SEPTIC SHOCK

SEPTIC SHOCK

1. ASSESSMENT

   • Clinical Manifestations of Stages of Septic Shock
     • Stage I: Compensatory Stage
       • Activation of SNS to compensate for the hypotension & ↓ cardiac output.
         • Tachycardia (↑HR >90 beats/min)
           • pulse present
         • ↑Epinephrine & Norepinephrine= vasoconstriction
           • BP adequate to provide vital organs)
             • Normal BP with narrow pulse pressure
             • Slight drop in BP
       • ↓Renal Blood flow & perfusion
         • ↓Urinary Output
           • Edema- due to fluid Retention
       • ↓Blood flow to Lungs
         • Tachypnea (>20 breaths/minute)
         • ↑Ventilation- perfusion mismatch)
       • Anxious, restlessness, & combative
       • Flushed Skin
         • due to systemic vasodilation
     • Stage II: Progressive/ Decompensated Stage
       • **Hypotension
         • SBP ≤ 90mmHg
         • MAP ≤ 65mmHg
         • ↓SBP of >40mmHg
         • ↓Peripheral perfusion
           • Weak or Absent pulses
           • DIstal extremeties ischemia
             • Hypothermia (core temperature <36 °C)
             • Cool & Clammy skin
           • ↓Capillary refill (>2sec)
       • ↓Cerebral perfusion
         • Altered Mental Status
           • Listless or Agitated
           • ↓Responsiveness to stimuli
           • Unconciousness
       • Myocardial ischemia or Infraction
         • Dysrrhthmia
       • Acute Respiratory Distress Syndrome
         • Moist Crackles
         • Alveolar edema
       • Tachypnea (>20 breaths/min)
         • PaCO2 <32mmHg
       • ↓Urinary output
       • Tacycardia (>90 beats/min)
     • Stage III: Refractory Stage ***END STAGE (IRREVERSIBLE)
       • Loss of conciousness
         • Unresponsive to stimuli
         • Pupils dilated and unresponsive
         • Loss of reflexes
       • Profound Hypotension & Bradycardia
         • ↓CO
           • ↓BP inadequate to perfuse vital organs
       • Respiratory failure
         • Hypoxemia
       • Anuria
       • Disseminated Intravascular coagulation
     • Initial stage
       • Asymptomatic
         • Adequate perfusion & oxygenation to vital organs
       • Reversible
       • Cells switch to anaerobic metabolism due to lack of perfusion caused by vasodilation.
         • Produce pruvic and lactic acid.
           • Rise in lactic acid level
       • presence of sepsis
         • Fever (Temperature>38.3°C)
         • Positive blood culture
   • Rick Factors
     • Current infection
       • Pneumonia
       • Appendicitis
       • UTI
       • Endocarditis
     • Age
       • Elderly
         • Decreased functioning of the immune system
       • Young children/infants
         • Organ and immunological immaturity and inability to self manage hygiene, more susceptible to UTIs and other infections
     • Medical History
       • Indwelling catheter (IV, urinary)
       • Immunocompromised (AIDS, chemotherapy, immunosuppressive drugs
       • Recent surgery
       • Recent childbirth
       • Malnutrition
       • Severe Injury
         • Burns
         • Large wounds
     • Gender
       • Females are more susceptible to UTIs due to shorter urethras

2. COMPLICATIONS

   • Multiple organ dysfunction syndrome
     • Renal
       • Renal failure
     • Hepatic
       • Liver failure
     • Cardiac
       • heart failure
     • Respiratory
       • Lung injury characterized as diffuse alveolar damage
     • Neurological
       • Ischemic stroke resulting from microthrombi
     • Tissue death in extremities
     • Gastrointestinal
       • Intestinal ischmemia or infarction
   • Post-sepsis syndrome
     • Insomnia
     • Hallucinations
     • Panic attacks

3. TREATMENTS

   • Nursing interventions
     • Airway
       • Ensure potency
         • Endotracheal intubation
         • Natural airway
     • Breathing
       • To avoid hypoxemia
         • Maintain SaO2 at or > 90%. Deliver 100% O2 via
           • Bag Valve Mask
           • Non rebreather mask
         • Mechanical ventilation may be necessary
           • Decreases metabolic demands of breathing
     • Circulation
       • Manage hypotension with fluid resuscitation
         • Insert 2 large bore IV catheters
       • Insert urinary catheter
         • To measure urinary output
     • Disability
       • Continuous assessment of end organ perfusion
         • Neurological function
           • Assess for altered mental status
             • Glasgow coma scale for level of conciousness
         • Renal function
           • Urinary output is a marker for adequate renal perfusion
             • Normal adult urinary output is 0.5mL/kg/hour or more
           • Lab values (BUN, Cr)
   • Drug therapy
     • Fluid resuscitation
       • IV bolus of isotonic crystalloid solution or colloids
       • Hemodynamic monitoring may be necessary to evaluate large-volume fluid resuscitation
         • PA catheter or central venous catheter
         • Arterial pressure monitoring
     • Antibiotics
       • Early initiation with broad spectrum antibiotic
         • Combination therapy with beta-lactam plus an aminoglycoside
         • Mono therapy with 3rd generation cephalosporin
       • Culture sample taken to determine causative pathogen
         • Usually gram negative bacteria
         • once pathogen is determined, more specific antibiotic regimen is initiated to cover the infecting agent
     • Vasopressors
       • Norepinephrine via central catheter; increases vascular tone
         • Used for hypotension unresponsive to fluid resuscitation
     • Anticoagulants
       • Low molecular weight heparin
         • DVT prophylaxis
     • Hydrocortisone
       • Given with vasopressors
         • Decreases inflammation, reverses capillary permeability
     • Inotropes (dobutamine)
   • Nutrition therapy
     • Hypermetablolism often manifests as protein-calorie malnutrition
       • Nutritional status assessed by
         • Serum protein, BUN, serum glucose level, serum electrolytes
       • Enteral nutrition is initiated within 24 hours
         • Continuous drip of enteral feedings enhances GI perfusion
         • Parenteral nutrition is indicated when enteral nutrition is contraindicated
     • Daily weight measurement used as indicator of fluid status
       • Large weight gain
         • Common due to 3rd spacing
       • Significant weight loss
         • Dehydration should be ruled out before additional calories are provided
     • Blood glucose should be maintained at <8.3mmol/L

4. DIAGNOSIS

   • Blood Tests
     • ABG Analysis
       • HCO3
       • pH
       • PaCO2
     • Blood Culture Test
       • Gram-Positive Bacteria
       • Gram-Negative Bacteria
     • Complete Blood Count (CBC) with Differential
       • ↓ Platelet count
       • WBC
         • Leukocytosis ( Elevated WBC level) >10x10^9/L
           • Indicate presence of infection
         • Low WBC level)
           • Leukopenia
     • ↑Creatinine level
       • Due to decrease Kidney Creatinine clearance
     • ↑Lactic Acid in the Blood >4mmol/L
       • Indicating Hypoxemia
     • C-Reactive Protein (CPR) Test
       • ↑ C-reactive protein indicate presence of infammation in the body
     • Liver Enzyme level
       • Abnormal PT & PTT
         • Indicates acute hepatocellular injury due to hypoperfusion.
   • Electrocardiography (ECG)
     • ST-segment depression
     • Inverted T-waves
     • Arrhythmia resembling myocardial infarction
   • Other Culture Tests
     • Sputum Culture
     • Stool Culture
     • Urine culture
       • Urinalysis
     • Catheter Tip culture
   • Chest X-Ray
     • May show evidence of infection, such as consolidation, pleural effusion, or pneumothorax

5. PATHOPHYSIOLOGY

   • Infectious agent enters systemic circulation
     • Widespread leukocyte activation
       • Release of pro inflammatory cytokines: tumour necrosis factor, IL-1
         • Peripheral vasodilation and increased capillary permeability
           • Increased extracellular fluid and decreased intravascular fluid
             • Hypotension
               • Maldistribution of circulating blood volume
                 • Hemodynamic collapse
         • Complement and coagulation cascade activation
           • Microvascular damage
           • Micro thrombi formation
             • Obstruction of microvascular
               • Local ischemia to vital organs such as kidneys and brain leading to organ dysfunction
               • Cell hypoxia leading to lactic acid accumulation
                 • Metabolic acidosis
         • Febrile response

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