NUR 4320 Module 2 Septic Shock Paper: Early Antibiotics, Fluids and Vasopressors After the Protocol Trials Example

The First Hour and the Next Six: Nursing Care for Septic Shock in Somerville

Student Name

B.S.N., Accelerated Second Degree, Thomas Edison State University

NUR-4320: Nursing Care of Clients with Complex Health Conditions

Mentor Name

Month Day, Year

The First Hour and the Next Six: Nursing Care for Septic Shock in Somerville

The Patient

Ms. Russo and her hospital are invented. Ms. Russo, 71, lives alone and was found by her neighbor confused and feverish. In the emergency department her temperature was 39.4 Celsius, heart rate 124, respiratory rate 28, blood pressure 82/44 and oxygen saturation 93 percent. Her lactate was 4.6 mmol/L, and her urine was cloudy. She had right flank tenderness. The student was in the emergency department for a clinical shift and followed her to the ICU.

Sepsis and Shock

In sepsis, the body's response to an infection goes awry and damages organs badly enough to threaten life, and septic shock is sepsis with circulatory and cellular problems severe enough to need vasopressors to keep blood pressure up and with a raised lactate despite fluids. Ms. Russo's low blood pressure, confusion and high lactate showed shock and poor tissue perfusion.

The Guideline

Evans et al. (2021) published the Surviving Sepsis Campaign international guideline. For adults who may be in septic shock or are very likely septic, it recommended starting antimicrobials at once, within an hour of recognizing the problem if possible, after drawing blood cultures if this causes no delay. For sepsis-induced hypoperfusion or shock, it suggested a crystalloid volume of at least 30 mL/kg over the first three hours, preferring balanced solutions, and guiding further fluids by dynamic measures of fluid responsiveness and by capillary refill rather than giving fluids by formula. It recommended norepinephrine as the first-line vasopressor, a starting goal mean arterial pressure of 65 mm Hg and adding vasopressin when norepinephrine doses rise. It also recommended measuring lactate and repeating it to guide resuscitation.

The Protocol Trials

Rivers et al. (2001) randomly assigned patients with severe sepsis or septic shock in one emergency department to six hours of early goal-directed therapy, a protocol targeting central venous pressure, mean arterial pressure and central venous oxygen saturation with fluids, vasopressors, transfusion and inotropes, or to standard care. In-hospital mortality was lower with the protocol, about 31 percent compared with 47 percent. The trial changed sepsis care around the world.

Later, the ProCESS Investigators (2014) compared protocol-based early goal-directed therapy, a less invasive protocol-based standard therapy and usual care in thirty-one U.S. emergency departments. There was no significant difference in 60-day mortality among the three groups. The authors concluded that, in an era when early recognition, prompt antibiotics and adequate fluids had become routine, the specific invasive protocol was not needed. What remained essential was speed.

Nursing Diagnoses

Three nursing diagnoses guided care: decreased cardiac output and ineffective tissue perfusion related to septic shock, risk for fluid overload and acute confusion related to hypoperfusion.

The First Hour

The nurse collected paired blood cultures from two sites plus a urine culture, started two intravenous lines and gave the first liter of balanced crystalloid within minutes. The broad-spectrum antibiotic was hung forty minutes after she arrived. The student recorded times for each step, since the hospital tracks time to antibiotics, and helped place a urinary catheter for hourly output.

The Next Hours

After two liters, her blood pressure was 88/50 and her lungs had new crackles. The physician started norepinephrine through a central line, and the nurse titrated it to a mean arterial pressure of 65 or above as ordered. The student watched her capillary refill, mental status and urine output and helped with a repeat lactate at two hours, which had fallen to 3.1. A bedside ultrasound showed that her heart was filling adequately, and no more fluid was given, reflecting the guideline's caution against fluid by formula.

Source Control

A CT scan showed an obstructing kidney stone with infection behind it. Urology placed a drain within hours, a critical step, since antibiotics alone cannot clear an infection behind a blockage.

Evaluation

By the next morning, Ms. Russo was alert, her norepinephrine was weaned off, her lactate was normal and her urine output was steady. Her antibiotics were narrowed when culture results returned.

Communicating Under Pressure

In the first hour, the room filled with people: two nurses, a physician, a pharmacist, a technician drawing blood and the student. The student noticed how the charge nurse kept order by stating each task aloud and confirming when it was done, for example calling out that cultures were drawn before the antibiotic was hung. Closed-loop communication of this kind prevented a second dose of the same fluid from being started by someone who had not heard the first. When Ms. Russo's neighbor arrived, the student found her a chair, took her name and number for the chart and learned that Ms. Russo had seemed tired for three days, a detail the physician wanted to hear.

After the ICU

Survivors of septic shock often leave the hospital weaker, with problems of memory and mood. The case manager arranged home physical therapy and a visiting nurse, and the student added teaching for Ms. Russo about the warning signs of a new infection and when to call for help. Because she lives alone, a follow-up call was planned within a week of discharge.

Early Warning on the Ward

The student also asked how cases like this are caught when the patient is already admitted. The unit used an early warning score that combined vital signs and mental status, and a rising score prompted a nurse to call the rapid response team. Ms. Russo's confusion would have triggered it.

Limits

Guidelines balance evidence and expert judgment, and some recommendations are weak. Fluid needs vary, and older adults with heart disease may tolerate less. A student follows the nurse's direction and does not titrate vasopressors.

Conclusion

Ms. Russo's septic shock called for fast, coordinated action. The 2021 guideline set the priorities, Rivers's trial showed the value of early resuscitation and the ProCESS trial showed that speed and reassessment matter more than a rigid protocol. Timely cultures and antibiotics, guided fluids, norepinephrine and source control turned her course around.

References

Evans, L., Rhodes, A., Alhazzani, W., Antonelli, M., Coopersmith, C. M., French, C., Machado, F. R., Mcintyre, L., Ostermann, M., Prescott, H. C., Schorr, C., Simpson, S., Wiersinga, W. J., Alshamsi, F., Angus, D. C., Arabi, Y., Azevedo, L., Beale, R., Beilman, G., . . . Levy, M. (2021). Surviving Sepsis Campaign: International guidelines for management of sepsis and septic shock 2021. Critical Care Medicine, 49(11), e1063-e1143. https://doi.org/10.1097/CCM.0000000000005337

ProCESS Investigators. (2014). A randomized trial of protocol-based care for early septic shock. New England Journal of Medicine, 370(18), 1683-1693. https://doi.org/10.1056/NEJMoa1401602

Rivers, E., Nguyen, B., Havstad, S., Ressler, J., Muzzin, A., Knoblich, B., Peterson, E., & Tomlanovich, M. (2001). Early goal-directed therapy in the treatment of severe sepsis and septic shock. New England Journal of Medicine, 345(19), 1368-1377. https://doi.org/10.1056/NEJMoa010307