Abstract Introduction and objectives The care plan of a 42-year-old woman with anaphylactic shock, secondary to ingestion of amoxicillin/clavulanic acid, with upper airway involvement due to laryngeal angioedema, is presented. Previously she had had two episodes of angioedema of unknown origin. The incidence of this phenomenon is between 3.2 and 10 cases/100,000
people/year. An evaluation was made and three altered necessities stood out: breathing and circulation (she needed mechanical ventilation and noradrenalin perfusion), elimination (she required furosemide to keep an acceptable diuresis time), and hygiene and skin protection (she presented generalised hyperaemia, lip, lingual and oropharyngeal oedema). The hospital's Clinical Research
Ethics Committee requested the patient's informed consent to access her clinical history. According to the altered necessities, seven diagnoses were prioritised according to NANDA taxonomy: risk of allergic response, risk of infection, risk of ineffective renal perfusion, decreased cardiac output, impaired spontaneous ventilation, risk of unstable blood glucose level, and risk of dysfunctional
gastrointestinal motility. Scores of outcome criteria showed a favourable evolution after 24h. The development of a standardised NANDA-NOC-NIC language in the clinical case presented allowed us to organise the nursing work, facilitating recording and normalising clinical practice. As a limitation of this case, we did not have serial plasma levels of histamine and tryptase to assess
the evolution of anaphylactic symptoms. Highlight the importance of health education in a patient with a history of angioedema. Keywords: Anaphylaxis Nursing care Critical care Intensive care unit Resumen Introducción y objetivos Se presenta el plan de cuidados de una señora de 42años con shock
anafiláctico secundario a la ingesta de amoxiclavulánico, con compromiso de la vía aérea superior por angioedema de laringe. Previamente tuvo 2 episodios de angioedema. La incidencia de este fenómeno oscila entre 3,2 y 10casos/100.000 personas/año. Se realizó una valoración donde destacaron tres necesidades alteradas: respiración y circulación (precisó ventilación mecánica invasiva y
perfusión de noradrenalina), eliminación (requirió furosemida para mantener diuresis horarias aceptables) e higiene y protección de la piel (presentó hiperemia generalizada, edema labial, lingual y orofaríngeo). El Comité de Ética de Investigación Clínica del Hospital solicitó el consentimiento informado de la paciente para el acceso a la historia clínica. De acuerdo con las necesidades
destacadas, se priorizaron siete diagnósticos según la taxonomía NANDA: riesgo de respuesta alérgica, riesgo de infección, riesgo de perfusión renal ineficaz, disminución del gasto cardíaco, deterioro de la ventilación espontánea, riesgo de nivel de glucemia inestable y riesgo de motilidad gastrointestinal disfuncional. Los criterios de resultados evidenciaron una evolución favorable pasadas
24h. El desarrollo del lenguaje estandarizado NANDA-NOC-NIC en el caso clínico presentado nos permitió organizar metodológicamente el trabajo enfermero, facilitando el registro y normalizando la práctica. Como limitación, no se dispuso de niveles plasmáticos de histamina y triptasa para valorar la evolución del cuadro anafiláctico. Destacar la importancia de la educación sanitaria en una paciente con antecedentes de angioedema. Palabras
clave: Anafilaxia Atención de enfermería Cuidados críticos Unidad de cuidados intensivos Full Text Introduction There is currently no definition for
anaphilaxis1–3 nor is there any consensus about the criteria for diagnosis.1,2 The European Academy of Allergy and
Clinical Immunology defines anaphylaxis as a severe, life-threatening generalised or systemic hypersensitivity reaction.1,3 The presence of circulatory instability (anaphylactic shock) is potentially life
threatening1,4,5 when it compromises the airways.4,5 The need for artificial ventilation means they need to be
admitted to the intensive care unit (ICU).6 The incidence rate ranges from 3.2 to 10 in 100,000 people/year, with a mortality rate that reached 6.5%. Evans and
Tippins3 have confirmed that the right knowledge and handling of anaphylaxis can prevent it from escalating into anaphylactic shock. The main causes of anaphylaxis vary according to
age1,5,6: medication among adults, food in paediatric patients and insect stings.1,5 Other documented causes are latex
and physical stimuli (exercise or cold).7 In order of prevalence, the affected organs are the
following7: Skin and mucous membranes (80–90% of cases): local or diffuse erythema, itching, rash, hives and/or angioedema. Respiratory system (70%): itchy and
blocked nose, sneezing, itching or pressure in the throat, coughing, wheezing and/or dyspnoea. Gastrointestinal tract (30–40%): nausea, vomiting, cramp and/or diarrhoea. Cardiovascular system (10–45%): low blood pressure that can lead to fainting; tachycardia and/or cardiac arrhythmias.
Central nervous system (10–15%): migraines, convulsions and/or changes to the mental state.
Others, less frequent: sudden death, uterine contractions, loss of muscle tone in the sphincter, loss of vision/or ringing in the ears.
The severity of the anaphylactic reaction is related to the speed at which the symptoms progress, the type of antigen, the route of entry and the affected organs. Factors such as old age, the presence of associated cardiovascular or respiratory conditions (especially asthma), treatment with angiotensin-converting enzyme inhibitors or beta-blockers, or underlying mastocytosis are associated with severe reactions and a higher mortality rate. Severe anaphylaxis is defined by the presence of cyanosis, haemoglobin saturation (HbSat)≤92% (94% in children), low blood pressure, confusion, low muscle tone, loss of consciousness or incontinence. Angioedema (Fig. 1) is the clinical manifestation of anaphylaxis that could potentially have more complications: the sudden and temporary inflammation of some areas of the dermis, subcutaneous tissue and mucous membranes,1,3,5,6,8 after a rise in capillary permeability, which causes liquid to pass from the intravascular space to the interstitial space,5,6,8 and which, if it affects the airways, could compromise their permeability.3–6,8
Presentation of the caseA woman aged 42 admitted to the ICU for anaphylactic shock after ingesting co-amoxiclav due to pharyngitis.
Personal medical historyAngioedema in 2013 (treated with corticosteroids and adrenalin), arterial hypertension treated beta-blockers, iron-deficiency anaemia treated with iron sulphate, underactive thyroid due to Hashimoto's thyroiditis being treated with levothyroxine sodium, Beta-thalassemia and anxiety disorder.
When the ambulance service arrived at her home she showed a 3 on the Glasgow coma scale, low blood pressure and absent peripheral pulse with electrical activity on the monitor. The family reported a situation with a lack of air and fainting after taking the medication. Orotracheal intubation made difficult due to the severe oedema in the glottis, requiring the use of a Fastrach laryngeal mask©. Capillary blood glucose: 97mg/dl. The ambulance service administered intramuscular adrenaline, intravenous corticosteroids and started midazolam infusion. When she arrived at the hospital she needed a noradrenaline infusion. She had hyperaemia, labial, lingual and oropharyngeal oedema, isocoria and photoreactive pupils. HbSat at 98%.
Regular medication: atenolol 50mg c/24h and levothyroxine sodium 175mg c/24h.
Nursing assessmentAssessment of Virginia Henderson's 14 basic needs upon arrival at the ICURespiration and circulationRespiration. The endotracheal tube was changed for a size 7 with subglottic aspiration. Controlled mechanical ventilation. Upper airway stenosis due to angioedema. Poor adaptation to mechanical ventilation, therefore it was necessary to start propofol infusion and muscle relaxant bolus. Blood gases: FiO2 at 0.35; pH: 7.35; PCO2: 47mmHg; PO2: 106mmHg; HCO3−: 25.9Mmol/l; mmol/l; HbSat: 98%. Endotracheal secretions with blood and mucopurulant discharge; the cultures gave a positive result for Escherichia coli, and treatment with levofloxacin was started at 500mg every 24h.
Circulation. Mild sinus tachycardia (103beats/min), requiring noradrenaline infusion at 0.42μg/kg/min to keep average artery pressure above 80mmHg (removed after 48h). Bilateral peripheral pulses present and capillary refill below 2s.
Food and drinkWearing a Salem nasogastric tube curving downwards with bile bag; after 48h, this was replaced with a Silk to start enteral nutrition. She occasionally needed metoclopramide due to gastroparesis.
Arterial blood glucose level: 226mg/dl, rapid-acting subcutaneous insulin started every 6h.
BMI: 31.84kg/m2 (type i obesity).
EliminationWearing a Foley vesical catheter. Due to the persistence of partial hourly diuresis<0.5ml/kg/h 10mg of furosemide were added every 8h.
Movement and maintaining the correct positionLying on her back with cushions beneath her feet to avoid club foot and beneath her arms to avoid oedemas in the downward facing areas.
Sleep and restSedation and analgesia with midazolam and morphine hydrochloride infusions and paracetamol and metamizole alternating every 6h; even still, reacting to physical stimuli. The Richmond Agitation Sedation Scale varies between −4 and −3. Pain assessed by visual analogue scale: not assessable.
After tubes were removed she presented anxiety. Started on 10mg of intravenous clorazepate every 8h.
Maintaining body temperatureNormothermic (36°C). Leucocyte formula changed due to the pharyngitis (leukocytes: 31,000/l; neutrophils: 85%; lymphocytes: 10%; eosinophils: 0%).
Personal hygiene maintenance and skin protectionWarm skin, generalised hyperaemia which went down over the course of some days. Correct hygiene situation, euhydration and without damage. EMINA scale 14.
Risk preventionWhen hospitalised, there was another suspected allergic reaction after administering propofol and atropine (administered due to continued bradycardia) after seeing another episode of generalised hyperaemia.
Needs not assessable due to sedation: dress and undress, communication, worship and personal values.
Care planaTable 1 shows the diagnosis labels, actions and nursing activity in the care plan, according to the NANDA and NIC categories. Fig. 2 contains the Likert scales used to assess the indicators in the results. Table 2 shows the relationship between the NANDA, NOC and indicators in the results
DiscussionThe diagnosis of systemic anaphylaxis is based on identifying the specific symptoms (obstruction in the airway, low blood pressure, gastrointestinal symptoms and generalised skin reaction), either isolated or in combination, after exposure to a substance that may cause immediate hypersensitivity and that are caused by the release of chemical mediators from mastocytes to basophils, after interaction between specific IgE antibodies.8
In this case, it can be seen that, with the medical history of angioedema, a study of the patient's allergies may not have been complete, since a potential sensitivity to amoxicillin had not been studied, among other medications, and especially when it is known that allergic reactions to beta-lactam antibiotics are a frequent cause of allergic reaction to medication, through a specific immunological response.3
The care plan presented is intended as a tool for use and streamlined managing, to allow nursing professionals to standardise their actions with patients suffering from anaphylactic shock on the ICU, to be subsequently assessed based on the criteria established in the plan. Furthermore, it is intended to homogenise interventions to reduce variation in how care is provided, increasing safety and the quality of care, as argued by Cuzco and Guasch.10 After reviewing the currently available literature, no similar studies have been found with which to contrast our nursing diagnostics. The indicators in the results from our care plan indicated an improvement, which means they could be taken as a reference point for future research.
Among the main limitations, it should be pointed out that it was impossible to come to a consensus on the aims of nursing actions with sedated patients. The study also did not have serialised information on the histamine and tryptase levels in the plasma to assess the severity and the development of the anaphylactic condition, as some authors recommend.1,5,6 Cardona1 emphasises the importance of health-care training. We should emphasis the important role that nursing professionals play in getting patients to take on board the relevant self-care actions in each case, and in avoiding situations such as adrenaline self-injectors going out-of-date with patients with a history of angioedema.
ConclusionsThe results criteria showed a positive development after 24h. The development of the standard NANDA-NOC-NIC terminology in a clinical case study allowed us to methodologically organise nursing work, providing records and standardising practice.
Ethical responsibilitiesProtection of human and animal subjectsThe authors declare that no experiments have been carried out on human beings or on animals for this research.
Confidentiality of dataThe authors state that they have followed the protocol of their work centre regarding the publication of patient data.
Right to privacy and informed consentThe authors have obtained the informed consent of the patients and/or individuals referred to in this article. This document is held by the author in charge of correspondence.
References
[1]
V. Cardona Dahl.
Guía de actuación en anafilaxia.
Med Clin (Barc), 136 (2011), pp. 349-355
Available from: //www.sciencedirect.com/science/article/pii/S0025775310009577 [accessed 15.07.16]
[2]
H.A. Sampson, A. Muñoz-Furlong, R.L. Campbell, N.F. Adkinson, S.A. Bock, A. Branum, et al.
Second symposium on the definition and management of anaphylaxis: Summary report — Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network Symposium.
Ann Emerg Med, 47 (2006), pp. 373-380
Available from: //www.sciencedirect.com/science/article/pii/S0196064406000837 [accessed 15.07.16]
[3]
C. Evans, E. Tippins.
Emergency treatment of anaphylaxis.
Accid Emerg Nurs, 13 (2005), pp. 232-237
Available from: //www.internationalemergencynursing.com/article/S0965-2302(05)00053-6/pdf [accessed 04.11.16]
[4]
A. Blasco Bravo, M. Aguilar Conesa, F. Montero Pérez, M. Labrador Horrillo, A. Martínez Virto, M. Andrés Gómez, et al.
Guía de práctica clínica abreviada del manejo de los angioedemas mediados por bradicinina en urgencias.
Monogr Emerg, 7 (2013), pp. 1-17
Available from: //www.taiss.com/publi/absful/guia-practica-clinica-abreviada-manejo-angioedemas-mediados-bradicinina-urgencias-taiss.pdf [accessed 15.07.16]
[5]
J.A. Bernstein, J.J. Moellman.
Emerging concepts in the diagnosis and treatment of patients with undifferentiated angioedema.
Int J Emerg Med, 5 (2012), pp. 39
Available from: //intjem.springeropen.com/track/pdf/10.1186/1865-1380-5-39?site=intjem.springeropen.com [accessed 15.7.16]
[6]
J.J. Moellman, J.A. Bernstein, C. Lindsell, A. Banerji, P.J. Busse, C.A. Camargo, et al.
A consensus parameter for the evaluation and management of angioedema in the emergency department.
Acad Emerg Med, 21 (2014), pp. 469-484
Available from: //onlinelibrary.wiley.com/doi/10.1111/acem.12341/epdf [accessed 15.07.16]
[7]
Associação Brasileira de Alergia e Imunopatologia.
Anaphylaxis: diagnosis.
Rev da Assoc Médica Bras (Engl Ed), 59 (2013), pp. 7-13
Available from: //www.scielo.br/pdf/ramb/v59n1/en_v59n1a04.pdf [accessed 15.07.16]
[8]
J. Ortega Carnicer, N. Perales Rodríguez de Viguri, A. Ambrós Checa.
Anafilaxia.
Avances en emergencias y resucitación III, pp. 1-11
[9]
Elsevier España, (2016),
Available from: //www.nnnconsult.com/ [updated 2016; accessed 11.07.16]
[10]
C. Cuzco, N. Guasch.
Aplicación y evaluación del plan de cuidados en pacientes ingresados en la unidad de cuidados intensivos.
Enferm Intensiva, 26 (2015), pp. 137-143
Available from: //linkinghub.elsevier.com/retrieve/pii/S1130239915000863 [accessed 13.10.16]
To draw up the plan, we reviewed the online platform NNNConsult.9
Please cite this article as: Zariquiey-Esteva G, Santa-Candela P. A propósito de un caso: intervenciones enfermeras a una paciente con shock anafiláctico en la UCI. Enferm Intensiva. 2017;28:80–91.
Copyright © 2016. Sociedad Española de Enfermería Intensiva y Unidades Coronarias (SEEIUC)