Septic shock is a life-threatening condition that occurs when an infection leads to a severe immune response, causing organ dysfunction and failure. It can be caused by various infections, but sometimes the underlying cause remains unknown, leading to a challenging diagnostic process. In the case of a 37-year-old female, a near-death experience due to septic shock was initially attributed to an unknown neglected cause. However, through exploration surgery, medical professionals were able to uncover the true culprit: a neglected left ovarian abscess.
What is septic shock?
Septic shock is a condition that arises when an infection spreads throughout the body, triggering a systemic inflammatory response. This response can cause a cascade of events, leading to organ dysfunction and failure. It is a medical emergency that requires immediate intervention to prevent further complications or even death.
The mystery of the neglected cause
Upon late admission to the clinic, the patient presented with symptoms of septic shock, including low grade temperature, rapid heart rate, nearly absent blood pressure, and altered mental status. and with the need to perform extensive diagnostic tests, the exact cause of the infection remained elusive. The medical team at our clinic was faced with a perplexing challenge, as time was of the essence to identify and treat the underlying cause. and certainly this can not be done inside an ordinary clinic lying in a low socio-economic community.
here came the big question: how to transfer the patient to the closest hospital and most importantly, how to transfer her alive. the clinic's medical team tried to stabilize the patient as much as they could.
The challenge of no visible veins
In some cases, patients with very low blood pressure may not have visible veins, making it difficult to start IV fluids. This can be due to factors such as dehydration, vasoconstriction, or medical conditions that affect blood flow. Without visible veins, healthcare providers may struggle to find a suitable access point for administering IV fluids.
Potential solutions which are nearly absent in this situation:
While the situation may seem challenging, healthcare providers have several options to overcome the difficulties of starting IV fluids in patients with very low blood pressure and no visible veins:
1. Ultrasound-guided IV placement: (not applicable in most clinics)
Using ultrasound technology, healthcare providers can locate veins that are not visible to the naked eye. This technique allows for more accurate placement of IV catheters, increasing the chances of successful IV fluid administration.
2. Intraosseous (IO) access
In cases where traditional IV access is not possible, healthcare providers can use intraosseous access. This involves inserting a needle directly into the bone marrow, providing a route for administering fluids and medications. IO access is particularly useful in emergency situations when time is critical. (but we didn't try to do that due to lack of facilities in an ordinary clinic.
3. Central venous catheterization: (and this is also NOT an ordinary procedure to perform in an ordinary clinic)
If peripheral veins are not accessible, healthcare providers may opt for central venous catheterization. This involves inserting a catheter into a large vein, such as the jugular or subclavian vein. Central venous catheterization allows for the administration of larger volumes of fluids and medications.
4. Transcutaneous oxygen saturation monitoring
Gasping for air can indicate respiratory distress in patients. Monitoring transcutaneous oxygen saturation levels can provide valuable information about the patient's oxygenation status. This can help healthcare providers determine the urgency of IV fluid administration and guide their treatment decisions.
5. Accessing Life-Saving IV Treatment: Emergency External Jugular Vein Cannulation
In critical emergency situations, establishing intravenous (IV) access is vital for administering medications and fluids. However, factors like dehydration and cardiac arrest can make accessing peripheral veins extremely difficult. External jugular vein cannulation serves as a rapid, reliable method for gaining IV access when peripheral venous cannulation fails or is impossible.
What is External Jugular Vein Cannulation?
External jugular vein cannulation involves inserting a catheter into the external jugular vein in the neck to establish IV access. The external jugular vein runs superficially under the skin, making it easily accessible in emergency scenarios. It provides a direct route to administer IV fluids, blood products, and medications when intravenous therapy is urgently needed.
Common high-risk scenarios include:
- Cardiac arrest - Fluids and epinephrine are critical.
- Major trauma - Rapid infusion of blood products and IV fluids may be life-saving.
- Burn patients - Difficulty accessing burned limbs makes external jugular cannulation ideal.
- Dehydration - The external jugular vein remains visible and palpable when patients are severely volume depleted.
- Obese patients - Excess subcutaneous fat can make gaining standard IV access impossible.
Performing Emergency External Jugular Vein Cannulation
Correct placement is confirmed via aspiration of venous blood before securing the catheter and initiating fluids or medications.
The external jugular offers rapid, reliable intravenous access in critical situations where every second counts. Its use has emerged as a vital technique in emergency medicine and critical care for delivering potentially life-saving treatment. With expertise and proper precautions, external jugular vein cannulation delivers IV access when standard approaches fail.
And finally the clinic's team heard the voice of the patient speaking with a very low voice asking for help.
a Routine laboratory investigation was asked to help in the diagnosis of this mystery
the results were double high after repeating it after 4 hours after transferring her to hospital
And this lead to...
Exploration surgery: Unveiling the truth
Given the severity of the patient's condition and the lack of progress in identifying the source of infection, the medical team decided to proceed with exploration surgery. During the procedure, they discovered a neglected left ovarian abscess, which had gone undetected by previous imaging studies.
The importance of early intervention
Ovarian abscesses are relatively rare but can have serious consequences if left untreated. They are typically caused by an infection that spreads to the ovaries, often originating from the fallopian tubes or nearby organs. If not promptly diagnosed and treated, these abscesses can lead to complications such as septic shock, as seen in this case.
And now the patient is perfectly will.
Lessons learned
This near-death experience serves as a reminder of the importance of thorough diagnostic investigations and timely intervention. In cases where the cause of septic shock remains unknown, exploration surgery can be a valuable tool in uncovering hidden sources of infection. Medical professionals should maintain a high index of suspicion and consider all possible causes, even when initial tests yield inconclusive results.
Conclusion
Through exploration surgery, the medical team was able to identify a neglected left ovarian abscess as the underlying cause of a near-death experience due to septic shock in a 37-year-old female. This case highlights the critical role of early intervention and the need for comprehensive diagnostic approaches in complex medical conditions. By sharing this experience, we hope to raise awareness and contribute to the ongoing efforts in improving patient outcomes in septic shock cases.
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