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Septic Shock

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Septic Shock

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