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Septic Shock

Mariam Oliva English

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Septic Shock

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
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
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
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