Septic Shock

Septic Shock

1. Assessment

   • Hemodynamic Assessments
     • Decreased Systemic vascular resistance & Central venous pressure
     • Tachycardia
     • Decreased pulse pressure
     • Hypotension
     • Decreased pulse pressure
     • Increased Pulmonary vascular resistance
     • Unstable pulmonary artery pressure
     • Unstable Cardiac Output
   • Signs & Symptoms
     • Body temperature above 38.3 or below 36 degrees celsius
       • Extreme temperature fluctuations (warm and flushed at early stages, cool at late stages)
     • SOB, confusion, Light-headedness, lethargy
     • Decreased Urine Ouput
     • Respiratory rate >20 bpm, hyperventilation
     • Low BP that does not respond to fluid replacement
     • Heart rate > 90 bpm, palpitations
     • Crackles, hypoxemia
     • Agitation
   • Risk Factors
     • Age (newborns, older adult >65)
     • Poor Nutrition
     • Major Surgery
     • Suppressed immune system (HIV, Chemotherapy)
     • Infection
       • Exposure to catheters, breathing tubes, IV’s
       • Viruses, Fungi, Parasites, Bacteria (gram negative - Escherichia coli and gram positive - Streptococcus pneumonia, Staphylococcus aureus)
       • Extended Hospitalization
       • Pneumonia
     • Prior Comorbidities
       • Diabetes
       • Heart Failure
       • Chronic Kidney Disease
       • Cancer

2. Diagnosis

   • Septic Shock = the presence of sepsis with hypotension despite adequate fluid resuscitation, along with the presence of tissue perfusion abnormalities
     • Sepsis is a systemic inflammatory response to infection.
   • Diagnostic Tests & Assessments
     • Patient History (i.e. infection, trauma, surgery)
     • Hemodynamic Monitoring (i.e. arterial pressure, central venous pressure, pulmonary artery pressure)
       • Systolic Arterial Pressure <90 mmHg
       • Mean Arterial Blood Pressure <65 mmHg
     • High Base Deficit
     • Elevated lactate levels (>4mmol/L)
     • 12-lead ECG & continuous cardiac monitoring
     • Positive Blood Culture
       • Blood, wound exudate, stool, urine, sputum, to determine microorganism causing infection.
     • Decreased Platelet Levels
     • Decreased Urine Sodium Levels
     • Increased Glucose Levels
     • Continuous Pulse Oximetry

3. Treatment

   • Restore Tissue Perfusion
     • Provide Fluid Ressucitation until the following labs are met: CVP = 15 mmHg, PAOP = 10-12mmHg
     • 6-10 L of isotonic crystalloids & 2-4 L of colloids
   • Supportive Therapy
     • Obtain Blood Cultures
     • Monitor Temperature
     • Control Blood Glucose Levels (between 4.44-6.11 mmol/L)
     • Prevent Stress Ulcers
   • Oxygen Maintenance
     • Secure a patent airway
     • Provide Oxygen
     • Initiate Mechanical Ventilation or intubation if needed
     • Continuous Monitoring of oxygen saturation
   • Drug Therapy
     • Antibiotics
       • Initially broad-spectrum antibiotics, then more specific antibiotics once microorganism has been identified
     • Corticosteroids (i.e. Hydrocortisone)
       • Increases heart rate, & Blood pressure
       • Decreases capillary permeability
     • Inotropes (i.e. Dobutamine)
       • To offset decrease in stroke volume from vasopressor drugs
     • Anticoagulants (i.e. low dose or low weight heparin, such as enoxzparin)
       • Prophylaxis of deep vein thrombosis
     • Histabine H2 Blockers (i.e. Pepcid)
       • Stress ulcer prophylaxis
     • Vasopressors (i.e. dopamine, norepinephrine, pressyn)
       • Increases Systemic vascular resistance, central venous pressure, and pulmonary artery occlusive pressure
       • increases blood pressure
       • Stabilizes Cardiac Output
       • Increases Vascular Tone
       • increases Mean Arterial Pressure
       • Increases Urine Output

4. Complications

   • Risk of experiencing these complications depends on the following:
     • Early Recognition
     • Age (< one year or >65 years old)
     • Prompt Treatment
     • Pre-existing medical conditions
     • Cause and Origin of Infection
   • Patients in Septic Shock at risk of experiencing:
     • Abnormal blood clotting
     • Heart Failure
     • Respiratory Failure
     • Loss of portion of extremities
     • Stroke
     • Liver Failure
     • Loss of proportion of Bowel
     • Kidney Failure
     • Death

5. By Devon Thompson & Deanna Armstrong

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