Thomas Edison, a 67-year old man, who runs a yard service cut his thumb while he was attaching an accessory to one of his lawn mowers. The following day his thumb was sore and the surrounding skin was red.Thomas was busy that day and he headed out early for work and did not return home until late evening. After reaching home he found his thumb to be swollen and throbbing, and yellowish-white pus was also oozing out. At the same time he experienced shaking chills and was nauseous after which his wife drove him to the emergency department.
Upon arriving at the ED, Thomas was experiencing pain and discomfort at the affected area. He was awake but disoriented to place. He was feeling short of breath, his skin was clammy and flushed, and heart rate had increased.
His objective data/ initial vital signs were noted as follows: temperature 39.8C, pulse rate 125, blood pressure 98/60 mmHg, respiratory rate 30bpm, SaO2 92% on room air, and BGL 7.2mmol. No other remarkable findings were noted during the examination.
Thomas’s medical history includes presence of comorbidities such as stage-3 kidney disease, type 2 diabetes which he was diagnosed at age 43, obesity (BMI-34), and recent hospitalization due to asudden episode of hypoglycemia. Thomas is an active smoker and consumes about 10-12 cigarettes daily. He has been smoking since past 33 years.
Advancing age, medical history of kidney disease and diabetes, obesity, recent hospitalization and smoking are factors which could have predisposed Thomas to sepsis infection by altering his immune system (Gameiro et al., 2018).
His findings along with obvious signs of microbial infection indicated by presence of pus justifies his diagnosis of sepsis.
Sepsis is a syndrome of physiological, biochemical, and pathological abnormalities that are induced by any infection (Gotts &Matthay, 2016). The primary causative agent of sepsis is bacteria, and only 5% are caused by fungi (Gotts &Matthay, 2016). About 20% of sepsis infections are blood infections with others being intra-abdominal, UTI, skin, or respiratory infections (Gotts &Matthay, 2016). Some factors that aid in development of sepsis include advancing age, co-exiting morbidities, and drug therapy (Gotts &Matthay, 2016).
Thomas cut this thumb while he was in his lawn attaching accessory to his mower. This implies that he almost certainly acquired a bacterial infection that was not nosocomial in origin. Thomas was 67. He was also diagnosed with other medical conditions for which he was taking medications. These factors aided in development of sepsis.
The pathophysiology of sepsis includes entry of a bacterial pathogen into the body via a cut on the skin (Minasyan, 2019). This is what happened when Thomas received a cut on his thumb through which bacteria must have gained entry into his system. Following the entry of microbes, the host generates a response against the invader which is initiated by macrophages that bind to the microbial components causing phagocytosis of the invading bacteria thereby killing it (Minasyan, 2019). During this process, pro-inflammatory cytokines are released which cause fever by increasing the temperature set point, and induce an inflammatory reaction (Minasyan, 2019). This is why Thomas’s body temperature was found to be increased, along with physical signs such as inflammation, redness, swelling, and presence of pus which indicated that an inflammatory reaction occurred (Minasyan, 2019).
Thomas must be inspected for physical findings. This includes inspecting his general appearance, his vital signs, his skin, extremities, and neurological state (Makic, 2019). It is expected that general appearance of Thomas will be toxic and febrile (Makic, 2019). His vitals should reveal hypotension, increased heart rate, increased temperature, and tachypnea (Makic, 2019). His skin must be mottled or pallor indicating poor tissue perfusion. Skin and extremities should be warm to touch, and neurologically he should be disoriented (Makic, 2019).
Palpating Thomas’s affected area must reveal tenderness, guarding, and rebound tenderness which are classic signs of sepsis (Postelnicu & Evans, 2017). Any other painful areas needs to be palpated which can reveal local infection (Postelnicu & Evans, 2017).
Percussing the chest wall of Thomas from side to side and top to bottom can reveal abnormal sounds which can help in assessing his condition (Postelnicu & Evans, 2017). Over a healthy lung, precussion produces a resonant sound (Postelnicu & Evans, 2017). Depending on the underlying tissue, the sound can range from being flat to dull (Postelnicu & Evans, 2017). Since Thomas presented with shortness of breath and difficulty in breathing therefore percussion should reveal a dull sound which indicates zones of effusion (Postelnicu & Evans, 2017).
Auscultation helps in evaluating the sounds produced by cardiovascular system, blood vessels, lungs, (Prescott & Angus, 2018). This can be performed by placing a stethoscope and listening to the sounds (Prescott & Angus, 2018). Sound of air passing in and out of the lungs can be heard when auscultating Thomas since he presented with a systemic inflammatory response which can impact various organs (Prescott & Angus, 2018). A rapid respiratory rate and rhythm may also be noted which reveals tachypnea (Prescott & Angus, 2018).
Piperacillin-tazobactam is a combination of antibiotic (Pilmis et al., 2017). It belongs to the group of penicillins and beta-lactamase inhibitor (Pilmis et al., 2017). This combination of antibiotic effectively treats infections that are caused by both gram-negative andgram-positive bacteria (Pilmis et al., 2017). For sepsis, the standard empiric dosing of piperacillin-tazobactam is 4g/0.5g every 8 hours (Pilmis et al., 2017). Since Thomas was diagnosed with sepsis and the cause of his infection was most likely to be bacterial, however since the bacterial species causing the infection is not identified therefore using piperacillin-tazobactam as a treatment is justified for him which will act against a wide range of bacteria (Pilmis et al., 2017).
The mechanism of action of piperacillin-tazobactam involves two different mechanisms. Piperacillin is a beta- lactam (penicillin) antibiotic (El-Haffaf, Caissy&Marsot, 2021). It acts by killing bacteria that cause infections (El-Haffaf, Caissy&Marsot, 2021). This action of piperacillin is achieved by inhibiting bacterial cell wall synthesis (El-Haffaf, Caissy&Marsot, 2021). It does so by binding specifically to the penciling- binding proteins (PBPs) that are located inside the cell wall of the bacteria (El-Haffaf, Caissy&Marsot, 2021). As a result the cross linking of the peptidoglycan is inhibited. This prevents cell wall synthesis of the bacteria and the bacteria remain cell- wall deficient (El-Haffaf, Caissy&Marsot, 2021). Without a cell wall, the bacteria undergoes lysis and dies. This is how piperacillin displays bactericidal effect (El-Haffaf, Caissy&Marsot, 2021).
Tazobactam is a beta-lactamase inhibitor (Pilmis et al., 2017). It irreversibly inhibits the beta-lactamase enzymes and thereby broadens the spectrum of piperacillin by making it effective against those organisms that possesses beta-lactamase enzyme and would otherwise degrade this drug (Pilmis et al., 2017). A combination of piperacillin and tazobactam is therefore an effective antibiotic that enhances the activity of piperacillin and effectively eradicates all bacterial infections (Hagel et al., 2019).
This treatment should positively impact Thomas Edison. The antibiotic combination will act against the bacteria which caused sepsis and will clear the infection from his system, thereby making his body system go back to normal (Rhodes et al., 2018). It will reduce his stay at the hospital and also reduce associated morbidities and thereby, mortality (Rhodes et al., 2018).
The specific nursing care that must be provided to Thomas in relation to administration of piperacillin-tazobactam includes monitoring his electrolyte levels especially potassium, his intake and output levels, performing urinalysis, and renal function tests (Vora, 2016). Pattern of Thomas’s daily bowel activity and consistency of his stool must also be noticed. This is because piperacillin-tazobactam can cause colitis thereby GI effects must be monitored (Vora, 2016). The nurses must also look for any signs of superinfection (Le et al., 2018).
References
El-Haffaf, I., Caissy, J. A., &Marsot, A. (2021). Piperacillin-tazobactam in intensive care units: a review of population pharmacokinetic analyses. Clinical pharmacokinetics, 60(7), 855-875.https://link.springer.com/article/10.1007/s40262-021-01013-1
Gameiro, J., Gonçalves, M., Pereira, M., Rodrigues, N., Godinho, I., Neves, M., … & Lopes, J. A. (2018). Obesity, acute kidney injury and mortality in patients with sepsis: a cohort analysis. Renal Failure, 40(1), 120-126.https://doi.org/10.1080/0886022X.2018.1430588
Gotts, J. E., &Matthay, M. A. (2016). Sepsis: pathophysiology and clinical management. Bmj, 353.https://doi.org/10.1136/bmj.i1585
Hagel, S., Fiedler, S., Hohn, A., Brinkmann, A., Frey, O. R., Hoyer, H., … &Pletz, M. W. (2019). Therapeutic drug monitoring-based dose optimisation of piperacillin/tazobactam to improve outcome in patients with sepsis (TARGET): a prospective, multi-centre, randomised controlled trial. Trials, 20(1), 1-10.https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-019-3437-x
Le, C., Chu, F., Dunlay, R., Villar, J., Fedullo, P., &Wardi, G. (2018). Evaluating vancomycin and piperacillin-tazobactam in ED patients with severe sepsis and septic shock. The American Journal of Emergency Medicine, 36(8), 1380-1385.https://doi.org/10.1016/j.ajem.2017.12.055
Makic, M. B. F. (2019). Sepsis: Noninvasive Assessment. Journal of PeriAnesthesia Nursing, 34(4), 861-863.https://doi.org/10.1016/j.jopan.2019.05.003
Minasyan, H. (2019). Sepsis: mechanisms of bacterial injury to the patient. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 27(1), 1-22.https://sjtrem.biomedcentral.com/articles/10.1186/s13049-019-0596-4
Pilmis, B., Jullien, V., Tabah, A., Zahar, J. R., & Brun-Buisson, C. (2017). Piperacillin–tazobactam as alternative to carbapenems for ICU patients. Annals of Intensive Care, 7(1), 1-17.https://annalsofintensivecare.springeropen.com/articles/10.1186/s13613-017-0334-x
Postelnicu, R., & Evans, L. (2017). Monitoring of the physical exam in sepsis. Current opinion in critical care, 23(3), 232-236.https://journals.lww.com/co-criticalcare/Abstract/2017/06000/Monitoring_of_the_physical_exam_in_sepsis.11.aspx
Prescott, H. C., & Angus, D. C. (2018). Enhancing recovery from sepsis: a review. Jama, 319(1), 62-75.https://jamanetwork.com/journals/jama/article-abstract/2667727
Rhodes, N. J., Liu, J., O’Donnell, J. N., Dulhunty, J. M., Abdul-Aziz, M. H., Berko, P. Y., … & Roberts, J. A. (2018). Prolonged infusion piperacillin-tazobactam decreases mortality and improves outcomes in severely ill patients: results of a systematic review and meta-analysis. Critical care medicine, 46(2), 236-243.https://doi.org/10.1097/CCM.0000000000002836
Vora, S. (2016, October). Acute renal failure due to vancomycin toxicity in the setting of unmonitored vancomycin infusion. In Baylor University Medical Center Proceedings (Vol. 29, No. 4, pp. 412-413). Taylor & Francis.https://doi.org/10.1080/08998280.2016.11929491
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