NU654 Unit 4 Sepsis Management Paper, Dialysis Example

Every Element on Time, One Element Adapted: A Sepsis Management Paper for Catheter-Related Septic Shock in a 66-Year-Old on Hemodialysis With a Weak Heart

[Student Name]

Purdue University Global

NU654: AGACNP Acute Care Diagnosis and Management III

Unit 4 Sepsis Management Paper

[Instructor Name]

[Date]

The patient is composite; times, volumes and values are bracketed.

The Case at Time Zero

Mr. [D.], [66], has received hemodialysis three times a week for [four] years through a tunneled right internal jugular catheter, and his last echocardiogram showed an ejection fraction of [30] percent. He makes no urine. His dry weight is [78] kg. Twenty minutes into his run at [09:40], he developed rigors; the run was stopped. At [10:00] time zero: temperature [102.4] F, pulse [118], blood pressure [82/46], respiratory rate [24], saturation [93] percent on room air. The catheter exit site was red, with a small amount of pus. Lactate was [3.6] mmol/L.

The Hour-One Bundle, Delivered

The Surviving Sepsis Campaign combined its three- and six-hour bundles into an hour-one bundle in 2018, asking clinicians to begin five elements within the first hour after recognition (Levy et al., 2018). For Mr. [D.]:

1. Lactate measured: [10:00], [3.6] mmol/L. Repeat ordered for [12:00].

2. Blood cultures before antibiotics: [10:12], two sets, one drawn through the catheter and one from a peripheral vein, plus a swab of the exit site.

3. Broad-spectrum antibiotics: vancomycin [2,000] mg loading dose at [10:25] and cefepime [2 g] at [10:30], both chosen for catheter-related infection in a dialysis patient and dosed for his kidney failure.

4. Fluid for hypotension: [500] mL of balanced crystalloid started at [10:15], a second [500] mL at [10:40] after reassessment.

5. Vasopressor for hypotension during or after fluid: norepinephrine started at [10:50] through a peripheral line while a central line was placed, adjusted to hold the mean arterial pressure at 65 mmHg or above.

Every element began within the hour. The fluid volume was the only element adapted, and the reasons follow.

Testing Each Element Against the Evidence

Lactate. A lactate of 3.6 in a hypotensive patient confirms septic shock by the Sepsis-3 criteria once a vasopressor is needed, and the guideline suggests guiding resuscitation by repeat lactate (Evans et al., 2021). No adaptation was needed.

Cultures and antibiotics. The guideline recommends antibiotics within one hour for possible septic shock, after cultures if they do not delay treatment. For a suspected infection of a tunneled dialysis catheter, the IDSA catheter guideline recommends vancomycin with gram-negative coverage chosen by local resistance patterns, and removal of the catheter when the patient has severe sepsis or hemodynamic instability (Mermel et al., 2009). The catheter was removed at [14:00] and a temporary catheter placed at another site after cultures were drawn. No adaptation was needed.

Fluid. This row is the longest, because it is where the patient and the bundle part company. Thirty milliliters per kilogram for Mr. [D.] would be about [2,340] mL. He cannot excrete water, and his ventricle ejects [30] percent of its volume. The 2021 guideline suggests 30 mL/kg of crystalloid within the first three hours, but grades this as a weak recommendation with low-quality evidence, and it recommends using dynamic measures and reassessment to guide further fluid (Evans et al., 2021). A weak recommendation based on low-quality evidence is exactly the kind a clinician may adapt for a patient unlike most of those studied, as long as the reason is written down. He received [1,000] mL in two measured boluses, each followed by assessment of his pressure, lungs and inferior vena cava, and norepinephrine was started early rather than more fluid.

Vasopressor. Norepinephrine is the recommended first-line agent, and giving it briefly through a peripheral vein until a central catheter is in place is acceptable (Evans et al., 2021). No adaptation was needed.

SEP-1 and the Fluid Decision

The CMS SEP-1 measure scores hospitals on whether each bundle element was delivered, and it includes the 30 mL/kg volume for septic shock. Its specifications allow a smaller volume when the clinician documents the reason, such as heart failure or end-stage kidney disease, and documents the volume ordered. The note for Mr. [D.] recorded the reason, the ordered volume of [1,000] mL, and the plan to reassess after each bolus. Without that note, the care would have been counted as a failure of the measure even though it was the right care. The paper treats this as a documentation duty, not a loophole: a measure that assumes an average patient needs a written reason when the patient is not average.

Results

By [12:00] his lactate had fallen to [2.4], his mean arterial pressure was [68] on norepinephrine [0.08] mcg/kg per minute, and his lungs had developed a few more B-lines on ultrasound without a rise in oxygen need. Blood cultures from both sites grew methicillin-susceptible Staphylococcus aureus at [16] hours, cefepime was stopped and vancomycin changed to cefazolin dosed after dialysis. Dialysis with ultrafiltration of [1.5] liters was done on [Day 2] once he was off norepinephrine.

What Could Have Gone Wrong Either Way

Both errors were possible, and the paper names them. Giving the full [2,340] mL to a man who cannot pass urine, with a ventricle that pumps a third of its volume, risked pulmonary edema that might have needed intubation or emergency dialysis while he was still on a vasopressor. Giving too little risked prolonged hypoperfusion and a rising lactate. The measured approach answered both risks with the same tool: small volumes followed by a look at the lungs and the pressure. When the second bolus raised his pressure only briefly and added B-lines to his lung ultrasound, the team stopped giving fluid and relied on norepinephrine, which is the decision the reassessment was designed to make. A fixed volume, given all at once, would have taken that decision away.

What the Case Shows About Bundles

A bundle is a set of reminders built for the average patient in septic shock. Delivering every element on time is the standard, and this paper does not argue against it. It argues that one element, the fluid volume, rests on the weakest evidence and fits this patient least, and that adapting it with a written reason is consistent with both the guideline and the measure. The other four elements were delivered exactly as written, because nothing about Mr. [D.] made them less appropriate. The skill the bundle cannot supply is knowing which of its parts a particular patient can safely receive, and writing that judgment down clearly.

References

Evans, L., Rhodes, A., Alhazzani, W., Antonelli, M., Coopersmith, C. M., French, C., Machado, F. R., Mcintyre, L., Ostermann, M., Prescott, H. C., Schorr, C., Simpson, S., Wiersinga, W. J., Alshamsi, F., Angus, D. C., Arabi, Y., Azevedo, L., Beale, R., Beilman, G., . . . Levy, M. (2021). Surviving sepsis campaign: International guidelines for management of sepsis and septic shock 2021. Critical Care Medicine, 49(11), e1063-e1143. https://doi.org/10.1097/CCM.0000000000005337

Levy, M. M., Evans, L. E., & Rhodes, A. (2018). The Surviving Sepsis Campaign bundle: 2018 update. Critical Care Medicine, 46(6), 997-1000. https://doi.org/10.1097/CCM.0000000000003119

Mermel, L. A., Allon, M., Bouza, E., Craven, D. E., Flynn, P., O'Grady, N. P., Raad, I. I., Rijnders, B. J. A., Sherertz, R. J., & Warren, D. K. (2009). Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the Infectious Diseases Society of America. Clinical Infectious Diseases, 49(1), 1-45. https://doi.org/10.1086/599376