Septic shock

Question

An 80 year old gentleman who had been admitted to the AMU from a residential home after a fall has become more unwell over the last 6 hours. The nurses are very concerned and have bleeped you to review him as soon as possible.

Answer

This is a common clinical scenario and the expectation from the candidate would be to get to the assessment of the patient after a brief review of the notes or get a handover from the nursing colleague regarding the patients baseline, his social status and if there were any advance wishes. I will start by doing a focussed Assessment –

Airway I would ensure the airway is patent and if necessary insert an airway adjunct such as OP or NP airway. If the patient is tolerating an airway adjunct I would be really worried and seek the help of the critical care team after my assessment.

Breathing I would look at the observations specifically the oxygen saturation and the respiratory rate. If the patient is hypoxia or if the patient has an increased work of breathing I’ll start the patient on supplemental oxygen therapy. I would also get an ABG for this patient to see what the ph, Po2, pco2 and hcO3.

Circulation I would look at the observations specifically the BP, heart rate and CRT. If there is evidence of hypotension or tachycardia I would give a fluid challenge to the patient to see if there is an adequate response. And if the patient remains hypotension despite the first fluid challenge I will give another fluid challenge and ensure the critical care team is aware of the patient.

Disability I would check the patients blood glucose, temperature and do a focused neurological assessment that includes GCS. Specifically if the GCS is less than 8 or if there is a focal neurological deficits I would be concerned and investigate this further.

Question

At this point the interviewer will give the following information to the candidate, the patient has been pyrexic, tachycardic and hypotensive with a BP of 100/60 and HR of 120 bpm. He is hypoxic needing 10 litres of oxygen to maintain SpO2 of 94% and there’s decreased air entry to the right base. His ABG is as follows – pH 7.2, pO2-9, pCO2-4.0, HcO3-18, Lactate -4.0.

Answer

From the Information provided the patient is septic and needs urgent management with IV fluids and oxygen therapy. I would also ensure the patient has had Bloods taken including blood cultures and the patient is started on antibiotics immediately after this. I would also monitor the patients urine output at this stage.

As the patient is in septic shock I would inform my senior and make the critical care team aware of this patient based on his functional baseline and clinical frailty score. I would also make the family or NOK aware on the clinical status and try to update them regarding his acute deterioration.

Question

This gentleman had a high CFS and the ICU don’t think he is a candidate for ICU admission. Your team have started the patient on antibiotics and he has not responded to 2 liters of crystalloids given as a bolus. What would you do next?

Answer

I would escalate this to my senior regarding the lack of response to fluids. This gentleman being unresponsive to shock indicates poor prognosis and would warrant a senior review and discussion with the family and NOK regarding the poor prognosis. This patient could be heading towards end of life care given the rapid deterioration. If after discussion with the family and the MDT it was decided to palliate the patient, I would ensure that I refer the patient to the palliative care team and discuss with nurse in charge to move the patient to a side room and prescribe the end of life medications to ensure the patient is comfortable.