Page 595 - ACCCN's Critical Care Nursing

572 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

dosage levels are therefore recommended in life-
threatening infections, as inadequate antibiotic penetra- BOX 21.1 Surviving Sepsis campaign
tion can occur due to impaired vascularity of infected
tissue (inhibits delivery of antibiotic), antibiotic anta- The Surviving Sepsis campaign is an international collaborative
gonism (uncommon but possible with combination formed in 2003 to reduce the mortality of sepsis. Guidelines for
therapy) and coexisting unrecognised bacterial infec- the management of severe sepsis and shock were updated in
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tion. Nursing assessment of patient response to antibi- 2008 and offer a comprehensive list of graded recommenda-
76
otic therapy (resolution or exacerbation of signs of sepsis) tions to care for these patients. Many of the recommendations
and surveillance for sites of unrecognised infection is for practice have implications for critical care nurses and the
therefore important. multidisciplinary team (see Online resources). The third edition
is due for release in 2012.
Exclusion of Secondary Insults and
Organ Support
Prevention of secondary inflammatory insults and organ and evaluation. The complex care required to nurse the
support includes a broad range of interventions including MODS patient is highlighted in the clinical case study.
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use of massive transfusion protocols, recognition of
abdominal compartment syndrome via urine catheter SUMMARY
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76
manometry, lung protective ventilation, early nutri- Multiple organ dysfunction is a common presentation to
60
tional support, 91,92 glycaemic control, haemodynamic critical care units across Australasia. Critical care nurses
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support using vasopressors and intropes, renal replace- require high-level knowledge of pathophysiology and
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ment therapy, nitric oxide therapy and extracorporeal early recognition of failure of individual organs and the
membrane oxygenation (ECMO). Routine evidence- antecedents to the development of organ failure. The
based measures are also essential, including hygiene, pathophysiological consequence of systemic inflamma-
bowel management, pressure area, mouth and eye tory response and sepsis requires understanding of indi-
care and other processes of care (e.g. FAST-HUG; see vidual organ function and responses to stressors so that
Chapter 20).
preemptive strategies can be initiated to prevent further
Awareness of the latest evidence that underpins manage- organ failure and support individual organs. Patients
ment of these complex patients is important, including with MODS are complex patients to manage, requiring
emerging therapies such as the use of statins 93,94 and ACE- highly-skilled nursing care that involves vigilant assess-
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inhibitors (see Research vignette). Also note that the third ment, planning of intervention priorities, monitoring
edition of the SSG is due for release in 2012 (see Box and ongoing treatment evaluation. Well-developed time
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21.1). There is a surprising dearth of literature specifi- management skills are required to include all routine
cally addressing the complex nursing care required by a cares and required treatment. Balancing care priorities
MODS patient. These patients require highly-skilled begins on patient presentation as highlighted by the
nurses who are able to balance competing priorities via importance of initial resuscitation and early antimicro-
ongoing patient assessment, care planning, monitoring bial therapy.

Case study

Mr Wyland, aged 43, was brought in by ambulance to the Emer- 0.9% was administered during resuscitation, and then a further
gency Department (ED). He was hypoxic, cyanotic, tachypnoeic, 500 mL of 4% albumin stat. Mr Wyland was subsequently reviewed
clammy and tachycardic with a history of severe COPD/asthma (no by an intensive care consultant for ventilation difficulties second-
domiciliary oxygen, ex-smoker 25 pack years). His wife had been ary to bronchospasm. He was placed on permissive hypercapnia
unwell with an upper respiratory tract infection in the past week. ventilation via SIMV volume-control with a VT 450 mL, peak flow
He had been administered oxygen at 15 L/min via a non-rebreather rate of 80 L/min, RR 8 bpm and 0 cm PEEP (to maximise expiratory
mask and nebulised ventolin twice in transit, with no clinical time and reduce gas trapping – I : E ratio 1 : 11). He was ordered
improvement. combination IV antibiotics (ticarcillin clavulanate and gentamicin)
and nasogastric oseltamivir (Tamiflu) which were administered 3.5
On initial assessment he was noted to be in extremis: Temperature
39.5°C, HR 135 bpm, BP 165/96 mmHg, SpO 2 88%, minimal air hours post-ED presentation. An adrenaline infusion was com-
entry bilaterally and very distressed. He was administered ventolin menced to improve his bronchospasm and hypotension that was
and atrovent nebulisers, IV MgSO 4 20 mmols, a ventolin IV infusion unresponsive to prior fluid challenges. His ventilation continued to
was commenced and hydrocortisone 100 mg was administered. be problematic and he was transferred to ICU after 6 hours in ED.
BiPAP was initiated, but poorly tolerated. During preparation for
intubation and mechanical ventilation, Mr Wyland went into respi- On admission to ICU he was in severe respiratory acidosis (ETCO 2
ratory, then cardiac, arrest (PEA). = 96). Sedation and drug paralysis infusions were commenced
(midazolam and vecuronium) and permissive hypercapnia ventila-
Four cycles of CPR were completed with stat doses of IV adrenaline tion continued with an increase in VT to 550 mL (Pplat 25 cmH 2O;
1 mg × 4 prior to ROSC after 11 minutes. One litre of normal saline I : E ratio 1 : 8.9). A ketamine infusion was added (to improve