Question

Sepsis and MODS

Patient Profile

W.A. is a 70-year-old female who presented to the emergency department with fever, severe nausea, vomiting, and diarrhea. She is admitted to the intensive care unit (ICU) with a diagnosis of kidney failure and septicemia. Her previous medical history includes glaucoma, chronic kidney failure, hypertension, and insulin-dependent diabetes. She had a left above-the-knee amputation 1 year ago.

Subjective Data

• W.A.’s daughter states she was able to do her daily chores at home independently, but for the last few days it was getting difficult for her to get around and that she needed to take frequent breaks because of shortness of breath and no energy. Her daughter also reports that W.A. had been having headaches with nausea and dizziness for the past few days.
• Goes to hemodialysis 3 days a week

Objective Data

Physical Examination

• Blood pressure 172/92, pulse 110, temperature 101.5°F, respirations 28
• Oxygen saturation 86% on 15 LPM via mask
• Oriented to name only
• Crackles in bilateral lower lobes
• 2+ edema bilateral lower extremities and hands
• Abdomen is distended with hypoactive bowel sounds x4 quadrants

Diagnostic Studies

• CBC: Hemoglobin 7 g/dL, hematocrit 23.8%, RBC 2.57 million/mm³, WBC 14.8 mm³
• Chemistry Panel: Serum sodium 132 mEq/L, serum potassium 6.0 mEq/L, calcium 9.3 mg/dL, phosphorus 6.0 mg/dL, glucose 197 mg/dL, albumin 2.4 U/L, serum blood urea nitrogen 77 mg/dL, serum creatinine 7.30 mg/dL, eGFR African American 10, BNP 182 pg/mL
• Urinalysis: Dark yellow and cloudy, protein 28 mg/dL, positive for casts, positive for red blood cells and white blood cells, positive for glucose and ketones
• Blood cultures pending

Discussion Questions

1. What is multiple organ dysfunction syndrome (MODS)? After reviewing W.A.’s presentation, what organ systems do you suspect are involved and why?

2. What do you think is the origin of W.A.’s septicemia?

3. What additional tests would you anticipate for W.A.?

4. What are the interprofessional care goals for W.A.?

Answer 1

1. Multi organ dysfunction syndrome is a derangement of physiological functioning of two or more organ systems which are not affected at the time of admission to the hospital or ICU. It is potentially reversible. As per the given scenario the following organ systems may be affected:

Respiratory system: an oxygen saturation of 86% with 15 liter per minute of oxygen, crackles in bilateral lower lobes and high respiratory rate of 28 breaths

Cardiovascular system: high Blood pressure (172/92 mmHg) and high pulse rate of 110 beats, 2+ edema bilateral lower extremities and hands

GI system : distended abdomen with hypoactive bowel sounds in all 4 quadrants

Central Nervous system : patient is oriented only to name

Hematological system : as evidenced by low hemoglobin levels, low hematocrit, low RBC count and elevated WBC count

Endocrine system : as the blood glucose level is high 197 mg/dL indicating hyperglycemia

Along with these organ systems the patient's Kidneys (evidenced by electrolyte imbalance, high BUN, creatinine , BNP and low GFR ) and immune system (evidence of septicemia) is also affected. These disorders were the cause of her ICU admission.

2. The cause of septicemia may be the hemodialysis session or chronic kidney disease (or organ failure like kidney failure) that is a known risk factor of sepsis and septic shock.

3. A blood culture may be performed to identify the causative organism

An ABG to identify the extent of lung dysfunction and presence of any associated acid base imbalance

A chest X-ray can also be performed as the patient had crackles to identify abnormal accumulations or structural shifts.

ECG may help to identify cardiac arrhythmias  as there was elevated serum potassium level

An X-ray abdomen or CT abdomen may help to identify paralytic ileus or intestinal obstruction.

4. Inter professional care goals may include:

Identifying the cause of sepsis

Starting appropriate antibiotic therapy to treat and eliminate the underlying infection

Supporting and maintaining the functioning of the kidneys

Reversing the organs to normal functioning and minimizing the potential damages as a result of MODS

Promoting maximum level of functioning

Adequate nursing care and physiotherapy to restore previous functional levels.