pediatric sepsis - Nursing Case Study

Pathophysiology

• Primary mechanism: In pediatric sepsis, a severe infection triggers a systemic inflammatory response in the child's body. The immune system, in trying to combat the infection, inadvertently causes widespread inflammation, damaging tissues and organs.

• Secondary mechanism: The inflammation leads to coagulation abnormalities, causing tiny blood clots that can block blood vessels, reducing blood flow to vital organs. This results in organ dysfunction like acute kidney injury or respiratory failure.

• Key complication: If sepsis progresses, it can lead to septic shock, characterized by a significant drop in blood pressure. This can decrease blood flow to vital organs even further, exacerbating organ damage and increasing the risk of death.

Patient Profile

Demographics:

5-year-old male, kindergarten student

History:

• Key past medical history: Mild asthma, recurrent otitis media

• Current medications: Albuterol inhaler as needed

• Allergies: No known drug allergies

Current Presentation:

• Chief complaint: High fever, lethargy, and difficulty breathing

• Key symptoms: Rapid heart rate, rapid breathing, confusion, decreased urine output

• Vital signs: Temperature 39.8°C, heart rate 145 beats per minute, respiratory rate 35 breaths per minute, blood pressure 85/50 mmHg, oxygen saturation 92% on room air.

Section 1

Change in Patient Status:

The child's condition has deteriorated over the last several hours. He has become increasingly lethargic and has had a decrease in urine output. His vital signs have also changed: his temperature has risen to 40.2°C, his heart rate has increased to 155 beats per minute, and his respiratory rate has climbed to 40 breaths per minute. His blood pressure has dropped to 80/45 mmHg, and his oxygen saturation has decreased to 88% on room air.

The clinical team notes that the child's skin is becoming mottled, a sign of poor perfusion, and his capillary refill time is delayed. His breath sounds are also worsening, with decreased breath sounds in the lower lobes bilaterally. This suggests that the sepsis may be progressing to septic shock and that his respiratory status is declining, possibly indicating the development of acute respiratory distress syndrome (ARDS). These changes in the child's status require immediate intervention and reevaluation of the current treatment plan.

Section 2

New Diagnostic Results:

The child's latest lab results have returned with alarming findings. His white blood cell count has spiked to 23,000 per mm3, indicating a severe infection. His lactic acid levels are also elevated at 5 mmol/L, suggesting tissue hypoperfusion. Furthermore, his blood gas analysis shows a pH of 7.25 and a pCO2 of 55 mmHg, indicative of respiratory acidosis. His arterial oxygen saturation (PaO2) is 70 mmHg, which is lower than the normal range and correlates with his reduced oxygen saturation.

The chest x-ray also reveals bilateral infiltrates, a sign that ARDS may have developed. This aligns with the worsening breath sounds in the lower lobes and his increased respiratory rate. The child's deteriorating condition is now complicated by the potential development of multiple organ dysfunction syndrome (MODS) due to the septic shock. These findings necessitate immediate reevaluation of the child's treatment plan. Next steps may involve initiation of mechanical ventilation, administration of broad-spectrum antibiotics, aggressive fluid resuscitation, and possible use of vasopressors to restore his blood pressure.

Section 3

Change in Patient Status:

Over the next few hours, the child's condition continues to deteriorate despite ongoing treatment. His respiratory distress is increasing, with a respiratory rate now climbing to 50 breaths per minute, and his oxygen saturation dropping to 85% on 100% oxygen via non-rebreather mask. He is also becoming increasingly lethargic and less responsive to stimuli. His heart rate has spiked to 160 beats per minute, and his blood pressure has dropped to 70/40 mmHg, showing signs of shock. His skin is cool to touch, with capillary refill time increasing to 4 seconds, indicating poor peripheral perfusion.

Despite aggressive fluid resuscitation, his urine output has decreased to less than 1 ml/kg/hr, suggesting possible acute kidney injury. His central venous pressure (CVP) remains low at 5 mmHg, indicating inadequate fluid volume. These signs point to a severe distributive shock secondary to sepsis, which could lead to multiple organ failure if not quickly corrected. It's crucial to reassess and intensify the treatment plan, which may include transitioning to invasive mechanical ventilation, escalating to high-dose vasopressor therapy, considering renal replacement therapy, and continually monitoring his hemodynamic status.

Section 4

Change in Patient Status:

The child's condition continues to worsen, despite aggressive treatment measures. He is now becoming increasingly lethargic and unresponsive to stimuli, and his respiratory distress has escalated to the point where he is struggling to maintain adequate oxygenation, even on 100% oxygen via a non-rebreather mask. His heart rate has continued to rise to 180 beats per minute, and his blood pressure has further dropped to 68/38 mmHg. His skin is now mottled and cool to touch, with a capillary refill time of 5 seconds, indicating worsening peripheral perfusion.

His urine output has further decreased, now less than 0.5 ml/kg/hr despite aggressive fluid resuscitation, indicating potential acute renal failure. A repeat blood gas analysis shows a pH of 7.15, pCO2 of 60 mmHg, pO2 of 72 mmHg, and bicarbonate of 18 mEq/L, suggesting worsening metabolic acidosis and respiratory failure. The CVP has further dropped to 3 mmHg, indicating a critical fluid volume deficit. The child's deteriorating condition suggests a progression towards multiple organ failure secondary to severe septic shock. At this point, immediate measures to correct the underlying sepsis and organ failures are needed, including invasive mechanical ventilation, high-dose vasopressor therapy, renal replacement therapy, and continuous hemodynamic monitoring.

Section 5

New Complications:

As the child's condition continues to deteriorate, the healthcare team notices a new onset of a high-grade fever of 39.5°C, despite the aggressive administration of broad-spectrum antibiotics, suggesting a persistent or worsening infection. The mottled skin has now developed into a rash that is spreading across his body, further confirming the systemic nature of the sepsis.

Lab results are also concerning, with a white blood cell count now elevated to 24,000 cells/mcL, indicating the body's ongoing fight against infection. His platelet count is decreasing rapidly, now at 80,000/mcL, suggesting potential disseminated intravascular coagulation (DIC), a serious complication often seen in severe sepsis. His liver function tests show elevated AST and ALT levels, suggesting liver damage or dysfunction, a further indication of the progression towards multiple organ failure. The child’s condition is now critical, and the team must act quickly to address these new complications and prevent further deterioration. This will require careful clinical reasoning to determine the best course of action, considering the child's rapidly changing condition and the increasing number of organ systems involved.