On primary assessment, Airways were open and self-maintained. Breathing was tachypnoeic at 26 breaths per minute, spontaneous and regular. Lungs were auscultated with decreased breath sounds bilaterally in the lower lobes. Circulation was in-tact with nil signs of bleeding, however, the skin was pale and cool to touch, the heart rate was tachycardic and felt weak at the peripheries with a good central pulse. Blood pressure was 94/68 on arrival with a temperature of 39.3, BSL 12.8, SpO2 90%. Nil obvious physical disabilities present or deformities. The patient was alert, however, was not oriented to TPP, GCS 14.
On secondary assessment, Full set of vital signs completed as follows: RR26, BSL 12.8, Temp 39.3, SpO2 90%, PR 123bpm, BP 94/68, Pain 4/10. ECG completed and appeared to be sinus tachycardia. Abdominal CT scan organised to confirm the source of infection and observe any deformities. Codeine 30mg was given PO for comfort. A full history is taken from the family as the patient was confused. Stated has 2/7 history of being generally unwell before today becoming confused and irritable when it was decided to call an ambulance.
After the primary assessment was completed, the observations were consulted with the doctor and the sepsis pathway was initiated with this individual believed to be secondary to a urinary tract infection / pneumonia. Blood tests and urine sample were drawn by the RN including cultures, and rapid rehydration therapy was initiated using normal saline 0.9%. Amoxiclav 1.2g IV was initiated as well as Roxithromycin 300mg PO to combat infection.
Amoxiclav IV.
Amoxiclav IV is an antibiotic which is typically made up of 1g of amoxicillin and 200mg of clavulanic acid, making up the total 1.2g. It also comes in a 600mg option which is 500mg amoxicillin and 100mg clavulanic acid (Medsafe New Zealand, 2017 June 02).
This medication would be contraindicated with any cephalosporin or penicillin class allergy or hepatic dysfunction resulting from penicillin class antibiotics. Interactions with this medication are rare (Medsafe New Zealand, 2017 June 02).
Amoxiclav works by interfering with the bacterias ability to produce a cell wall, leading to cell death (Medsafe New Zealand, 2017 June 02).
Some of the side effects of this medication can include a burning sensation in the arm if it is being injected too quickly, dizziness, nausea, diarrhoea and mucosal candida infections (Medsafe New Zealand, 2017 June 02).
A normal dose for this medication is 1.2g q6-q8 hourly dependant on the severity of the infection. For patients with impaired renal output, this can be adjusted to 1.2g stat followed by 600mg q12 hourly (Medsafe New Zealand, 2017 June 02).
Normal Saline 0.9%
This is an Isotonic solution which is used to increase the total extracellular circulating volume. It can also be used to as a mechanism to administer other parenteral drugs such as Amoxiclav. It is indicated in people who are unable to consume oral fluids, are dehydrated, people who are hyponatraemic (Medsafe New Zealand, 2017 April 6).
Possible contraindications may include chronic heart failure, renal impairment, liver cirrhosis and other clinical states where there is sodium retention and/or oedema and should always be used with risks and benefits taken into account. As it is commonly used as a vehicle to administer other drugs, interactions with other drugs should also be taken into account before administering (Medsafe New Zealand, 2017 April 6).
Some of the possible side effects can include fluid overload, pulmonary oedema, hypokalaemia, hypernatraemia, febrile response, infection at the injection site, acidosis and other electrolyte imbalances. Normal dosage ranges on the individual and their specific needs (Medsafe New Zealand, 2017 April 6).
This can interact with some medications and change their physical appearance i.e. change viscosity, therefore it is important to check each individual medications compatibility with normal saline before infusion.
Roxithromycin
Roxithromycin is a Macrolide which works by binding to the bacterial ribosome, prohibiting cell regeneration. It is indicated in people who have mild to moderate infections of the upper or lower respiratory tract such as in this patient. (Kanoh & Rubin, 2010).
Roxithromycin's recommended maximum dose is 300mg once daily (Kanoh & Rubin, 2010).
It can be contraindicated in people who are using warfarin as it can in some cases increase INR. If use of this antibiotic is extended, it can cause colitis and should be monitored closely if using opioid pain relief concurrently. It can cause in some very uncommon cases the QT interval to be prolonged, leading to arrhythmias such as VT, so this should also be taken into account if the patient has a cardiac history (Kanoh & Rubin, 2010).
Roxithromycin has relatively few interactions, it is safe to take while taking contraceptives, they do interact with ergot alkaloids, digoxin and other glycosides, midazolam and is a mild CYP3A inhibitor, so should not be taken with rifabutin or bromocriptine (Kanoh & Rubin, 2010).
Codeine 30mg
Codeine comes in an oral tablet, it is an opioid receptor agonist. It is metabolised in the liver with a half life of 3 hours. Part of the codeine is metabolised into morphine, providing some of the analgesic effects through the us of the CYP2D6 enzyme in the liver (Medsafe New Zealand, May 2018).
The maximum dose is 300mg in 24 hours (Medsafe New Zealand, May 2018).
Adverse effects of this medication range from nausea, vomitting, constipation, dizziness & drowsiness to pin-point pupils, bradypnoea, bradycardia, confusion, seizure, coma and hallucinations, similar to that of a morphine overdose (Medsafe New Zealand, May 2018).
It is indicated in those with mild to moderate pain and works well as analgesia, especially when combined with other medications such as ibuprofen and panadol. Regular use needs to be monitored and constipation may need to be controlled with laxatives if necessary (Medsafe New Zealand, May 2018).
This medication commonly interacts with MAOI, alcohol, hypnotics and anxiolytic agents, anticholinergics, antihypotensive drugs, antipsychotic medications, tricyclic antidepressants (Medsafe New Zealand, May 2018). If prescribed with these drugs, check with the prescriber and watch for adverse effects.