Haemato-oncology practice - Assignment Example

Describe the pathology of severe sepsis and providing a clear rationale, discuss the immediate management of severe sepsis Sepsis and septic shock occur as a result of complex interaction between the pathogenic agent and the immune system of the host. During any localized infection, the normal physiologic response includes host defense activation resulting in influx of the monocytes and activated neutrophils, local vasodilation, release of inflammatory mediators, increased permeability of the endothelium and activation of coagulation pathways.

In septic shock, these mechanisms further proceed to diffuse endothelial disruption, increased vascular permeability, thrombosis of end-organ capillaries and vasodilation. Damage to the endothelium further leads to activation of coagulation and inflammatory cascades leading to positive feedback loop which further causes end-organ and endothelial damage (Pinsky, 2011). The pathogenic agents induce exaggerated systemic inflammatory response. Due to systemic inflammatory response, imbalance of homeostasis occurs leading to disseminated intravascular coagulation, microthrombosis, organ dysfunction and even death(Pinsky, 2011).

The first step in the management of shock is to evaluate and stabilize airway, breathing and circulation. This includes intubation and mechanical ventilation if necessary. 100% oxygen must be given at a high flow rate in all cases. The saturations and other vital signs must be monitored continuously using cardio-respiratory monitor. To improve circulation, a good intravenous access must be secured. If it is difficult to access peripheral lines, central venous veins or intra-osseous lines must be accessed.

Intravenous fluids and if necessary, vasopressors and cardiac ionotropic agents must be given. The intravenous fluids used for resuscitation are crystalloids like normal saline and Ringer's lactate. The initial dose given is 20ml per kg as bolus over 5 minutes. This dose may be repeated if required. Thereafter, the fluids are given based on the maintenance requirements and losses. Appropriate intravenous antibiotics must be started. Initial laboratory work-up includes complete blood counts, serum electrolytes, renal parameters, liver function tests, chest radiography and arterial blood gas analysis.

Calcium, sodium bicarbonate and steroids are given as required. The management of shock is tailored to the cause and the stage of shock. In the irreversible stage, the cellular and tissue injuries cannot be reversed despite hemodynamic correction. There is widespread cellular injury as a result of lysosomal leakage. The damage is evident in organs like brain, heart, kidneys, adrenals and gastrointestinal tract. In the heart, nitric oxide synthesis occurs and myocardial contractile function worsens.

There may be wide-spread coagulation necrosis, subendocardial haemorrhage or contraction band necrosis (Claessens and Dhainaut, 2007). Structured Reflection Reflective practice is essential to clinical practice and provides a retrospective look at current practice and questions the reason for doing so. It is a good way of learning and it enables the practitioner to assess, understand and learn through their experiences (Burns and Grove 1997). In the following assignment, I shall discuss about a patient with cancer related septic shock based on Gibbs (1988) Reflective Cycle.

This is because, Gibbs Reflective Cycle is a straight