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Reaction and Response to the answers on this post. how well did…
Reaction and Response to the answers on this post. how well did they answer the question
Scenario
The client is a 50-year-old female who is diabetic and has an ulcer on her right foot seriously infected with staphylococcus. She had a debridement procedure and was prescribed to receive clindamycin 1g IV as soon as possible. She is 5 feet tall and weighs 175 pounds.
Her medical record indicates an allergy to cortisone. When you ask her whether she has any other drug allergies, she replies, “No, only to cortisone.” The drug comes up from the pharmacy about 1900, 3 hours after she returned to your unit after the debridement.
About 5 minutes after the infusion is started, the patient says she is having difficulty breathing feeling dizzy, and scared. You find her pulse rapid and thready. Her lips are dusky, and she begins to wheeze.
Explain your answers in detail and provide an evidenced based rationale for your answers.
Should you continue the clindamycin? Why or why not?
How should you manage her current IV access?
Should you call her surgeon or the Rapid Response Team (provide a rationale for your choice)?
Should you or should you not start oxygen on this patient, why?
Would epinephrine or diphenhydramine (Benadryl) be helpful in this situation? Why or why not?
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1. Should you continue the clindamycin? Why or why not?
Based on the quick onset of respiratory symptoms, it is possible that this patient is having an allergic anaphylactic reaction to the current antibiotic. For this reason, the clindamycin should be discontinued, and the provider contacted to prescribe an alternate antibiotic. Opakunle (2018) states, “the incidence of allergies caused by clindamycin are low, but they do exist” (p. 77). The article also mentions anaphylactic shock is among the possibilities, and vancomycin is an alternative medication that can be used in cases of clindamycin allergy. Additionally, according to the 2021 Nurses Drug Handbook, vancomycin is an antibiotic indicated for many serious infections, including serious skin and soft tissue infections caused specifically by the staphylococcus anaerobe (Jones & Bartlett Learning, 2021). Vancomycin is also indicated to treat bacterial septicemia. The fact that this patient is diabetic and has a current seriously infected foot ulcer with confirmed diagnosis of staphylococci present, puts her at a high risk for that infection to spread into her bloodstream. “Staph can cause serious infections if it gets into the blood and it can lead to sepsis or death” (CDC, 2019, Overview section). Diabetics in general have a heightened risk of developing sepsis and septic shock (Sepsis Alliance, 2023). This is due to their weakened immune systems which predispose them to infections and once an infection is present, they take longer to heal. Sepsis Alliance (2023) continues to state, “given that the infection risk is higher than average for people with diabetes, it is essential that they watch for signs of sepsis should they become ill with a possible infection” (Treatment section).
For these reasons while we DC the current infusion, we also need to consider sepsis as a very real possibility occurring simultaneously with the allergic reaction. We should not ignore it as it is indeed a life-threatening infection. An order for lactic acid levels, ABG, and WBCs, would be among the few recommendations to the physician.
Another scenario to consider is that the patient stated she has an allergy to cortisone, which is a naturally occurring corticosteroid metabolite. Her body is under increased stress with this serious infection and can cause increased levels of cortisol in the body, adding to or initiating this allergic type of response we are seeing in her. Interventions discussed focus on the allergic reaction and would treat the airway issue in all cases, while the switch to vancomycin addresses the allergic reaction, the staph infection, and possible bacterial septicemia.
2. How should you manage her current IV access?
Because it is suspected the client is having an acute, immediate hypersensitivity reaction to the clindamycin, the transfusion should be stopped, and the current IV line should be kept open with normal saline.
Epinephrine should be administered subcutaneously or intravenously, and a second large-bore IV line should be initiated. Large bore IVs are used to allow for rapid administration of fluids and meds for a quicker stabilization. An alternative antibiotic should be considered for a clindamycin allergy such as vancomycin, which is also indicated for staphylococcus infections. The new antibiotic infusion should be initiated once the client has stabilized from the hypersensitivity reaction.
Should you call her surgeon or the Rapid Response Team (provide a rationale for your choice)?
The patient is scared and presenting with difficulty breathing, wheezing, dizziness, a rapid and thready pulse, and her lips are dusky. Due to her swiftly deteriorating health status, the Rapid Response Team should be called. Calling her surgeon could delay valuable time in implementing lifesaving interventions. Rapid Response Teams are specially trained to identify and preemptively treat early warning signs of acute medical decompensation before cardiac arrest occurs. Research has shown that severe postoperative adverse events, such as respiratory failure and severe sepsis, have been reduced by 58% after the utilization of Rapid Response Teams (Frey, 2012).
Should you or should you not start oxygen on this patient, why?
This patient is displaying symptoms characteristic to a severe allergic reaction, possibly anaphylactic 5 minutes after the onset of an antibiotic infusion. According to Hinkle and Cheever (2018), if a patient is displaying respiratory compromise, then initiation of supplemental oxygen is provided, either in combination with CPR or to the patient with respiratory symptoms such as wheezing, difficulty breathing, and cyanosis. Our patient is displaying all three of these symptoms, therefore this intervention is supported to maintain adequate oxygenation of tissues while we attempt to stabilize the patient further.
Would epinephrine or diphenhydramine (Benadryl) be helpful in this situation? Why or why not?
In this situation where the patient already has a weakened immune system due to the infection, any introduction of medication that could put her further at risk should be avoided. This poor patient is already compromised as it is by her age, being over the recommended BMI for her height, and having a weakened immune system which put her at a disadvantage from the start. She may or may not have known she had this allergy or it could have developed over time without her being aware. According to Agostini et al. (2001), “diphenhydramine administration in older hospitalized patients is associated with an increased risk of cognitive decline and other adverse effects with a dose-response relationship” (Conclusions section). This medication is associated with higher chances of having adverse anticholinergic effects such as orthostasis, central nervous system depression, paradoxical excitement, visual disturbances, tachycardia, dry mouth, urinary retention, and constipation (Agostini et al., 2001). These effects can be exacerbated even further due to polypharmacy which can be a problem in our elderly population. While 50 is not considered old in my book, the adverse effects kick in after age 50 for this medication. If we have to choose between epinephrine or diphenhydramine, epinephrine should be the medication that should be used first. There are some adverse side effects associated with the use of epinephrine in the elderly population of age 70 and above but due to this patient’s age of 50, the risk is less. The risk will go up if the patient has cardiac issues but how much is the question? According to Wesley and Wesley (2017), “four of the 44 (9.1%) older patients who received epinephrine had cardiovascular complications (ventricular arrhythmias, ischemic ECG findings, elevated serum troponin T values and stroke) compared to 1 of 225 (0.4%) in the younger patients” (para. 4). Looking at the data we know that there is a risk for the population that is older than our patient, but we still need to be mindful and dose low and go slow. If we compare the known effects of epinephrine and diphenhydramine and we weigh the risk and reward, we can see that epinephrine will have a lower risk for our patient with fewer chances of adverse long-term effects. Being mindful of how we dose the epinephrine is important as the route we administer it to prevent overdosing on the medication. It is suggested to give the epinephrine via IV instead of IM to control the rate and flow. Watching for any changes in the cardiac cycle and being mindful of how often we check vitals in this situation is important. This would be the suggestion for this patient.
