Septic shock nursing

What is septic shock caused by

caused by bacteria in blood widespread infection

Risk factors for septic shock

Immunosuppression, hospitalization, malnourishment

Extremes of age (1 yr and 65 yr), infants w/infectious process, Chronic illness, Invasive procedures, hospitalization

sepsis patho

bacteria cause immune response that leads to poor tissue perfusion, increased capillary permeability leads to fluid leaking from capillaries, & vasodilation interrupt bodies ability to adequately perfuse, oxygenate & distribute nutrients

more sepsis patho

inflammatory response activates coagulation system, body forms clots whether needs them or not

Early phase or warm phase

BP WDL or hypotensive but responsive to fluids. HR increases to tachycardia, hyperthermia, bounding pulses are evident.

What happens to urinary & GI

urine @ normal levels or decreased, GI nausea, vomiting, diarrhea, or decreased bowel sounds

What are some signs of hyper metabolism with sepsis

increased serum glucose and insulin resistance

What are some mental status changes

Subtle changes in mental status, such as confusion or agitation, may be present.

What are some labs seen

The lactate level is elevated because of the maldistribution of blood. Inflammatory markers such as white blood cell counts and C-reactive protein are also elevated

Progression of sepsis causes

less tissue perfusion, acidotic, compensatory mechanisms fail, pt shows signs of organ dysfunction, bp doesn't respond to fluid and vasoactive agents, signs of end organ damage are evident

What are some signs of end organ damage

renal failure, pulmonary failure, hepatic failure

What does the progression from sepsis to septic shock look like

bp drops, skin is cool, pale and mottled. Temp is normal or below. HR & RR remain rapid. Urine production ceases, multiple organ dysfunction progressing to death occurs.

In late septic shock/cold phase how does death occur

respiratory, cardiac and/or renal failure

what are S&S of SIRS

Fever >100.4F or <96.8F

Heart rate >90 bpm

Respiratory rate >20 or PaCO2 <32 mm Hg

WBC count >12,000 cells/mm3, <4000 cells/mm3, or

>10% immature WBC (bands)

hypotension

systolic <90, or drop of > = to 40 from baseline, systolic is top number, when heart contracts

sepsis

must have 2 or more SIRS criteria as a consequence of

documented or presumed infection

Severe sepsis

S&S of sepsis associated with organ dysfunction, hypotension, or hypoperfusion;

How would signs of organ dysfunction be assessed

Oliguria <0.5 renal failure, LOC brain failure, coagulation disorders, liver altered or failure

clinical signs and symptoms include those of sepsis as well as septic shock

• Lactic acidosis <4

• Oliguria or hypouresis

• Altered level of consciousness

• Thrombocytopenia and coagulation disorders • Altered hepatic function

septic shock

Shock associated with sepsis, S&S of sepsis + hypotension and hypo perfusion despite adequate fluid resuscitation

multiple organ dysfunction syndrome or MODS

the presence of altered function of one or more organs in an acutely ill patient requiring intervention and support of organs

What are the cardiovascular signs of MODS

• Cardiovascular: hypotension and hypoperfusion

What are the respiratory signs of MODS

• Respiratory: hypoxemia, hypercarbia, adventitious breath sounds

What are the renal signs of MODS

• Renal: increased creatinine, decreased urine output

What are the hematologic signs of MODS

• Hematologic: thrombocytopenia, coagulation

abnormalities

What are the metabolic signs of MODS

• Metabolic: lactic acidemia, metabolic acidosis

What are the neurologic signs of MODS

• Neurologic: altered level of consciousness

What are the hepatic signs of MODS

• Hepatic: elevated liver function tests, hyperbilirubinemia

What are sepsis goals

id and treat patients in early sepsis, within 6 hours to optimize patient outcome

how do we ID sepsis early

does pt. meet criteria for SIRS,

Does pt. have S&S of infection

• Positive blood cultures

• Currently receiving antibiotic or antifungal therapy

• Examination or chest x-ray suggestive of pneumonia

• Suspected infected wound, abdomen, urine, or other

source of infection

Does the patient have signs of acute organ dysfunction? What are some cardiovascular signs

• systolic BP <90 or MAP <65 , or drop in SBP >40 mm from baseline

• Is hypotension responsive to fluid resuscitation, or is vasopressor support needed?

• Is the serum lactate >4 mmol/L?

Does the patient have signs of acute organ dysfunction? What are some respiratory signs

respiratory rate >20 PaCO2 <32

• Is increasing oxygen or mechanical ventilator support

needed?

Does the patient have signs of acute organ dysfunction? What are some renal signs

urine output <0.5 mL/kg/hr

Does the patient have signs of acute organ dysfunction? What are some hematologic signs

lab analysis S&S of coagulopathies

Does the patient have signs of acute organ dysfunction? What are some metabolic signs

insulin resistance, metabolic acidosis, or serum lactate >4mmol/L

Does the patient have signs of acute organ dysfunction? What are some hepatic signs

elevated liver function tests, hyperbilirubinmemia

Does the patient have signs of acute organ dysfunction? What are some CNS signs

changes in LOC, range from agitation to coma

What are some early interventions

aggressive fluid resuscitation of 20 mL/kg/h of crystalloid or colloid equivalent

What is the fluid resuscitation goal

CVP of 8-12 mmHg, MAP>65, urine output >0.5 mL/kg/h and ScVo2 >70%

What if fluids don't restore BP and cardiac output

use vasopressors

What do we do for the infection

obtain blood, sputum, urine, and wound cultures, administer broad spectrum antibiotics

How do we support the respiratory system

mechanical vent if needed

What about blood

transfuse with packed RBC's if hemoglobin is <7g/dl

What is the pt is anxious

use IV sedation, avoid neuromuscular blockers when possible

How do we correct metabolic effects

keep serum glucose <150

How do we prevent problems r/t hematologic effects

interventions & meds to prevent DVT and stress ulcer prophylaxis like pantoprozole/protonix

What if the pt. still doesn't respond to fluid or vasopressor therapy

consider IV steroid therapy

What should we consider if adult pt. with sepsis induced organ dysfunction has high risk of death

recombinant human activated protein C, (rhAPC; drotrecogin alfa [Xigris])

How does drotrecogin alpha or Xigris work

acts as an antithrombotic, anti-inflammatory & profibrinolytic agent, thus restoring balance to coagulation dysfunction

When do we admin drotrecogin alpha or Xigris

as early as possible, SE are bleeding, can be reduced by stopping medication

What pts. is drotrecogin alpha or Xigris contraindicated in

active internal bleeding, recent hemorrhagic stroke, intracranial surgery or head injury

What are other ways we id and treat possible routes of infection

remove IV lines and place in a different location, if it's a high risk pt. may use antibiotic coated central lines

What other routes of infection

Foley, drain and debride wounds

When does dysregulation of the coagulation system seem to occur

severe sepsis

Why fluid therapy

to correct hypoperfusion from incompetent vasculature and inflammatory response, reestablishing perfusion is key in treating sepsis

What about nutritional therapy

supplementation should be started in first 24 hours after ICU admission, continuous insulin IV can control hyperglycemia

how do we provide nourishment

enteral are preferred to parenteral

How do we handle invasive procedures

aseptic technique, strict handwashing, monitor all lines for infection, watch for pressure ulcers and infection

What should nurse be cognizant of

look for patients at risk such as extensive trauma, burns, diabetes. Don't present typical symptoms

What may be the first sign of sepsis in an elderly patient

Confusion

What about fever

may not be treated until dangerous >104 or unless patient is uncomfortable

How might the nurse reduce hyperthermia

acetaminophen or apply hypothermia blanket but watch for shivering bc it increases O2 consumption

What problems can decreased perfusion cause with medications

they're normally cleared by liver and kidneys and levels may become toxic

Given this information what labs should I monitor

antibiotic agents blood levels, BUN, creatinine, WBC, hemoglobin, hematocrit, platelet levels and coagulation studies

What should the nurse monitor for this and other types of shock

hemodynamic status, I&O, nutritional status, daily weights, closely monitor serum albumin, pre albumin levels to determine pt. protein requirements