Septic Shock

Septic Shock

1. Diagnosis (Vaughan et al., 2016)

   • Acute oliguria; urine output < 0.5 ml/kg/h
   • Lactate levels: greater than 2 mmol/L
     • as a result of tissue hypoxia
   • MAP less than 65 mmHg
     • how well organs are working
   • Persistent hypotension despite fluid resuscitation and the need for vasopressors
     • SBP < 90 mmHg
     • O2 saturation < 93 %
   • unexplained metabolic acidosis
     • pH < 7.35 & bicarb < 20 mmol/l
   • Dx Studies
     • Hemodynamic monitoring
     • 12-lead ECG
     • Blood cultures
       • Should be obtained before antibiotic tx. However antibiotic tx should not be delayed

2. PATHOPHYSIOLOGY (Lewis et al. 2014)

   • Bacteria: the release of endo/exotoxins
     • body defense system effectively destroys bacteria
       • GOOD
     • gram-negative, gram-positive bacteria & fungal infections are common
     • Body's response to infection results in systemic S/S of widespread inflammation
     • Patients at Risk:
       • Immunocompromised
       • The elderly & neonates
       • Surgical procedures
       • Indwelling devices
       • organ transplant
       • Pregnant women
       • chronic illness
   • Evolution of Sepsis
     • SIRS
       • SEPSIS: SIRS + infection
         • SEVERE SEPSIS: Sepsis + end organ damage
           • SEPTIC SHOCK: severe sepsis + hypotension
             • release of large numbers of immune mediators
               • r/t in widespread inflammation
                 • Peripheral vasodilation with hypotension, maldistribution of blood flow with hypoxia
             • Ultimately lead to death if not corrected in time!
     • Stages of Shock
       • 1. Initial Stage
         • Shift from aerobic to anaerobic
           • Lactic acid accumulation
       • 2. Compensatory Stage
         • Attempts aimed, patient recovers, otherwise the path continues
           • Attempts made at maintaining homeostasis
       • 3. Progressive Stage
         • Decreased CO
         • Anasarca
         • Decreased cellular perfusion & capillary permeability
         • Changes in mental status
       • 4. Refractory Stage
         • waste products accumulation such as lactate, urea, ammonia, CO2
   • Clinical Manifestations
     • Cardiovascular
       • tachycardia HR > 100
         • weak pluses
       • Hypotension
       • capillary refil < 2 sec
     • Pulmonary
       • crackles
       • tachypnea
       • shortness of breath
     • Renal
       • Decrease urine output
     • Skin
       • cyanosis
       • pallor
       • cool/clammy
     • Neurological
       • Anxiety
       • Confusion
     • Gastrointestinal
       • Nausea & Vomiting
       • Decrease bowel sounds

3. THE NURSING PROCESS (Vaughan et al., 2016)

   • 1. ASSESSMENT
     • Identify what stage of septic shock patient is in!
     • Assess patient's ABCD
       • AIRWAY
         • Patent airway?
         • +/- patient talking
         • Potential obstructer's
       • BREATHING
         • breath sounds
         • chest expansion
         • depth & rate
         • O2 saturation
       • CIRCULATION
         • pulse (rhythm & depth)
         • capillary refil
         • blood pressure
         • colour of skin
         • urine output
       • DISABILITY
         • consciousness/responsiveness
         • pupil size/equality/reactivity
         • GCS
     • Hx: events leading to shock
       • onset & duration of symptoms
   • 2. PLANNING
     • NURSING GOALS
       • Adequate tissue prefussion
       • Restoration of baseline blood pressure
       • Restoration of organ function
       • Avoidance of complications from prolonged states of hypoperfusion
   • 3. IMPLEMENTATION
     • 3 Hour Sepsis Bundle
       • Serum lactate measurements
       • Blood cultures
       • Adminster broad spectrum antibiotics
         • Do this as fast as possible
       • Fluid resuscitation:crystalloid fluid for hypotension
         • To restore prefussion
     • COLLABORATIVE CARE INTERVENTIONS
       • provide supplemental O2
       • Initiate intubation
       • Hemodynamic mointoring
       • Enteral nutrition
     • 6 Hour Sepsis Bundle
       • Re-measure lactate levels
       • Administer Vasopressors to maintain MAP 65 mmHg or higher
         • dopamine
     • Provide emotional support to family & patient
       • Address any anxiety, fear, or pain
         • These symptoms can aggravate respiratory distress!
         • Provide education regarding procedures to decrease anxiety
       • Inform family about patient status
       • Active listening
       • provide culturally sensitive care
       • Address the spiritual needs of family & patient
     • supportive care
       • Monitor temperature
       • Pressure ulcer prophylaxis
       • Control blood glucose levels
       • DVT prophylaxis
   • 4. EVALUATION
     • Evaluate patient status and the effectiveness of interventions
       • Neurological assessment qH
       • Monitor urine output qH
       • ECG mointoring
       • Continuos SpO2
       • Monitor temperature q15 mins

4. PREVENTION (Vaughan et al. 2016)

   • Identify those at risk!
   • Carefully monitor for the development of infections
   • Strict hand-washing regime!
     • Patient teaching opportunity: teach patient proper hand washing technique
       • Patient Education
         • Avoid cold/flu
           • Vaccinations: flu shot
         • Oral care
         • Smoking cessation
         • Diet
         • Personal hygiene
   • Aseptic technique
   • Decreasing then number of indwelling catheters
   • Sterilizaiton of equipment

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