Chapter 12 Shock, Sepsis, and multiple organ dysfunction syndrome Flashcards
Shock is a clinical syndrome
◦ Life-threatening response to alterations in circulation
◦ Inadequate tissue perfusion
◦ Imbalance between cellular oxygen supply and demand
Shock Impacts all body systems
◦ Can lead to organ failure and death
◦ Influenced by compensatory mechanisms
◦ Influenced by successful interventions
Cardiovascular system
◦ Closed system:
◦ Vascular bed:
◦ Closed system: heart, blood, vascular bed
◦ Vascular bed: arteries, arterioles, capillaries, venules, and veins
Microcirculatory system
◦ Portion of the vascular bed between the arterioles and venules.
Pathophysiology
- Shock begins with?
- Alterations in at least one of four components:
- Shock begins with cardiovascular system failure - Alterations in at least one of four components: ◦ Blood volume ◦ Myocardial contractility ◦ Blood flow ◦ Vascular resistance
Stages of Shock
Stage I:
- Stage I: Initiation
- Hypoperfusion: inadequate delivery or extraction of oxygen
- No obvious clinical signs
- Early, reversible
Stages of Shock
Stage II:
- Stage II: Compensatory
- Sustained reduction in tissue perfusion Initiation of compensatory mechanisms
◦ Neural: baroreceptors and chemoreceptors
◦ Endocrine: ACTH and ADH
◦ Chemical
◦ Low oxygen tension
◦ Hyperventilation and respiratory alkalosis
Stages of Shock
- Stage III:
- Stage III: Progressive
- Failure of compensatory mechanisms
- Profound cardiovascular effects
◦ Hypoperfusion
◦ Vasoconstriction
◦ Extremity ischemia
◦ Cellular hypoxia
◦ Anaerobic metabolism
◦ Lactic acid production (metabolic acidosis)
◦ Failure Na+/K+ pump
Stages of Shock
- Stage III: Cont
- Stage III: Progressive (Cont.)
- Increased capillary hydrostatic pressure
- Intravascular fluid shifts
◦ Interstitial edema
◦ Decreased circulating intravascular volume - Decreased coronary perfusion
◦ Myocardial Depressant Factor (MDF) released
◦ Decreased myocardial contractility
Stages of Shock
- Stage IV:
- Stage IV: Refractory
- Prolonged inadequate tissue perfusion
◦ Unresponsive to therapy
◦ Dysrhythmias
◦ Pulmonary edema
◦ Respiratory Distress Syndrome (RDS)
◦ Cerebral changes
◦ Renal decreased GFR
◦ Contributes to multiple organ dysfunction and death
Systemic Inflammatory Response Syndrome (SIRS)
- Widespread systemic inflammatory response
- Associated with diverse disorders
◦ Infection
◦ Trauma
◦ Shock
◦ Pancreatitis
◦ Ischemia - Most frequently associated with sepsis
- Upsets balance between proinflammatory and antiinflammatory processes
- Normally localized process becomes systemic
- Release of mediators
◦ Increased permeability of endothelial wall
◦ Fluid shifts into intravascular spaces
◦ Depletion of intravascular volume = relative hypovolemia
Shock Assessment for CNS
Central nervous system ◦ Most sensitive to early changes ◦ Initial stage ◦ Anxiety/restlessness ◦ Late stage: Coma
Shock Assessment for Cardiovascular System
Cardiovascular system ◦ Blood pressure • Initial compensatory stages ◦ Slightly elevated ◦ Narrow pulse pressure • Late stages ◦ Pulses
Shock Assessment for Pulmonary System
Pulmonary system
◦ Early stages
◦ Rapid, deep respirations
◦ Late stages: Shallow respirations, Poor gas exchange
Shock Assessment for Renal System
Renal system ◦ Decreased glomerular filtration ◦ Activated renin- angiotensin-aldosterone system ◦ Sodium retention ◦ Water reabsorption ◦ Oliguria
Shock Assessment for GI System
Gastrointestinal (GI) system
◦ Slowing intestinal activity
◦ Decreased bowel sounds, distension, nausea, and constipation
Shock Assessment for Hepatic
Hepatic
◦ Altered liver enzymes
◦ Clotting disorders
◦ Increased susceptibility to infection
Shock Assessment for Hematological System
Hematological ◦ Consumptive coagulopathy (DIC) ◦ Enhanced clotting/inhibited fibrinolysis ◦ Depletion of clotting factors ◦ Clotting in the microcirculation
Shock Assessment for Integumentary System
Integumentary
◦ Skin color, temperature, texture, and turgor
◦ Cyanosis-late/unreliable sign
◦ Skin turgor evaluation
Laboratory Values
- Various laboratory studies
- Serum lactate level
- Various laboratory studies ◦ Hemogram ◦ Serum chemistry ◦ Coagulation studies - Serum lactate level ◦ Measure of overall state of shock ◦ Indicator of decreased oxygen to cells ◦ Indicator of adequacy of resuscitation
Management of Shock Domains
General management of shock
- Treat underlying cause ◦ Reverse altered circulatory component ◦ Maintain circulatory volume and organ perfusion - Domains-Combination treatment/therapy ◦ Fluids ◦ Oxygenation ◦ Pharmacotherapy ◦ Temperature ◦ Nutrition ◦ Skin integrity ◦ Psychological support ◦ Mechanical therapy ◦ Minimize oxygen consumption
IV Access and Fluid Challenge
- Rapid infusion of a?
- Hemodilution of?
- Blood products
- Complications
- Two Peripheral IV catheter sites 14 or 16 Gauge OR Central Line
- Rapid infusion of a crystalloid solution
◦ Lactated Ringer’s or normal saline
◦ 250 mL up to 2 liters - Hemodilution of plasma protein
- Blood products
◦ IV access of a 20-gauge and higher
◦ Infuse with only normal saline
◦ Transfusion reaction; keep vein open with normal saline solution - Complications
◦ Pulmonary edema
◦ Transfusion reaction
Oxygenation for shock/sepsis
- Maintain airway
- Oxygenation
- Mechanical ventilation
◦ Sedation
◦ Neuromuscular blockade
Pharmacological Support for shock/sepsis
- Based on
- Central venous access
- Based on
- Cardiac output
- Heart rate
- Preload, afterload, and contractility
- Central venous access
- Administration
- Hemodynamic monitoring
Pharmacological Management for Cardiac output
- Chronotropic drugs
- Dysrhythmia agents
- Bradycardia in neurogenic shock may require atropine
Pharmacological Management for Preload
- Hypovolemic and distributive shock — IV fluid challenge - Cardiogenic shock — venous vasodilators
Pharmacological Management for Afterload
- Distributive shock — vasoconstriction
- Cardiogenic shock — arterial vasodilators
Pharmacological Management for Contractility
- Cardiogenic shock — dobutamine
- Beta blockers
Pharmacological Management (Cont.)
- Sedatives
- Analgesics
- Insulin (two consecutive glucose readings are above 180 mg/dL)
- Corticosteroids
- Antibiotics
- Low–molecular-weight heparin to prevent DVTs
- H2-receptor antagonist or protein pump inhibitor to prevent gastric stress ulceration
Body Temperature Regulation
- Rapid administration of IV fluids may reduce temperature
- Hypothermia
- Depresses cardiac contractility
- Impairs cardiac output
- Impairs oxygenation
- Fluid warmer
- Warm blankets
Nutritional Support
- Enteral nutrition
- Parenteral nutrition
- Enteral nutrition
◦ Within 24 to 48 hours of admission
◦ Preferred route of nutritional support
◦ Hindered by paralytic ileus - Parenteral nutrition
◦ Given if enteral nutrition is not tolerated
Skin Integrity
- Skin care
◦ Turn every 2 hours ◦ Protective barrier cream ◦ Pressure-relieving devices ◦ Elevate heels off the surface of the bed ◦ Foley catheter if indicated
Psychological Support
- Provide information to patient and family
- Advance directive discussions
Classifications of Shock
- Hypovolemic shock
◦ Inadequate intravascular blood volume - Cardiogenic shock
◦ Heart fails to act as an effective pump - Obstructive shock
◦ Physical impairment to adequate circulating blood flow - Distributive shock
◦ Widespread vasodilation and decreased vascular tone resulting in a relative hypovolemia
◦ Neurogenic
◦ Anaphylactic
◦ Septic
The nurse admits a 35-year-old patient to the emergency department following a 3-day history of nausea and vomiting. Vital signs assessed by the nurse include a BP of 70/50 mm Hg, HR 145 beats/min, RR 36 breaths/min, and SpO2 of 92% on room air. The nurse recognizes which classification of shock?
D. Hypovolemic
- Inadequate circulating volume
- Causes
- Inadequate circulating volume ◦ Internal or external losses of blood or fluid - Causes ◦ History ◦ External or internal loss of fluid - Clinical manifestations
Hypovolemic Shock Management
- Identify underlying cause
- Restore circulating volume
- Appropriate fluid replacement
- Identify underlying cause ◦ Eliminate underlying cause - Restore circulating volume ◦ Appropriate fluid selection ◦ Blood ◦ Isotonic crystalloids ◦ Fluid challenge (3-for-1 rule, 300-mL replacement for 100-mL blood loss) - Appropriate fluid replacement ◦ Blood pressure (MAP 65-70 mm Hg) ◦ Hemodynamic values ◦ Urine output ◦ Laboratory results
Cardiogenic Shock
- Heart fails to act as an effective pump
◦ Decreased cardiac output; impaired perfusion - Causes
◦ Left ventricular myocardial infarction - Clinical manifestations
◦ Left ventricular failure
◦ Right ventricular failure
Cardiogenic Shock Management
- Pharmacological
- Increase cardiac output
- Decrease afterload
- Mechanical
- Pharmacological ◦ Decrease preload ◦ Diuretics, venous vasodilators - Increase cardiac output ◦ Positive inotropes - Decrease afterload ◦ Arterial vasodilators - Mechanical * IABD * VAD
The nurse is caring for a patient being treated with an intraaortic balloon pump. Which intervention is most important to include in the patient’s plan of care?
A. Turning side to side every 2 hours
B. Assessing peripheral pulses
C. Padding bony prominences
D. Applying splint to affected limb
B. Assessing peripheral pulses
Obstructive Shock
- Physical impairment to adequate circulatory blood flow
- Causes
- Clinical manifestations
- Clinical manifestations ◦ Chest pain ◦ Dyspnea ◦ Jugular venous distension ◦ Hypoxia ◦ Cause-dependent findings
Management of Obstructive Shock
Treat the cause
Treat the cause
◦ Cardiac tamponade (pericardiocentesis)
◦ Tension pneumothorax (thoracentesis)
Distributive Shock
Widespread vasodilation and decreased systemic vascular resistance ◦ Relative hypovolemia - Types ◦ Neurogenic ◦ Anaphylactic ◦ Septic
Distributive Shock— Neurogenic
Interruption of?
Causes
- Interruption of sympathetic nervous system impulse transmission
- Causes
◦ Upper spinal cord injury
◦ Spinal anesthesia
◦ Nervous system damage
◦ Vasomotor depression
Distributive Shock—Neurogenic
Clinical manifestations
◦ Bradycardia with hypotension
◦ Warm, dry, and flushed skin
◦ Hypothermia due to impaired thermoregulation
Distributive Shock—Neurogenic
Management
Management
◦ Immobilization of spinal injuries
◦ Positioning of spinal- blocked patients
◦ IV fluids for hypotension
◦ Vasopressors (only after
volume is replaced)
◦ Slow rewarming to prevent further vasodilation
Distributive Shock—Anaphylactic
Introduction of an?
Causes
Introduction of an antigen into a sensitive individual, initiating an antigen-antibody response ◦ Release of vasoactive mediators ◦ Histamine Causes ◦ Severe allergic reaction
Distributive Shock—Anaphylactic
Clinical manifestations
Clinical manifestations ◦ Airway ◦ Upper ◦ Lower ◦ Angioedema ◦ Cardiovascular ◦ Integumentary
Distributive Shock—Anaphylactic
Management
Management ◦ Removal of offending agent ◦ Airway ◦ Pharmacology ◦ Medications ◦ Fluid replacement
Distributive Shock—Septic
Follows invasion of a?
Causes
Clinical manifestations
- Follows invasion of a host by a microorganism ◦ Progressive - Causes ◦ Immunosuppression ◦ Significant bacteremia - Clinical manifestations ◦ Metabolic acidosis ◦ Acute encephalopathy ◦ Oliguria ◦ Hypoxemia ◦ Coagulation disorders ◦ Hypotension ◦ Decreased skin perfusion/mottling ◦ Petechiae
Distributive Shock—Septic
Management – Prevention
Management – Prevention
◦ Hand hygiene
◦ Aseptic technique
◦ Identification of infection risk
Distributive Shock—Septic
Management – Treatment
Management – Treatment ◦ Antibiotic therapy ◦ Early goal-directed therapy ◦ First 6 hours ◦ ACTH ◦ Glycemic control ◦ Temperature control
Multiple Organ Dysfunction Syndrome (MODS) Progressive dysfunction of? - Most common causes - Can occur after any? - Mortality rates
- Progressive dysfunction of two or more organ systems
- Most common causes
◦ Sepsis
◦ Septic shock - Can occur after any severe injury or illness
- Mortality rates
◦ 45% to 55% with failure of two organ systems
◦ 80% with three or more
◦ 100% with three or more for more than 4 days
Multiple Organ Dysfunction Syndrome
- Maldistribution of?
- Organs severely affected
- Maldistribution of blood flow to various organs ◦ Impaired tissue perfusion ◦ Decreased oxygen supply to cells - Organs severely affected ◦ Lungs ◦ Splanchnic bed ◦ Liver ◦ Kidneys
Multiple Organ Dysfunction Syndrome
- Clinical manifestations
- Clinical manifestations ◦ Tachypnea/hypoxemia ◦ Petechiae/bleeding ◦ Jaundice ◦ Abdominal distension ◦ Oliguria>anuria ◦ Tachycardia ◦ Hypotension ◦ Change in level of consciousness
Multiple Organ Dysfunction Syndrome
Management
- Management ◦ Control infection ◦ Antibiotics ◦ Provide adequate tissue oxygenation ◦ Maintain 88% to 92% arterial oxygen saturation ◦ Maintain hemoglobin above 7 to 9 g/dL ◦ Restore intravascular volume ◦ Aggressive fluid resuscitation ◦ Isotonic crystalloids ◦ Support organ function
Shock, Sepsis, and MODS
- Patient outcomes
- Patient outcomes ◦ Improved tissue perfusion ◦ Alert, oriented ◦ Normotensive ◦ Warm, dry skin ◦ Adequate urine output ◦ Normal hemodynamics ◦ Lab values within normal limits ◦ Absence of infection ◦ Intact skin
