Considerations in treatment
It is essential to consider what the next course of treatment and care should be. In addition to identifying the priorities of treatment, the issues here need to be considered.
The results of samples sent for laboratory assessment should be chased if results are not yet back. It is the responsibility of the person taking the samples to ensure the results are back and are analysed in a timely way.
Repeating a blood gas and obtaining a lactate level is important to assess the degree to which is developing the severity of septic shock.
Identifying the cause of the infection is essential if possible to do ideally prior to starting antibiotics. However this should not delay the administration of antibiotics if your patient is at high (red) or moderate (amber) risk of sepsis. It is important to identify the cause of the infection to allow the selection of appropriate antibiotics in accordance with the guidelines. The administration of antibiotics should not be delayed if the patient is at high (red) risk of death from sepsis.
Take a full history and ask about possible infective symptoms e.g. cough and shortness of breath, urinary frequency and pain on passing urine? Take appropriate samples e.g. sputum and viral throat swab or mid-stream urine. Undertake a ward based urinalysis if symptoms of a urinary tract infection.
Inappropriate antibiotic use should be avoided and a review of antibiotic therapy should be undertaken with further information regading the clinical diagnosis (and from any culture results which may be available).
Early fluid resuscitation is essential in helping to restore the blood circulating volume. 's systolic blood pressure is low and she was given intravenous fluid in ED. Further fluid boluses of 500 mL given over less than 15 minutes may be required if her vital signs do not improve. Fluids should be started promptly and will typically involve crystalloid solutions (e.g. 0.9% sodium chloride, Hartmann's solution or Plasmalyte 148).
High flow oxygen may help to minimise the development of lactic acid, and therefore metabolic acidosis, as it will maintain the oxygen supply to cells and tissues for aerobic metabolism. NICE guidelines (2016) identify a need to titrate the amount of oxygen given to maintain oxygen saturations between 94% to 98% (88% to 92% in patients who have a known COPD and may be at risk of a hypercapnic respiratory failure).
If remains hypotensive, despite the fluid administration, then she may require inotropes and/or vasopressor medication. Inotrope medication supports the contractions of the cardiac muscle and vasopressor medication constricts the peripheral blood vessels increasing the peripheral resistance. If these are required, will require continuous ECG monitoring and will need to transfer to the Intensive Care Unit (ICU).
Escalating care is essential where a patient is deteriorating and patient severity criteria is changing. It is necessary to involve a senior decision maker whether a critical care outreach team, medical emergency team, rapid response team or senior medical staff to support the need for escalation.