Septic Shock Simulation

Mr. Budd, age 72, arrive by ambulance in the ED. He was unconscious and had stab
wounds to the other upper right abdomen and lower right chest, which were
sustained in his home while fighting off a burglar. The paramedics started 2 large
bore IV catheters in his right and left antecubital spaces and infused LR wide open.
An endotracheal tube was inserted and ventilation with a resuscitation bag at 100%
oxygen was begun.

A 5 cm stab wound to the right lower chest and a 7.5 cm stab wound to the right
upper abdomen were inspected, and pressure dressings to the sites were secured.
Chest tubes were inserted into the right plural space. Immediately 500 ML‘s of red
drainage returned via the lower chest tube. Vital signs were:

BP 70/50
Heart rate 125, sinus tachycardia
SPO2 88%
Respirations 30

A Foley catheter was inserted and drained 400 ML‘s of dark yellow urine. After
infusion of more than 2000 mL of LR, Mr. Budd was sent to surgery.

1. List the signs of shock identified while Mr. Budd was in the ED.

During surgery a right thoracotomy and abdominal laparotomy were performed. A

lacerated intercostal artery was ligated in the chest. Exploration of the abdomen
revealed extensive injury. The liver and duodenum were lacerated. Extensive
hemorrhage and leaking of intestinal contents were apparent after opening the
peritoneum. The injuries were repaired, the peritoneal cavity was irrigated with
antibiotic solution, and incisional sump drains were placed in the duodenum. During
the four hour surgery, Mr. bud received six units of blood and an additional 3 L of
LR. A pulmonary artery catheter and arterial line were inserted.

2. Identify Mr. B’s risk factors for infection.

3, Interpret the vital signs obtained after the chest tube was placed.
4. What type of shock is Mr. B in?

ICU After Surgery

When Mr. Budd arrived in the surgical ICU, he was receiving ventilatory support.
Ventilator settings were as follows: assist control mode, respiratory rate 12, tidal
volume 800 mL, FiO2 60%. The following vital signs and hemodynamic readings
were obtained:
BP 92/52
Heart rate 114
Respiratory rate 12 t
Temperature 97.2
SPO2 86%
CVP 4
PCWP 6
C0 5
CI 2.9
SVR 1040

ABGs were normal except for mild hypoxia. The WBC was elevated at 13.6, and
hemoglobin was 10 g/dL.

5. Interpret the vital signs.

6. Interpret the hemodynamic parameters in terms of preload, afterload and cardiac
output and index.

POD #1
Mr. Budd remains drowsy and he continues to receive ventilatory support. His pain
was controlled by IV morphine. The nasal gastric tube continues to drain large
amounts of green fluid, and the duodenal sump drained large amounts of greenish
brown fluid. His chest and abdominal dressings remain dry. The chest tubes drain
small amounts of bloody fluid. Urine output was 40 to 60 mL per hour. His abdomen
is slightly firm and distended, and he has no bowel sounds.

7. Which parameters indicate whether this patient is stable or unstable?

POD #2
Mr. Budd’s condition remained reasonably stable until his second postop day. At this
time he became difficult to arouse, but did respond to commands. His respirations
were rapid and shallow. Urine output dropped to 20 mL per hour. His skin became
warm dry and flushed. The following vital signs, hemodynamics, and lab values were
reported:
BP 80/50
Heart rate 132 bpm
Temperature 97.2°F
SPO2 92%
WBCs 22,000
glucose 270
CVP 2
PCWP 4
C0 8
CI 4.7
SVR 560

8. Compare the general assessment parameters in vital signs listed here to those
obtained earlier. What signs are indicative of shock and sepsis?
9. Use your knowledge of septic shock to interpret the hemodynamic readings.
Culture and sensitivity reports from wound drainage indicated gram-negative
bacilli. Appropriate antibiotics were administered, as well as IV hydrocortisone.
Total parenteral nutrition was started. To prepare for the suspected hyper dynamic
phase of septic shock, the LR was increased to 150 ML‘s per hour and dopamine was
started at 5 µg per kilogram per minute.

10. Which bacteria are gram-negative and why are they a threat to patients?
11. Explain the reason for the following interventions: IV antibiotics,
hydrocortisone, TPN, lactated ringer‘s, & dopamine

POD #6
By the six postoperative day, Mr. Budd’s condition had deteriorated dramatically.
His skin was cool and mottled. His sclera were yellow. He was no longer responding
to stimuli. IV norepinephrine started at 6 µg per minute, and dopamine was started
at 3 µg per kilogram per minute. He began having short runs of ventricular
tachycardia. ST segment elevation and T-wave inversion were noted in the V leads
on the ECG. Crackles were heard over the lung fields. Urine output was only 3 to 5
mL per hour. His abdomen was enlarged and firm; the abdominal suture line had
dehisced, and peritoneum could be seen.

12. Why does Mr. B require both norepinephrine and dopamine?

13. What might be causing the runs of ventricular tachycardia?
14. What might be causing the other ECG changes?

The following vital signs and hemodynamics were obtained:

BP 70/52
Heart rate 140 bpm
Respiratory rate 14
Temperature 96.4°F
CVP 8
PCWP 24
C0 2
CI 1.1
SVR 2000
SPO2 86%

15. Interpret the vital signs and general assessment parameters.

16. Interpret the hemodynamic parameters in terms of preload, after load, and
CO/CI.
17. Explain the pathophysiology involved in the changes in hemodynamic
parameters over the last few days.

The following labs were obtained: pH 7.14, PaCO2 49, HCO3 12, PaO2 55, lactic acid
3 mEq/L, K 5.9,Na 152, AST 82, creatinine 3.4, amylase 290, platelets 75,000, aPTT
98 seconds, troponin > 50
18. Analyze the ABGs lactic acid in electrolytes
19. Analyze the chemistry values, coagulation values, and cardiac markers.
20 Which organs are failing?

Despite efforts to support him, Mr. Budd’s hemodynamic status deteriorated further.
He went into ventricular fibrillation and resuscitation efforts were unsuccessful. An
autopsy revealed several abscessed areas in the Lungs, acute hepatic failure, and
areas of myocardial infarction.

Case Study created by Diane Dressler RN, MSN

Adapted from Melander, SM. (2004) Case Studies in Critical Care (3rd ed). Philadelphia: Saunders.