Page 143 Complete Your CE Test Online - Click Here Following are questions to consider: ● ● Does the patient have any invasive devices that may be the source of infection (urinary catheters, prosthetic devices, intravascular devices)? ● ● Has the patient undergone a recent trauma or surgery? ● ● Does the patient live in a setting that may have an increased risk of nosocomial or community-acquired infection, such as a long-term care facility? ● ● Does the patient have a productive cough that may indicate pneumonia? Source control can include the debridement of a wound, drainage of an abscess, and the prompt removal of intravascular devices or indwelling urinary catheters. Source control is particularly effective for the following conditions (Rhodes et al., 2017): ● ● Gastrointestinal perforation. ● ● Intraabdominal abscesses. ● ● Ischemic bowel. ● ● Cholangitis. ● ● Cholecystitis. ● ● Pyelonephritis. ● ● Necrotizing soft tissue infection. ● ● Implanted device infections. Imaging scans useful for pinpointing the source of infection include the following ( ● ● X-rays: Chest X-rays are useful for evaluating a lung infection, such as pneumonia. ● ● Computerized tomography (CT): CT scans are useful in visualizing infections in the appendix, bowel, pancreas, or kidney. ● ● Ultrasound: Ultrasounds are useful for diagnosing infection in the gall bladder or ovaries. ● ● Magnetic resonance imaging (MRI): MRIs are helpful in visualizing infection in soft tissue, such as abscesses in the spine. Self-evaluation: Question 9 A patient comes into the emergency room with symptoms of pneumonia. Which imaging test would the physician most likely order? a. MRI. b. Chest X-ray. c. Ultrasound. d. CT scan. Administer vasoactive medication if indicated Vasopressors may be required to maintain the patient’s blood pressure if fluid replacement alone is not sufficient to adequately restore perfusion, or if the patient develops cardiogenic pulmonary edema. The following vasopressors are recommended (Rhodes et al., 2017): ● ● Norepinephrine: The first choice in vasoactive medication. ● ● Vasopressin or epinephrine: Can be added to norepinephrine to raise MAP to a target goal or adding vasopressin to decrease epinephrine dosage. ● ● Dopamine: Recommended as an alternative to norepinephrine only in patients with low risk for tachyarrhythmias or absolute or relative bradycardia. ● ● Dobutamine: Recommended for patients with persistent hypoperfusion despite fluids and vasopressors. Dobutamine is an inotropic agent that may cause a blood pressure drop initially in low doses as a result of systemic artery dilation caused by peripheral vascular resistance. But as the dose increases, cardiac output increases enough to overcome the peripheral vascular resistance, and blood pressure is increased (Schmidt & Mandel, 2017). Administer glucocorticoid therapy if indicated Glucocorticoids are recommended only if the patient’s blood pressure does not respond to adequate fluid resuscitation and vasopressor medications (Rhodes et al, 2017; Schmidt & Mandel, 2017). It was once hypothesized that corticosteroid therapy would be beneficial in controlling the inflammation associated with sepsis; however, studies are still being conducted to evaluate the usefulness of corticoid therapy. The latest recommendations are only for those patients who experience hypotension in the presence of fluids and vasopressors. Administer blood transfusions if indicated Blood transfusions are reserved for those patients who have a hemoglobin level of < 7 g/dL unless it is suspected that the patient has myocardial ischemia, severe hypoxemia, or acute hemorrhagic shock (Rhodes et al., 2017; Schmidt & Mandel, 2017). Administer insulin therapy if indicated Blood glucose levels should be kept under 180 mg/dL (Rhodes et al., 2017). Insulin therapy should not be started unless there are two consecutive blood glucose levels > 180 mg/dL, and levels should be monitored every 1 to 2 hours until stabilized (Rhodes et al., 2017). As noted before, studies have shown that tighter control of blood glucose levels did not improve patient outcomes and led to hypoglycemia and increased mortality (Finfer et al., 2009). Provide renal replacement therapy if indicated As sepsis progresses, the kidneys may become injured and the patient may require some form of renal replacement therapy. Renal replacement therapy may be continuous or intermittent and can include hemofiltration, hemodialysis, and hemodiafiltration. The SSC guidelines (2017) recommend that renal replacement therapy (either continuous or intermittent) be used in patients with sepsis who have acute kidney injury. The guidelines further recommend that Continual Renal Replacement Therapy (CRRT) be used to manage fluid balance in hemodynamically unstable patients with sepsis (Rhodes et al., 2017). Renal replacement therapy is not recommended for patients who demonstrate an increase in only creatinine or oliguria with no other indications for dialysis (Rhodes et al., 2017). Provide venous thromboembolism prophylaxis Patients who have sepsis or septic shock are at risk for developing blood clots; therefore, measures to prevent the formation of clots should be taken. Pharmacologic agents, such as low molecular weight heparin, may be useful, as are mechanical types of prophylaxis, such as intermittent pneumatic compression or the use of compression stockings (Rhodes et al., 2017). Lovenox may be given to prevent or treat deep vein thrombosis. Nursing consideration: The nurse is often responsible for ensuring the use of compression stockings or intermittent pneumatic compression. The nurse should be aware of the importance of preventing clots by making sure mechanical prophylactic measures are used continuously and are functioning properly. Provide stress ulcer prophylaxis if indicated Any critically ill patient can develop stress ulcers while hospitalized. Stress ulcer prevention includes the administration of proton pump inhibitors or histamine receptor antagonists in the patient who has risk factors for gastrointestinal bleeding (Rhodes et al., 2017). Not all critically ill patients should receive stress ulcer prophylaxis, however, as there can be adverse reactions, such as infections from Clostridium difficile bacteria (C. diff.), community-acquired pneumonia, and spontaneous bacterial peritonitis in patients with cirrhosis (Eisa, Alraies, Alraiyes, & Bazerbachi, 2014). Because patients on wide- spectrum antibiotics are at risk of C-diff., it is important to watch for watery diarrhea, blood/pus in the stool, and increased heart rate and fever, which are signs of C-diff. superinfection. Stress ulcer prophylaxis can also increase risk for bone fracture and could interfere with other medications (Eisa et al., 2014). Stress ulcer prophylaxis in patients with sepsis should be used only in patients at risk for gastrointestinal bleeding, such as patients on prolonged mechanical ventilation (> 48 hours) and patients suffering coagulopathy (Rhodes et al., 2017).