Chapter 33, Case Study, Shock and Multisystem Organ Dysfunction Syndrome
1. Analyze the sequence of events that occurred in Mr. B.’s case.

Mr. B. had sustained a pelvic fracture, which resulted in hemorrhagic
shock. Hemorrhagic shock results in vasoconstriction and shunting of
blood away from the gastrointestinal (GI) tract. When the GI tract is
hypoperfused, translocation of bacteria from the GI tract to the systemic
circulation can occur resulting in sepsis.

Multiple blood transfusions and fluids were administered to stabilize his
hemodynamic levels prior to surgical management of the pelvis. Multiple
blood transfusions have been found to be associated with sepsis/systemic
inflammatory response syndrome (SIRS).

Mr. B. is intubated and the pelvis is surgically managed. It was noted
there were some issues with weaning from the ventilator due to his history
of chronic obstructive pulmonary disease (COPD). This prolonged
intubation and ventilation can lead to ventilator-associated pneumonia.
This is another potential source of infection, which can cause sepsis.

Mr. B. was extubated but later developed fever and elevated white blood
cell (WBC). These are signs of sepsis.

Blood cultures were obtained and a gram-negative bacteremia was
diagnosed. Mr. B. was treated with fluids, vasopressors, and steroids.
2. Describe the management goals and nursing interventions for hypovolemic and septic
shock.
Hypovolemic shock:

Management goals—restore circulating volume; resolve the cause of volume loss

Nursing management—obtain large-bore IV access; warm IV fluids to limit
hypothermia; frequently monitor end points of resuscitation, including vital signs,
urine output, hemodynamic parameters (CO, SvO2, cSvO2), and laboratory values
(lactate, base deficit)
Septic shock:

Management goals—(1) maximize oxygen delivery in relation to cellular oxygen
consumption using early, goal-directed therapy (within 6 hours of diagnosis); (2)
identify and treat infecting organisms with appropriate antibiotic treatment; (3) ensure
adequate ventilation and oxygenation; (4) restore the balance between coagulation
and anticoagulation; and (5) provide the appropriate metabolic environment

Nursing management—(1) administer IV fluids, vasopressors, and positive inotropic
agents as ordered; (2) obtain cultures (eg, urine, sputum, central-line catheter tips,
wound) as ordered, administering antibiotics as ordered in a timely manner, using
strict aseptic technique during procedures, and maintaining sterility of invasive
catheters and tubes; (3) suction endotracheal airway when appropriate and using
kinetic therapy as indicated; (4) initiate deep vein thrombosis prophylaxis according to
unit protocol, reposition the patient frequently, mobilize the patient as soon as
hemodynamically stable and hemostasis has been achieved, consult with physical
therapy, and conduct range-of-motion and strengthening exercises as indicated; and
(5) replace electrolytes as ordered, provide parenteral and enteral nutrition within 24
hours of diagnosis as ordered, and consult with nutritional support services
3. Discuss the management of Mr. B.’s septic shock. Was evidence-based care provided?
Oxygenation/Ventilation:

Postoperative day 1: placement on a ventilator-weaning protocol because the patient
is arousable, hemodynamically stable, and is not in a life-threatening state
Circulation/Perfusion:

Initial resuscitation (performed according to the Guidelines): 2 L of lactated Ringer’s
solution; a lactate level (7.7 mmol/L) confirmed hypoperfusion, and after being given
additional fluid, his CVP was greater than 8 mm Hg

Postoperative day 1: the patient responds to treatment

Postoperative day 4: the patient is appropriately placed on a vasopressor
(norepinephrine) because he remains in shock despite adequate fluid administration
and high-dose norepinephrine; he was appropriately placed on a dobutamine infusion
to augment cardiac output and tissue perfusion; his SvO2 remained less than the
recommended goal of 70%
Identify and Treat Cause of Sepsis: use of antibiotics

Postoperative day 4: antibiotics should have been ordered within the first hour of
recognizing that the patient had severe sepsis; antibiotic therapy was appropriately
readjusted after preliminary blood cultures revealed gram-negative rods
Deep vein thrombosis (DVT) prophylaxis: administered
Stress ulcer prophylaxis: administered
Recombinant Human-Activated Protein C: not a candidate

The patient was at a high risk for bleeding; he had a severe pelvic fracture and lost a
significant amount of blood.
Consideration for limitation of support: appropriate care of the patient and family

The patient and family were provided appropriate and timely information on likely
outcomes and realistic goals.

Based on patient and family desires, the plan of less aggressive support was
developed.