Septic Shock

Septic Shock

1. Sepsis is the simultaneous activation of systemic inflammation and coagulation due to microbial invasion

   • Septic Shock
     • Characterized by maldistribution of blood flow and arterial hypotension (systemic arterial pressure <90mmHg), leading to respiratory, heart and failure of other organs, and death

2. Diagnosis

   • Pathophysiology
     • Invading microorganisms
       • Activation of CNS and endocrine systems
         • Hypermetabolic state
         • Decreased tissue perfusion
         • Cellular oxygen demand
       • Release of pro-inflammatory cytokines (TNF, IL-1, etc.)
         • Myocardial depression, peripheral vasodilation, increased capillary permeability, microemboli, selective vasoconstriction
           • Impaired cellular metabolism
           • Maldistribution of circulating blood volume
           • Decreased cellular oxygen supply
           • Decreased tissue perfusion
       • Endothelial damage
         • Increased membrane permeability
         • Microemboli
   • Diagnostic Studies
     • Blood
       • Low Hgb
         • Anemia
       • Abnormal glucose levels
       • ↑ WBC Count
       • Prolonged PT and PTT
       • ↑BUN/Cr
       • (+) blood cultures
     • Urine
       • ↑ Specific gravity
       • ↑ Osmolarity
     • Serum Electrolytes
       • ↑ Serum Lactate Levels
       • ↑ Liver Enzymes (ALT, AST, GGT)
       • K+ imbalances
       • Na imbalances
   • Etiology
     • Risk Factors
       • Major surgery, chronic disease, long-term hospital stay, predisposition to infections, poor nutrition
       • Immunosuppressed
         • Clients on immunosuppressive agents, males, infants, pregnant women, older adults

3. Nursing Care

   • Assessment
     • 1) Initial Stage
       • Metabolism changes at cellular level
         • Aerobic to anaerobic
           • Lactic acid buildup
       • Not clinically apparent
     • 2) Compensatory Stage
       • SNS:↑HR, ↓BP due to ↓CO and narrowing pulse pressure
         • ↑ pro-inflammatory mediators
           • Epinephrine/norepinephrine to increase BP
             • Massive vasoconstriction (↑SVR)
         • Blood flow maintained to vital organs, e.g. heart and brain
           • Shunting of blood flow
             • Skin is cool and clammy, ↓peristalsis, causing paralytic ileus, ↓gas exchange., ↑dead space l/t VQ mismatch
               • Arterial O2↓ and RR/depth↑
       • Neurological status
         • Agitation, Restlessness
       • RAAS activation
         • ↑CO, ↑BP, ↑venous return, ↑Na/H2O reabsorption and secretion of K+
       • Attempts to maintain homeostasis and tissue perfusion and overcome anaerobic metabolism
     • 3) Progressive Stage
       • ↓ cellular perfusion and altered capillary permeability
         • Leaking of fluids and proteins into interstitial space
           • Interstitial edema
       • Prevent organ failure
       • Pulmonary initially affected
         • Systemic edema, bronchoconstriction and decreased surfactant production
         • Increased PA pressure d/t decreased blood flow and SNS stimulation
           • Blood flow to pulmonary capillaries decreases and V/Q mismatch increases
       • Cardiovascular
         • Ischemia in distal extremities, Increased risk of MI/dysrhythmia, weak PP, Decreasing BP
       • Gastrointestinal
         • Decreased blood flow increases risk for ulcers and bleeding, and decreases absorption
       • Other Systems
         • Decreased mental functioning Confusion, altered LOC, restlessnessLiver failure l/t decreased metabolism and excretion of waste products and drugs; increased ALT/AST
     • 4) Refractory Stage
       • ↑Peripheral vasoconstriction and ↓CO
         • Exacerbated anaerobic metabolism
           • Lactic acidosis
             • Increased permeability
               • Leaking of fluids and proteins into interstitial space
       • Decreased cerebral blood flow
         • Cerebral ischemia
       • Decreased coronary blood flow
         • Myocardial depression
   • Planning
     • Adequate tissue perfusion
     • Restoring normal or baseline BP
     • Recovery of organ function
     • Avoiding prolonged states of hypoperfusion
   • Implementation
     • Acute
       • The Sepsis Six
         • 1. Give 02 to keep sats above 94%
         • 2. Take blood cultures
         • 3. Give antibiotics
         • 4. Give a fluid challenge
         • 5. Measure lactate
         • 6. Measure urine output
       • ROS
         • Neurological
           • Monitor physical and emotional status and assess for orientation and LOC q1hr
         • Cardiological
           • Vascular IV access, assess VS (BP, HR, CVP) frequently, ECG monitoring, capillary refill, monitor hemodynamic status, auscultate S3/S4, palpate peripheral pulses
         • Respiratory
           • HOB 30-45°, chest radiography, maintain clear airway, frequent suctioning, mechanical ventilation, assess ABGs levels, LS/VS (RR, depth, rhythm, SaO2 q1hr), monitor oxygenation,
         • GI/GU
           • Assess: BS q1hr, abdominal distention, renal output (>0.5ml/kg/hr), BUN/Cr levels and check for occult blood in NG/stool
         • Integumentary:
           • Assess for. diaphoresis, cyanosis, pallor, edema, T° q1hr
       • Personal Hygiene
         • Prevent skin breakdown and infection, assess swallowing and gag reflex Frequent oral care
     • Health Promotion
       • Prevention
         • Prevent Complications
           • LMW heparin & VTE prophylaxis
         • Identify patient at risk
         • Decrease risk of infections
           • Effective hand hygiene
           • Aseptic technique during invasive procdures
           • Equipment change as per institutional policies
       • Monitor fluid balance, pain management, adequate rest, reposition q2hr, encourage family members in pt care
       • Therapeutic Communication
         • Non-verbal
   • Evaluation
     • Systemic Inflammatory Response Syndrome (SIRS)
       • Characterized by ↑inflammation/coagulation not always related to infection
     • Multiple Organ Dysfunction Syndrome (MODS)
       • Physiological deterioration of individual organs

4. Complications

   • GI bleeding
   • Pressure/Stress Ulcer
   • Electrolyte Imbalance
   • ARDS
   • Anemia
   • Pneumonia
   • AKI
   • Hyperglycemia
   • Bacteremia
   • DIC
   • DVT

5. Treatment

   • Fluid Therapy
     • Volume management-maintain BP and stabilize blood circulation
       • Crystalloids
         • Isotonic Solutions (0.9% NaCl, LR)
           • Monitor for circulatory overload, Increases intravascular volume, NS only for pts with liver failure
         • Hypertonic Solutions (1.8%, 3%. or 5% NaCl).
           • Leads to rapid volume expansion. Monitor for hypernatremia.
       • Colloids e.g. albumin, dextran
         • Monitor for circulatory overload in albumin & monitor for bleeding and hypersensitivity wth dextran
       • Blood Products (e.g. packed RBC, whole blood, plasma/ FFP)
         • Increase O2-carrying capacity
     • IV bolus of NS
       • If pt remains hypotensive, insert CVAD
   • Oxygen
     • Mechanical ventilation
     • PaO2 between 80-100mmHg
     • PEEP
       • increases CO by increasing heart contractility and reducing afterload
   • Nutrition and Metabolic Management
     • Monitor plasma transferrin and prealbumin levels to monitor hepatic protein synthesis
     • Enteral nutrition should be initiated
       • If cannot be used then initiate parenteral
     • Monitor glucose levels, should be less than 8.33 mmol/L
     • Protein-calorie malnutrition is one of the primary manifestations of hypermetabolism and MODS
       • Encourage high protein diet
   • Pharmacotherapy
     • Antibiotic Therapy
       • Asses blood/urine/sputum cultures to help treat infections
       • Broad spectrum, followed by specific antibiotics
         • Administer within the first 6hrs for best possible outcome
         • E.g. azithromycin, ciprofloxacin, pipercillin, etc.
     • Vasopressors
       • Norepinephrine
         • Increases BP and MAP for hypotensive pts.
         • Administer via CVAD
         • Monitor dysrhythmias
       • Dobutamine
         • Increases contractility and decreases diastolic volume
         • Corrects hypovolemia
         • Administer via CVAD
         • Monitor HR, BP and for tachydysrhythmias
     • Patient comfort
       • Address pain, e.g. fentanyl
       • Address anxiety and fear
       • Encourage family to be involve in pt care

6. Client Centred Care

   • Open and therapeutic communication between patient and healthcare team
   • Treatment, care and care information should be culturally appropriate
   • Patient, family/caregivers should be given the opportunity to make informed decisions about healthcare
   • Patient and family goals should be established early in treatment
   • If patient recovers from sepsis....
     • Healthcare team should educate and provide patient with resources for good mental health post-sepsis
     • Healthcare team should explain post-sepsis issues to family members/care givers, e.g. cognitive, physiological changes, etc.
     • Educate patient on how to prevent infections

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