Adult Meningococcal Septicaemia

1
Adult Meningococcal Septicaemia

• an overview of the first 6 hours in Intensive
  Care
• a nursing perspective
• based on real events

2
Arrival in ICU

• self ventilating on oxygen
• talking coherently but frightened
• peripherally dilated, pyrexial but BP and HR
  stable
• passing small amounts urine
• widespread purpuric rash
• low blood glucose
• family in attendance

3
Within the first hour on ICU

• patient becoming tired and increasingly drowsy
• - able to rouse patient intermittently
• HR increasing, BP dropping
• - fluid resuscitation in progress
• - inotropes commenced
• - low dose steroid infusion
• urine output becoming negligible
• purpuric rash unchanged

4
Further deterioration - What next?

• Deteriorating neurological status with
  escalating metabolic acidosis herald need for
• intubation and positive pressure ventilation
• non invasive cardiac monitoring
• - gives further data to manage cardiovascular
  collapse
• haemofiltration
• - aim to control metabolic acidosis and fluid
  balance
• naso gastric feeding
• family support

5
Intubation and Ventilation

• intubation and positive pressure ventilation
• - potentially an initially de-stabalising event
• respiratory observations
• - closely managed by the bedside nurse
• pO2 management
• pH management
• - lowering pCO2 can help to correct acidotic pH
• sedation
• - to promote comfort and tolerance of therapies

6
Cardiovascular Management

• continuous cardiac monitoring
• - blood pressure and central venous pressure
  readings allow the nurse to titrate fluids
  and noradrenaline
• blood tests
• - arterial blood gases are taken frequently to
  plot patient progress as are formal blood tests
• rash inspection
• - nurse is constantly assessing the extent and
  quality
• intravenous antibiotics
• - paramount importance

7
Further Cardiovascular Management

• non invasive cardiac monitoring
• cardiac output CO
• cardiac index CI
• systemic vascular resistance SVR
• provides further empirical data to more
• accurately target therapies to support a
• cardiovascular system that is further collapsing
• due to progressive septic shock

8
Renal Management

• haemofiltration
• - to manage escalating acidotic pH and fluid
  balance
• lactate free solution
• - avoid further lactate load for patient with
  high lactate
• use of sodium bicarbonate as buffer
• temperature management
• - temperature drops significantly due to
  extracorporeal circuit

9
Nutrition

• commencement of nasogastric enteral feeding
• - hypermetabolic patient
• - promotes gut integrity
• blood glucose kept between 4-7mmol/l
• - thought to improve outcome in septic patients
• use of locally devised protocols
• - for nasogastric feeding and insulin infusion

10
Patient Care

• primary goal for the nurse is to provide support
  to the patient
• patient care needs should be managed in the light
  of physiological requirements
• The beside nurse must prioritise care needs with
  therapy needs

11
Family Support

• With such a rapid onset critical illness family
  require specific support
• honest information as soon as possible
• opportunity to ask questions
• time with patient
• rest and time for reflection
• information for other family

12
Multidisciplinary Team

• Effective management of this rapidly changing
  situation requires the multidisciplinary team to
• act promptly
• support each other
• collaborate with skills/tasks
• share information