Page 101 - JSOM Summer 2024

• Titrate O to >92% SpO ; consider a simple face mask if • Cleanse the NGT site.
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requiring >8L of O . • Flush any unused IV line every 12h; check the IV site that is
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• Continue NGT to low continuous or intermittent suction. infusing vasopressor hourly.
• Continue dexamethasone, antibiotics, and chemical VTE • Perform Urinary Catheter care.
prophylaxis. • Document strict intake and output (I&Os) to track the pa-
• Appropriate re-dosing of antibiotics. tient’s fluid status.
• Ensure patient is being repositioned or ambulates every 2h.
Recommended Nursing Care: • Encourage coughing and deep breathing hourly when awake.
• Assist patient with skincare/bed bath. • Assist patient with oral/dental care.
• Maintain head of bed elevation >30 degrees.
• Check BP readings hourly or more frequently if frequent Recommendations to prepare the patient for MEDEVAC
titration of vasopressors is needed. • Make copies of all documentation and labs to send to the
• Cleanse the NGT site. en-route care (ERC) team.
• Flush any unused IV line every 12h; check the IV site that is • Provide the patient with eye and ear protection.
infusing vasopressor hourly. • Reinforce all tubes and lines with tape.
• Perform Urinary Catheter care. • Ensure all fluids/medication bags are labeled.
• Document strict intake and output (I&Os) to track the pa- • Label all lines with tape approximately 6 inches from the IV
tient’s fluid status. site with the medication or type of fluid infusing to the site.
• Ensure the patient is being repositioned or ambulated every 2h. • Empty urinary catheter bag.
• Encourage coughing and deep breathing hourly when awake. • Consider administering 4mg IV ondansetron (Zofran) be-
• Assist patient with oral/dental care. fore flight.
• Re-dose pain medication before flight, anticipating that
Time: +72h pain will increase due to the stressors of flight.
The patient no longer requires fluid boluses. Unable to wean • Review the Medication Administration Record with the
off epinephrine but at a stable rate. RR improved with inter- ERC team.
ventions and was able to titrate down supplemental O . Noti-
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fied that MEDEVAC is available in 12h. Discussion
• HR 92bpm; BP 100/68mmHg; RR 22–28 breaths/min; O
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saturation 94% on 4L via nasal cannula; temp 38.5°C. This hypothetical scenario describes the management of a pa-
• Epinephrine: 4μg/min. tient with septic shock from an abdominal source that is most
• IV fluid rate: LR at 50mL/h. likely acute perforated appendicitis. Most military general
• Cumulative total IV fluid input: 16,312.5mL (~16.3L); surgeons have managed a patient with sepsis from perforated
1200mL over 24h. appendicitis, particularly in the operational environment. In
• Cumulative total UOP: 1,635mL; 600mL over 24h. the active-duty population, the overall incidence rate of ap-
30mL/h over the last 12h; yellow. pendicitis is 18.4 per 10,000 person-years, and nearly 14% of
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• Cumulative NGT output: 6.6L; 1.3L over 24h. Starting to patients present with perforation. Between 1987 and 2017,
clear up, but still light green. appendectomy was the second most common major opera-
• Unable to run more laboratory data. tion performed by U.S. Navy general surgeons deployed on
• Abdominal pain is well controlled with scheduled acet- warships (who manage all acute surgical diseases for the em-
aminophen and as needed IV morphine. barked crews on the various warships deployed in carrier and
• No flatus, less burping. expeditionary strike groups). 23–26 Sailors and Marines with ap-
pendicitis have been impacting naval operations for decades.
Recommended Interventions: During World War II, “probably no other single disease caused
• Telemedicine consultation. If diuretics are given, it more anxiety to submarine personnel than appendicitis.” It
should only be done in conjunction with a telemedicine was diagnosed by submarine pharmacist’s mates (the precur-
consultation. sors to Independent Duty Corpsmen) during 116 war patrols,
• Continue current care. and a submarine had to come off combat patrol or leave their
• Continue dexamethasone 8mg IV daily (prior steroid area of operation in 11 (9.5%). 27
history).
• IV fluids rate: LR at 50mL/h. As demonstrated in this scenario, the key principles in manag-
• Goal UOP: 0.3–0.5mL/kg/h. ing the septic patient include rapid identification of potential
• Titrate vasopressors with a SBP goal >90mmHg or MAP sepsis, early administration of antibiotics, early fluid resuscita-
>60mmHg. tion, source identification, and source control. While early anti-
• Titrate O to >92% SpO . biotics have demonstrated a mortality benefit in septic patients,
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• Continue dexamethasone, antibiotics, and chemical VTE appropriate fluid resuscitation should not be delayed for anti-
prophylaxis. biotic administration; ideally, both are given simultaneously. A
• Appropriate re-dosing of antibiotics. complete history and physical exam are critical to determining
a potential source to aid the forward-deployed caregiver in an-
Recommended Nursing Care: tibiotic selection. While not exhaustive, Box 2 lists common
• Consider changing IV dressings if needed. causes of sepsis to consider. Also, consider endemic infectious
• Assist patient with skincare/bed bath. diseases in the area of deployment or recent port calls.
• Maintain head of bed elevation >30 degrees.
• Check BP readings hourly or more frequently if frequent In this scenario, acute perforated appendicitis is the cause of
titration of vasopressors is needed. septic shock, but in the deployed environment SSTIs are also

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