Topic 7-8 D

Q-1

In this scenario, both SIRS and Sepsis are accompanied by a plethora of complications that initially require the same types of interventions but can vary in the intensity of interventions (Hotchkiss et al., 2016);'(Marik & Taeb, 2017). SIRS and Sepsis both have the same foundational etiology as having a process that disrupts the normal body function (Hotchkiss et al., 2016);(Marik & Taeb, 2017). However, the differences lie in the intensity of the offending etiology (Marik & Taeb, 2017). Even though SIRS is a precursor to Sepsis, SIRS is defined as an exaggerated defense of the body to a stressor, while Sepsis is defined as SIRS with a suspected source of infection (Marik & Taeb, 2017). We can continue to build on this definition by Severe Sepsis including Sepsis with at least one or more end-organ failures, and with hemodynamic instability, we can cumulate it into the final definition of septic shock (Marik & Taeb, 2017).

In my experience, when we had a patient who presented with tachypnea, tachycardia, and hemodynamic variability we would begin by ordering labs to include a CBC and CMP (Marik & Taeb, 2017). We would be looking for any inconsistencies or any clues as to what ails the patient (Marik & Taeb, 2017). If leukocytosis was discovered, or fever was discovered, we would then pan-culture the sputum, blood, and urine (Marik & Taeb, 2017). If the patient was stable at this time, but clinically presented as sepsis, we would begin with initial fluid resuscitation as tolerated until we achieved hemodynamic stability (Hotchkiss et al., 2016);(Marik & Taeb, 2017). We would also manage their airway as needed, starting with oxygenation support and moving to non-invasive mechanical ventilation to finally invasive mechanical ventilation (Hotchkiss et al., 2016);(Marik & Taeb, 2017). Finally, we would add vasopressor support as needed and per patient depending on their presentation (Hotchkiss et al., 2016);(Marik & Taeb, 2017).

In order to determine the source of infection we would be interviewing the patient to determine if there has been any new skin lesions, bug or animal bites, recent travel, cough, fever, or chills that have occurred recently (Hotchkiss et al., 2016);(Marik & Taeb, 2017). One of the biggest helpful hints is if the patient has any pain anywhere because when they describe the presenting sign of pain, most of the time they will say "it hurts when I cough" which is an indicator that they have been coughing for a while and that there could be underlying pneumonia for example (Hotchkiss et al., 2016);(Marik & Taeb, 2017). If the patient presents with pain in either their abdomen or chest, we could begin with the ruling in or out any differentials such as pneumonia, pericarditis, endocarditis, cholecystitis, appendicitis, pancreatitis, or infection of the colon (Hotchkiss et al., 2016);(Marik & Taeb, 2017). Depending on the interview and health history, we then would order the appropriate test for that area to see if tests would reveal any information about possible sources of infection (Hotchkiss et al., 2016);(Marik & Taeb, 2017). 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 Marik, P. E., & Taeb, A. M. (2017). SIRS, qSOFA and new sepsis definition. Journal of Thoracic Disease, 9(4), 943–945. https://doi-org.lopes.idm.oclc.org/10.21037/jtd.2017.03.125

Q-2

Three Differential diagnoses and the treatment parameters

1. ARDS: Pulmonary opacities peak after 10 days, which is more evidenced by chest radiograph as extensive opacities are associated with poor outcomes in Covid-19 patients (Kerpel et al 2020). Extensive opacities in Covid pneumonia patients may progress to ARDS which is characterized by decreasing saturation below 85%. ARDS is characterized by acute diffuse inflammatory damage to the alveolar-capillary barrier associated with vascular permeability reduced lung compliance, compromising air exchange, and hypoxia (Batah, & Fabro, 2020).

Management: - Prone therapy which helps for postural drainage off from lungs and clearing secretions and more oxygenation to lungs even in the early stage of Covid pneumonia will improve recovery time. Moderate PEEP levels without exceeding the tidal volume of 6 ml/kg with adjunctive therapy and prone therapy are beneficial in ARDS (Ferrando et al, 2020) helps to open up the collapsed alveoli and recruit for alveoli to participate in the air exchange which ultimately the oxygenation. The next step of management is to add nitric oxide which reduces the surface tension in the alveoli and helps for better air exchange and oxygenation. Intermittent treatment with furosemide plus albumin had significantly increase oxygenation, raise serum albumin levels and lower cumulative fluid balance (Ferrando et al, 2020) and helps to clear out additional fluid off from the lungs if it is evident in radiology.

 

1. Sepsis: -Surviving sepsis campaign Coronavirus disease 2019 recommends systemic steroids, venous thromboembolism prophylaxis, use of convalescent plasma and therapeutic anticoagulation, use of remdesivir in non-ventilated patients (Alhazzani et al, 2021). Many of our Covid-19 patients are getting septic, hypotensive, spikes fever with leukocytosis. Management is fluid resuscitation conservatively and the use of vasopressors starts with norepinephrine.

2. Pulmonary embolism: - Common finding in Corona virus-2 infection has been associated with increased risk of thrombosis (Marginean, Masic, Brailovsky, Fareed, & Darki, 2020). Symptoms of decreasing oxygenation and ultimately affecting cardiac output leading to fatal arrhythmias such as ventricular tachycardia, atrial fibrillation with rapid ventricular rate, v-fib, and cardiac arrest. 

Risk factors of treatments of Covid patients.

The risk factors in covid treatment and management were pneumothorax from higher PEEP on the ventilator causing spontaneous pneumothorax requires treatment with insertion of a chest tube. Bleeding is another complication from therapeutic anticoagulation such as bleeding from the GI tract or from the airway and other sites. Sepsis superimposed from VAP and ventilator dependency and as a complication of steroid therapy. Disability and delayed muscle and joint functions, and organ function due to long-term use of sedation, narcotic analgesics, and paralytics.

Reference.

Kerpel, A., Apter, S., Nissan, N., Houri-Levi, E., Klug, M., Amit, S., ... & Marom, E. M. (2020). Diagnostic and prognostic value of chest radiographs for COVID-19 at presentation. Western Journal of Emergency Medicine, 21(5), 1067. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7514404/

Batah, S. S., & Fabro, A. T. (2020). Pulmonary pathology of ARDS in COVID-19: A pathological review for clinicians. Respiratory medicine, 106239. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S0954611120303796

Ferrando, C., Suarez-Sipmann, F., Mellado-Artigas, R., Hernández, M., Gea, A., Arruti, E., ... & Villar, J. (2020). Clinical features, ventilatory management, and outcome of ARDS caused by COVID-19 are similar to other causes of ARDS. Intensive care medicine, 46(12), 2200-2211. Retrieved from https://link.springer.com/article/10.1007/s00134-020-06192-2

Alhazzani, W., Evans, L., Alshamsi, F., Møller, M. H., Ostermann, M., Prescott, H. C., ... & Rhodes, A. (2021). Surviving sepsis campaign guidelines on the management of adults with coronavirus disease 2019 (COVID-19) in the ICU: First update. Critical care medicine, 49(3), e219-e234. Retrieved from https://journals.lww.com/ccmjournal/Fulltext/2021/03000/Surviving_Sepsis_Campaign_Guidelines_on_the.21.aspx

Marginean, A., Masic, D., Brailovsky, Y., Fareed, J., & Darki, A. (2020). Difficulties of managing submassive and massive pulmonary embolism in the era of COVID-19. Case Reports, 2(9), 1383-1387. Retrieved from https://www.jacc.org/doi/full/10.1016/j.jaccas.2020.05.017

Q-3

In the geriatric patient population, the initial clinical presentation including the chief complaint, HPI, as well as recent relevant health history will assist in determining the source of the infection. An altered level of consciousness in an elderly patient with a recent onset, urologic surgery, and use of a urinary catheter will increase my suspicion of a UTI (Peach et al., 2016, p.5).

A productive cough, with a dark sputum, and infiltrates on the CXR will increase my clinical awareness that a respiratory tract infection is the source. Additionally, determining if the infection is bacterial as in community acquired pneumonia or a viral infection similar to rhinovirus. Proper identification for the suspected source of infection and starting empirical antibiotic therapy is paramount for reducing the mortality and morbidity for patients greater than 65 years of age (Liang, 2016, p.515).

 CBC with diff, CMP, D-Dimmer, Lactate Level, Blood cultures, UA, ABG, procalcitonin. and CXR portable will be initial diagnostic procedures for determining the source of infection and severity of the symptoms.

How are the critical care and emergent situation conditions and disorders inclusive of systemic inflammatory response syndrome (SIRS) and sepsis different?

SIRS has a less predictive value for the development of sepsis and septic shock while a potential indicator for screening geriatric patients for bacteremia in the ED. Criteria is having two of the following: temperature of >38 C of <36C, tachycardia with a heart rate > 90 beats/min, tachypnea with a respiratory rate rate>20, and a WBC count >12,000 mm3. If there is no source of the of infection, treatment will be similar to monitor the patient. If there is unstable hemodynamics then crystalloid IV fluid boluses depending on the results vasopressor therapy will be started similar to the protocol for sepsis. (Chou et al, 2016, p.4).

Sepsis is a serious medical condition caused by an infection resulting in physiologic, biochemical, and pathophysiological changes in response This can include an inflammatory response. The severity of sepsis is determined by the existence of organ failure through the qSOFA criteria screening tool. This screening tool indicates a strong potential for the occurrence while the lab results will confirm the exitance of end organ hypoperfusion and dysfunction (Liang, 2016, p.517). Researchers determined that approximately 60% of the sepsis cases involve patients > 65 years of age and older and there is a strong correlation of the urinary tract being the source of the infection in 30% of the cases (Liang, 2016, p.515).

The treatment modality changes because of the exitance of end organ dysfunction as well as an identified source of infection. With the disease progression towards septic shock aggressive interventions will be taken to maintain MAP > 65 mm Hg.

Using a patient from your clinical practicum for whom you have provided care, describe and explain the diagnostic workup to determine the source of infection or inflammatory response. Support your answer with two or three peer-reviewed resources.

An elderly gentleman with PMHx of dementia, HTN, and DM, presented with increased confusion as well as witnessed ground level fall. PMHX. Temperature 38.8 C, heart rate 99 beat/min, WBC 11.8 mm3, ordered a CT Head WO contrast, (determine neurological status) results negative, CXR results no infiltrates, and UA positive for bacteria, nitrates, and leukocytes esterase. The plan was to admit, cardiac monitoring, gentle IV hydration therapy and treat recurrent UTI with ceftriaxone 1-gram IV q24 hr. Continuous monitoring so that the patient doesn’t development sepsis.

 References

Chou, H. L., Han, S. T., Yeh, C. F., Tzeng, I. S., Hsieh, T. H., Wu, C. C., Kuan, J. T., & Chen, K. F. (2016, December 9). Systemic inflammatory response syndrome is more associated with bacteremia in elderly patients with suspected sepsis in emergency departments. Medicine, 95(49), e5634. https://doi.org/10.1097/MD.0000000000005634

Liang, S. Y. (2016, August). Sepsis and other infectious disease emergencies in the elderly. Emergency Medicine Clinics of North America, 34(3), 501-522. https://doi.org/0.1016/j.emc.2016.04.005

Peach, B. C., Garvan, G. J., Garvan, C. S., & Cimiotti, J. P. (2016, April 6). Rick factors for urosepsis in older adults: A systematic review . Gerontology and Geriatric Medicine, 2, 1-7. https://doi.org/10.1177/2333721416638980