Waterhouse Friderichsen - Essay Example

? Waterhouse Friderichsen Waterhouse Friderichsen Introduction This paper describes the pathophysiological changes that occur in Waterhouse Friderichsen and ethical issues surrounding the end-of-life for persons affected by this condition. Therefore, the paper has two sections; description of the pathophysiological systemic condition and end of life debate. To have a clear description of Waterhouse Friderichsen, a hypothetical client scenario will be used. Other than concentrating on the primary organ affected by Waterhouse Friderichsen, other organs affected by the same will also be discussed. The final section under this medical condition will focus on impacts of healthcare and nursing. The hypothetical case study will be of a 35 year old female patient who was found with signs and symptoms associated with Waterhouse Friderichsen. Majority of cases have been reported in children, but the increased rate of meningococcal infections have led to high incidences of Waterhouse Friderichsen in adults. In many cases, patients with Waterhouse Friderichsen die within 24hrs, but a few have managed to survive beyond 48hrs. Cases of full recovery have also been reported in some regions. This fact proves that the syndrome is not fatal when early diagnosis is made. Worldwide incidences of Waterhouse Friderichsen syndrome are not many, although cases of the condition go unnoticed in many instances (Manchanda et al, 2008). Case Analysis This is a hypothetical case of a 35 year old female patient who got admitted after showing signs of high grade fever accompanied by chills and vomiting over a period of 7days. The patient also had a skin rash on the abdomen and trunk, which appeared on the 5th day of infection. Following admission, the patient developed a hemorrhagic rash. On assessing the family history, there was no any significant information to associate the infection with family history. Medical examination revealed that the patient was unstable, and there was the presence of cyanosis. The patient was febrile with a pulse rate of 90/min and a systolic BP of 70mmHg. Neurological examination revealed positive signs of Kerning and Brudzinski. There were rashes all over the body but predominated on the abdomen and trunk. Collection of CSF was done under aseptic conditions and its processing done under standard bacteriological procedures. Microscopy on CSF was done routinely, and a cell count of 9400/mm3 was reported. Of the total cell count, 86% were polymorphs while 14% were lymphocytes. An increase in CSF proteins to 309mg%, and a decrease in glucose to 20mg% were reported. A Gram stain preparation of the CSF revealed pus cells accompanied with gram-negative diplococcus. CSF cultures were done on MacConkey agar, chocolate agar, and blood agar and incubated overnight. After overnight incubation, there were tiny translucent colonies on blood agar and chocolate agar. Standard bacteriological procedures identified the tinny translucent colonies to be those of Neisseria meningitides. A CT scan conducted on the patient confirmed adrenal hemorrhage, which is present in Waterhouse Friderrichsen syndrome. Antibiotic sensitivity using 5 antibiotics showed no resistance to any of the antibiotics under examination. Antibiotics under examination were sulfamethoxazole, chloramphenicol, ceftriaxone, trimethoprim, and penicillin. The patient was put on ceftriaxone and steroids but went into a shock. On the third day of admission, water Friderichsen syndrome was reported as the cause of death. Discussion Waterhouse Friderichsen syndrome was reported first in 1911 by Rubert Waterhouse. This syndrome is caused by failure of the adrenal gland due to massive bleeding into the gland. The cause of bleeding is a bacterial infection, most common bacteria being meningococcus Neisseria meningitides. This medical condition presentswith rash, fever, coagulopathy, rash, and shock. During the course of its development, multiple organs are affected, leading to multiple system failure. One significant sign in Waterhouse Friderichsen syndrome is disseminated intravascular coagulation (DIC). Most of medical conditions caused by meningococci affect children below the age of 2years. However, these infections do occur at any age (Schoeller&Schmutzhard, 2001). Neisseria meningitides are the main etiological agent of Waterhouse Friderichsen syndrome. However, there are other organisms associated with this syndrome. Examples of these organisms include Neisseria gonorrhea, Streptococcus pneumonia, Staphylococcus aureus, Escherichia coli, Pasturellasp, and Hemophilus influenza among other organisms. Apart from microbial infections, Waterhouse Friderichsen can also occur as a result of noninfectious conditions. These conditions include trauma, anticoagulant treatment, postoperative adrenal hemorrhages, and antiphospholipid syndrome(Hamilton et al, 2004). As mentioned earlier, damage on the adrenal gland due to Waterhouse Friderichsen leads to sever damage on other organs. This paper will now focus on kidney and liver damage during Waterhouse Friderichsen. Correlation between adrenal gland, kidney, and liver Adrenal glands lie on top of each kidney. The main function of these glands is to synthesize hormones that help in homeostasis. To achieve this function, adrenal glands have to interact with the pituitary gland and the hypothalamus. The kidney and the liver are among the body organs, which rely on hormones released by the adrenal gland in order to function properly. Therefore, any damage on the adrenal gland compromises the functioning of these two vital body organs. One hormone synthesized by the adrenal glands is aldosterone. The main functions of aldosterone are to regulate the amount of extracellular fluids and potassium balance. The regulation of these products occurs at the distal nephron located in the kidney. There are receptor sites for aldosterone on the distal nephron (Seifter et al, 2005). Binding of aldosterone to its receptor sites leads to an increase in the number of open sodium channels. This phenomenon allows for reabsorption of sodium ions from nephron filtrate back to the blood. Therefore, aldosterone helps in promoting retention of potassium ions and water in circulation, which is crucial for regulation of blood pressure and electrolytes. In cases of insufficient aldosterone, a lot of potassium is lost through urine, which leads to low blood pressure. On the other hand, excess of aldosterone translate to high blood pressure (Seifter et al, 2005). The other hormone released from the adrenal glands is adrenaline. This hormone is released during high stress situations. One of its functions is to increase blood flow in the liver and to influence the liver to produce glucose from its glycogen stores. Release of glucose from the liver increases the level of energy in cells, which is vital for responding to emergencies. Insufficiency of adrenaline implies that there will be reduced blood flow to the liver as well as reduced conversion of glycogen to glucose during the fight or flight responses (Seifter et al, 2005). The overall function of hormones of the adrenal gland is to help the body in responding to stressful conditions. Byproducts derived from these responses are processed by the liver and kidneys for clearance from the body. Any damage on the adrenal gland means stressful conditions will not be handled effectively. In addition, a state of imbalance will be present once the adrenal glands are unable to release hormones that regulate the functioning of the liver and kidneys (Seifter et al, 2005). The hallmark of Waterhouse Friderichsen due to meningococcal infection is skin hemorrhages. Microscopic examinations of the skin hemorrhages reveal endothelial damage, which causes hemorrhages, and micro thrombi in minor blood vessels. This observation is in line with Sanarelli-Shwartzman reaction. The lesions observed are as a result of cytokine primed vasculitis and endotoxins derived from bacterial infection. Disseminated intravascular coagulation (DCI) is typical with Waterhouse Friderichsen. DCI is marked with systemic formation of fibrin, which occurs as a result of increased levels of thrombin, suppression of the physiologic anticoagulation cascade, and delayed clearance of fibrin. Delays in the removal of fibrin are as a result of impaired fibrinolysis (Sonavane et al, 2011). In situations where DIC causes a shortage of clotting factors and platelets, excessive hemorrhage is evident throughout the body. Bleeding can be in the form of small red spots and bruises beneath the skin. Heavy bleeding may occur through body openings and into body organs such adrenal glands in Waterhouse Friderichsen syndrome. Excessive blood clotting may produce symptoms of low urine output and shortness of breath. In severe cases, there are signs of shock, low blood pressure, and multiple organ failure. Researchers are convinced that DCI is present in Waterhouse Friderichsen and is responsible for widespread hemorrhages and severe shock (Manchanda et al, 2008). The impacts of care on healthcare and nursing Care and treatment of Waterhouse Friderichsen syndrome should be done quickly because this condition has the potential to cause death within 24 hours. Patients with signs of bacterial meningitis infection must be admitted in accident and emergency care units. The first line treatment involves the use of antibiotics, which are administered through the intravascular route. Majority of antibiotics in use include the third generation cephalosporin due to their ability to act against gram negative and gram positive bacteria. The drug of choice in this case is Ceftriaxone due to its proved sensitivity meningococcal bacteria. Hydrocortisone can also be administered intravenously where veins are accessible, but if they are inaccessible, the drug can be administered through intramuscular route (Schoeller&Schmutzhard, 2001). Over time, prophylactic use of steroids has shown its potential in saving patients suffering from Waterhouse Friderichsen syndrome. Initial treatment steroids such as dexamethasone before any antimicrobial treatment may serve in preventing meningococcal inflammation as a result of bacterial cell death. The use of hormone therapies has not proved much of effectiveness in the treatment of Waterhouse Friderichsen. The use of noradrenaline has shown to cause increased blood pressure. Therefore, nurses administering this hormone should check blood pressure after every 15 minutes. Combating restlessness associated with meningococcal septicaemia is a paramount concern to every caregiver. Therefore, the number of times blood measurements are taken should be minimized to allow the patient to rest (Schoeller&Schmutzhard, 2001). The restlessness is mainly due to cerebral anoxia. Therefore, the use of oxygen tents may be useful in putting the patient into sleep. In restless patients without hypotension and shock, sedation may be done in order to put the patient into rest. In such cases, paraldehyde may be used due to its rapid action, excretion, and low toxicity. The use of noradrenaline makes use of infusions a mandatory. The important thing to note is that anuria may be present due to hypotension, which leads to reduced renal blood flow. This phenomenon is corrected using noradrenaline. In summary, caring and nursing interventions involve intravenous medication, large doses of antibiotics at initial stages of the illness, use of hormone therapies, and sufficient sedation (Manchanda et al, 2008). End of life debate Waterhouse Friderichsen has an extremely poor prognosis. Almost all patients affected by this condition die within 24 hours of admission. In order to provide proper healthcare to such patients, physicians must have a clear understanding of ethical issues surrounding end of life care. This will ensure that patient’s autonomy is respected even when the patient lacks the capacity to make decisions. Medical interventions geared towards assisted suicide such as withholding essential medical care can be undertaken if they are consistent with the wishes of the dying patient. The guiding principles in the end of life debate include autonomy, nonmaleficence, fidelity, beneficence, and justice (Randall & Downie, 2009). Autonomy gives a patient the right to make independent decisions regarding his/her life. On the other hand, physicians should respect any decision made by the patient regardless of whether the patient has the potential to make decisions or not. Moves by physicians to consult caregivers over a patient’s decision violate the patient’s autonomy. On the other hand, nurses have the primary responsibility of giving nursing care. In doing so, nurses should safeguard a person’s values, spiritual beliefs, rights, and customs. In addition, nurses have the responsibility to issue informed consents to patients on care and treatment. Nurses should treat patients’ information with confidentiality and should use their judgmentwhen sharing patients’ information. A patient may request the physician to withdraw certain essential medical care in order to bring the patient’s life to an end. In such circumstances, respect for autonomy must prevail over the physician’s interests. Physician assisted suicide to a terminally ill patient brings to end painful sufferings that the patient may be experiencing (Randall &Downie, 2009). In addition, family members are relieved the pain of seeing one of theirs undergoing a lot of suffering. Such experiences may affect the family members psychologically. Apart from relieving pain, the family is saved from the economic hardship that may come along with taking care of the patient. Other issues that may influence a patient to request for a physician assisted suicide include depression, worries over losing dignity, and worries of becoming a burden to family members. Of most importance is for the physician to investigate the reasons behind the call for physician assisted suicide (Randall &Downie, 2009). Opponents of physician assisted suicide argue that life is a gift from God, and he is the only one who can take it away. Therefore, despite having autonomy in self-determination, a person should not take any move that will end his life. In addition, opponents further point out that there are relevant medical interventions that can alleviate pain, depression, and any other fear, which the patient may be experiencing. Physicians are guided by principles of beneficence, nonmaleficence, justice, and fidelity (Randall &Downie, 2009). Under these guiding principles, physicians and nurses must do good for the benefit of the patient, avoid inflicting intentional harm, be fair in delivering healthcare, and remain faithful when giving healthcare. Despite the fact that patients have autonomy over self-determination, physicians and nurses should exercise a high level of morality when dealing with issues of end to life (Randall & Downie, 2009). An attempt to withhold medical interventions at the end of life upon the patient’s request is a respect for autonomy. Physicians and nurses have the duty to manage patients’ suffering at final stages of their lives. Physician assisted suicide may create a conflict between patients and physicians. In addition, it has the potential to reduce caregivers’ ability to provide care and comfort. In my own opinion, physicians should not adhere to patient’s requests, which violate the physician’s ethical standings and conscience. The bottom line in the end of life debate is for physicians and nurses to provide medical care for a terminally ill patient (Randall & Downie, 2009). Conclusion The case of Waterhouse Friderichsen has been addressed in details. Effects of this medical condition occur on multiple systems, but the primary organ is the adrenal gland. Damage on the adrenal grand leads to adrenal insufficiency, whereby there are insufficient amounts of adrenal hormones. Therefore, there is a poor regulation of body processes regulated by adrenal hormones. This medical condition presents with a number signs and symptoms, but the most vital sign is DCI. The hallmark of this condition is characterized by skin hemorrhages. Several medical interventions are available, but use of antibiotics seems to be the most widely used regiment. Waterhouse Friderichsen has a poor prognosis, hence the need for a good plan on caring for the suffering patient. The end of life debate in relation to Waterhouse Friderichsen is an issue of concern to physicians and nurses. These two medical practitioners have the duty of ensuring that terminally patients receive proper care in their final days. Each has codes of ethics that govern their actions when giving care to patients. One unifying thing in their codes of ethic is the call to manage suffering in terminally ill patients. References Hamilton,D., Harris, M., Foweraker, J. &Gresham, D. (2004). Waterhouse–Friderichsen syndrome as a result of non-meningococcal infection. Journal of clinical pathology, 57, 208-209. Manchanda, V., Gupta, S. & Bhalla, P. (2008). Meningococcal disease: History, epidemiology, pathogenesis, clinical manifestation, diagnosis, antimicrobial susceptibility and prevention. Indian Journal of Medical Microbioly, 24, 7–19. Randall, F. &Downie, R. (2009). End of life choices: Consensus and controversy. Oxford: Oxford University Press. Sonavane, A., Baradkar, V.,Salunkhe, P.& Kumar, S. (2011). Waterhouse-Friderichsen Syndrome in an Adult Patient with Meningococcal Meningitis.Indian Journal of Dermatology, 56(3), 326–328. . Seifter, J., Ratner,A. & Sloane, D. (2005). Concepts in Medical Physiology. New York: Lippincott Williams & Wilkins. Schoeller, T. & Schmutzhard , E. (2001). Waterhouse–Friderichsen Syndrome. The New England Journal of Medicine, 344, 1372. Read More