reference

Barkley, T.W. (2021). Adult-gerontology acute care nurse practitioner: Certification review/clinical update continuing education courses (pp 59-60). CA: Barkley & associates Inc.

Catena, F., De Simone, B., Coccolini, F., Di Saverio, S., Sartelli, M., & Ansaloni, L. (2019). Bowel obstruction: a narrative review for all physicians. World Journal of Emergency Surgery, 14(1), 1-8. Retrieved from https://wjes.biomedcentral.com/articles/10.1186/s13017-019-0240-7

Pestel, G., Fukui, K., Higashi, M., Schmidtmann, I., & Werner, C. (2018). Meta-analyses on measurement precision of non-invasive hemodynamic monitoring technologies in adults. Der Anaesthesist, 67(6), 409-425. Retrieved from https://europepmc.org/article/med/29789877

Q-2

If I am a supervisor in a medical-surgical unit I will teach them about Necrotizing Fasciitis so I can emphasize the importance of not only assessing the airway, breathing, and circulation of the patient but also the skin of the patient and watch out for any signs that may require the patient to have emergent surgery. First, I will describe necrotizing fasciitis as a rare, life-threatening infection of the skin, soft tissues, and muscles that progressively causes rapid destruction of the fascial planes (Stevens & Badour, 2020). It involves the epidermis, dermis and mainly affects the subcutaneous tissue, fascia, and muscles. It has an annual occurrence that ranges from 0.3- 15.5 cases in every 100,000 population. Then, I will talk about the classifications of necrotizing fasciitis such as a Type I and Type II Necrotizing infection. Type I - polymicrobial necrotizing infection is caused by aerobic and anaerobic bacteria. It is mostly seen in older adults with underlying comorbidities such as diabetes and those with peripheral vascular disease (Stevens & Badour, 2020). Then, I will talk about the patients who are at high risk of developing necrotizing fasciitis such as those who have a major penetrating trauma, minor laceration or blunt trauma, those women who are pregnant, had childbirth, loss pregnancy, recent gynecologic procedures, obese, immunosuppressed and alcoholics. Then, I will educate and emphasize to the staff about the different stages of necrotizing fasciitis and the need to call the primary physician if they see any signs and symptoms of hemorrhagic bullae, crepitus, and skin necrosis with dusky discoloration progressing to frank gangrene so the primary can focus on getting the surgery team involved and send the patient to the operating room as soon as possible. Then, I will introduce the concept of using the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) as a tool to help the providers to diagnose patients who have early signs and symptoms of necrotizing fasciitis and to help them distinguish necrotizing fasciitis from other soft tissue infections. This tool is based on laboratory indicators such as white blood cell count, hemoglobin, sodium, glucose, creatinine, and C- reactive protein (Ranjan et al, 2017). Patients who have a score of fewer than five points are considered low risk, those who score more than six points are at immediate risk and are highly suspicious of necrotizing fasciitis. A score of eight points is considered at high risk and is strongly predictive of the disease (Ranjan et al 2017). Lastly, also it is important to teach them what to expect when managing this patient such as appropriate pain management, providing hemodynamic support such as high IV fluid replacement, albumin replacement for capillary leak syndrome, use of IVIG, and providing a volume-based feeding protocol for the patient (Makadia et al, 2017).

References:

Makadia, J., Bhanot, N. , Mancini, S.A. & Min, Z. (2017). Clinical evolution, management, and resolution of type II necrotizing fasciitis. Internal Emergency Medicine 10 p. 389-391. Retrieved from https://link.springer.com/content/pdf/10.1007/s11739-014-1139-7.pdf

Ranjan, A., Kumar, A., & Verma, R. (2017). How Far The Laboratory Risk Indicator For Necrotizing Fascitis (Lrinec) Score Validate For Early Diagnosis of Necrotizing Fascitis. National Journal of Integrated Research in Medicine, 8(6), 4–7.Retrieved from https://eds-a-ebscohost-com.lopes.idm.oclc.org/eds/detail/detail?vid=1&sid=7ef7c44e-ae2b-4059-901a-8db30c1cbdae%40sessionmgr4007&bdata=JnNpdGU9ZWRzLWxpdmUmc2NvcGU9c2l0ZQ%3d%3d#AN=128289116&db=a9h

Stevens, D.L. & Baddour, L.M. (2020). Necrotizing Soft Tissue Infections. Retrieved from https://www.uptodate.com/contents/necrotizing-soft-tissue-infections?search=necrotizing%20fasciitis&source=search_result&selectedTitle=1~135&usage_type=default&display_rank=1

Q-3

Pneumonia/Pneumonitis; Septic Shock

Presentation From the acute care nurse practitioner's view, the patient usually will arrive at the ER lethargic, and appearing very ill (Hotchkiss et al., 2016); (Jean-Francois et al., 2019); (Speiser et al., 2018). When nursing staff hooks the patient up to the monitor you would normally see tachycardia, tachypnea, and hypotension (Hotchkiss et al., 2016). If someone arrives looking ill and has the vital signs to back it up, we need to start thinking that there is a major infectious participant that we need to find or rule out. Normally we can identify areas of infection such as wounds, a UTI, or a pulmonary infection source (Jean-Francois et al., 2019).

Labs: The standard of care for suspected sepsis/septic shock is to find the source of infection (Hotchkiss et al., 2016); (Jean-Francois et al., 2019); (Speiser et al., 2018). It is important to work together as a team with the healthcare team to utilize all the information available in order to appropriately diagnose the patient (Hotchkiss et al., 2016); (Jean-Francois et al., 2019); (Speiser et al., 2018). Did nursing staff notice or find anything that shouts possible infection? Are any wounds present? Just some of the questions to start asking. If no skin areas are suspicious of infection, we have to take a step back and widen our magnifying glass. The Standard of care is to now take blood, urine, and sputum cultures to locate the source of infection (Hotchkiss et al., 2016); (Jean-Francois et al., 2019); (Speiser et al., 2018). Some signs may point you in the right direction, such as copious thick sputum that is coughed up, or frequent coughing from the patient with complaints of difficulty breathing (Jean-Francois et al., 2019). These clues will help you locate the source of infection and in this case it's Pneumonia.

With the cultures taken, we should also obtain a CBC, and a CMP to note their WBCs, H/H, and electrolyte panel as this will allow us to get an accurate picture of where the patient is at, clinically (Hotchkiss et al., 2016); (Jean-Francois et al., 2019); (Speiser et al., 2018). We should also obtain an ABG to take a look at their respiratory status and calculate an anion gap (Hotchkiss et al., 2016); (Jean-Francois et al., 2019); (Speiser et al., 2018). One final lab is also a gold standard of a Lactic Acid, >2.0, this well tells us essentially "how septic someone is for how long" (Hotchkiss et al., 2016); (Jean-Francois et al., 2019); (Speiser et al., 2018). A large portion for this case is to get a chest x-ray once we have an indication that the pulmonary system is involved, and we will most likely see pneumonia either developing or full-blown (Hotchkiss et al., 2016); (Jean-Francois et al., 2019); (Speiser et al., 2018). With these pieces of information we will be able to discern where the patient is at and attempt to make a working diagnosis (Hotchkiss et al., 2016); (Jean-Francois et al., 2019); (Speiser et al., 2018).

Diagnosis One thing to remember with a diagnosis of septic shock from pneumonia is that you need an infectious source, such as Streptococcus pneumonia causing pneumonia, causing cardiovascular instability leading to hypotension and utilization of vasopressors (Hotchkiss et al., 2016). This hypotension and hypoperfusion will most likely cause issues with end organs, specifically the kidneys first, and we will see evidence of that via decreased urine output, remember this for later (Hotchkiss et al., 2016). With these pieces of information, we can take the lab values, and combine it with the patient presentation. For the patient presentation, we need to know the patient's work of breathing, level of consciousness, vital signs, urine output, and auscultation of lung, heart, and abdominal sounds (Hotchkiss et al., 2016). Combining these with a Chest Xray, we can lead to the diagnosis of pneumonia, and with the addition of vasopressors for hypotension, we can conclude that it is septic shock secondary to pneumonia (Hotchkiss et al., 2016); (Jean-Francois et al., 2019); (Speiser et al., 2018). Treatment: An important note, is that treatment begins the moment they walk into the ER, for example, with hypotension we would start with fluid resuscitation, then move to vasopressors if needed (Hotchkiss et al., 2016); (Jean-Francois et al., 2019); (Speiser et al., 2018). Remember that the art of Diagnosing and treating patients is dynamic, beginning at the ER and never-ending.

Hemodynamic Monitoring Initial hemodynamic monitoring includes Non-invasive blood pressure, however, with severe hypotension requiring vasopressors we should move to invasive blood pressure monitoring with an ART line in order to obtain more accurate b/p readings for subsequent titration of vasopressors (Speiser et al., 2018). This portion is dependent on patient presentation and not laboratory dependent (Hotchkiss et al., 2016); (Jean-Francois et al., 2019); (Speiser et al., 2018).

Hemodynamic Support Support is dependent on patient presentation and partial lab values. For example, if a patient is tachypneic with the use of accessory muscles, unable to speak a full sentence without gasping for air, or ABG values indicating intubation such as a low PaO2 or high CO2, then they will need to be intubated (Hotchkiss et al., 2016); (Jean-Francois et al., 2019); (Speiser et al., 2018). They will also need to be sedated in order to be able to tolerate ventilator support (Speiser et al., 2018). If they are hypotensive despite fluid resuscitation, then vasopressors are indicated as well (Speiser et al., 2018). All these are pieces of the puzzle and we are to treat symptoms with supportive measures (Speiser et al., 2018).

Respiratory Support Respiratory support as mentioned above could include BIPAP or intubation and is dependent on ABG values and patient presentation (Hotchkiss et al., 2016); (Jean-Francois et al., 2019); (Speiser et al., 2018). A new idea that has been presented was normally used in ARDS treatment to improve patient outcomes by calculating tidal volume and quickly became a gold standard due to its successful outcomes (Hotchkiss et al., 2016). I would recommend utilizing this in all patients who end up on a ventilator, as it will lessen the risk of possible side effects of too much tidal volume.

Fluid ResuscitationFluid resuscitation begins when we first discover a patient is hypotensive. However, to figure out if a patient will actually respond to resuscitation we can do quick, cheap, and effective measures in order to determine effectiveness. The passive leg raise is a maneuver performed by simply placing the bed in reverse Trendelenburg, so that way all the blood volume in the lower extremities is pulled by gravity towards the cardiovascular center and able to be redistributed to the body in a more effective way (Hotchkiss et al., 2016); (Jean-Francois et al., 2019); (Speiser et al., 2018). With the additional "volume" returning to the heart, if the blood pressure increases, then the patient is dehydrated or has low volume, and will respond to fluid (Hotchkiss et al., 2016); (Jean-Francois et al., 2019); (Speiser et al., 2018). If there is no change in blood pressure, the patient has adequate volume and will not respond to fluids (Hotchkiss et al., 2016); (Jean-Francois et al., 2019); (Speiser et al., 2018). Antibiotic SupportAntibiotic support begins after cultures are drawn but are first placed on a broad spectrum (Hotchkiss et al., 2016); (Jean-Francois et al., 2019); (Speiser et al., 2018). This is to cover for all possible organisms that are common, and have been known to cause pneumonia recently (Hotchkiss et al., 2016); (Jean-Francois et al., 2019); (Speiser et al., 2018). A common combination of antibiotics are Vancomycin, Zosyn, and Rocephin or Merrem (Hotchkiss et al., 2016); (Jean-Francois et al., 2019); (Speiser et al., 2018). This combination will cover your gram negative and positive as well as atypicals (Hotchkiss et al., 2016); (Jean-Francois et al., 2019); (Speiser et al., 2018). An important note is that once you get cultures back, you need to de-escalate or move on the antibiotic ladder in order to become more concise with your antibiotic coverage (Hotchkiss et al., 2016); (Jean-Francois et al., 2019); (Speiser et al., 2018).

No need to create more antibiotic resistance just because we forget to remove antibiotics that have no effect (Hotchkiss et al., 2016); (Jean-Francois et al., 2019); (Speiser et al., 2018).

Nutrition: Nutrition is a great thought but usually does not need to be provided until day 3-5 (Hotchkiss et al., 2016); (Jean-Francois et al., 2019); (Speiser et al., 2018). This means that during days 0-2 we need to focus on stabilization and support in order to ready the body for accepting nutrition (Hotchkiss et al., 2016); (Jean-Francois et al., 2019); (Speiser et al., 2018). We know of two routes of nutrition, enteral and parenteral, both with positives and negatives (Hotchkiss et al., 2016); (Jean-Francois et al., 2019); (Speiser et al., 2018). In this case, we need to rely on patient presentation, such as, are they able to tolerate enteral? Most of the time we will utilize enteral support via an NGT, but every so often we will have to resort to parental (Hotchkiss et al., 2016); (Jean-Francois et al., 2019); (Speiser et al., 2018).

Post-CareDepending on how long the patient is intubated and sedated, they may need post-acute care. Some include ALFs or SNFs, and for the patients who end up trached and pegged, we will be looking at LTACs (Hotchkiss et al., 2016); (Jean-Francois et al., 2019); (Speiser et al., 2018). Each has its own criteria for who they take and who they don't. All we can do is help support the patient and advocate for them to get into the appropriate facility. If the patient needs more intensive rehab, then a rehab special facility would be indicated. References:

Hotchkiss, R. S., Moldawer, L. L., Opal, S. M., Reinhart, K., Turnbull, I. R., & Vincent, J. L. (2016). Sepsis and septic shock. Nature reviews. Disease primers, 2, 16045. https://doi.org/10.1038/nrdp.2016.45 Jean-François Llitjos, Aïcha Gassama, Julien Charpentier, Jérôme Lambert, Charles de Roquetaillade, Alain Cariou, Jean-Daniel Chiche, Jean-Paul Mira, Matthieu Jamme, & Frédéric Pène. (2019). Pulmonary infections prime the development of subsequent ICU-acquired pneumonia in septic shock. Annals of Intensive Care, 9(1), 1–9. https://doi-org.lopes.idm.oclc.org/10.1186/s13613-019-0515-x Speiser, J.L., Karvellas, C.J., Shumilak, G. et al. Predicting in-hospital mortality in pneumonia-associated septic shock patients using a classification and regression tree: a nested cohort study. j intensive care 6, 66 (2018). https://doi.org/10.1186/s40560-018-0335-3