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septic shock

1
Q

what is shock?

A

A condition in which tissue perfusion is inadequate to deliver oxygen and nutrients to support vital organ and cellular function

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2
Q

what is Sepsis?

A

life-threatening organ dysfunction caused by a dysregulated host response to infection (immune response is way too dramatised)

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3
Q

what is septic shock?

A

severe sepsis with hypotension and perfusion abnormalities *DESPITE fluid resuscitation

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4
Q

what is distributive shock?

A

occurs during septic shock
blood volume pools peripherally and there is dec blood flow to organs which causes decreased tissue perfusion

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5
Q

what causes distributive shock

A

decrease SVR d/t arterial dilation allowing blood to pool peripherally

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6
Q

required for blood pressure regulation in sepsis

A

adequate blood volume
cardiac pump
vasculature

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7
Q

MAP and blood pressure regulation

A

tissue and organ perfusion depend on MAP
-Must maintain a MAP of 65 or greater for organ perfusion.

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8
Q

what is MAP?

A

average calculated blood pressure during 1 cardiac cycle
MAP= SBP + 2(DBP) /3

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9
Q

signs and symptoms of septic SHOCK

A

-tachycardia
-tachypnea
-hypotension
-hyperthermia
-WBC changes (inc or dec)
-cognitive/behavioural changes
-s & s of infection
-dec urine output
-N/V, dec bowel sounds/motility
-hyperglycemia/insulin resistance
-skin is mottled

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10
Q

diagnostic criteria for sepsis (SOFA assessment)

A

-#1 infection (documented or suspected) plus one or more:
-altered mental status
-Fever
-HR >90
-hyperglycemia (>7.77) with NO DM
-hypothermia (<36)
-edema or positive fluid balance (>20mL/Kg over 24h)
-tachypnea (>22)
-inc CRP
-inc procalcitonin
-leukocytosis (WBC>12)
-leukopenia (WBC <4)
-normal WBC BUT >10% immature forms
-SBP <90 or MAP <70, or dec SBP in >40
-acute oliguria despite fluids
-arterial hypoxemia (<300)
-abnormal coags (INR >1.5 OR PTT >60s)
-bilirubin >68.4
-ileus
-serum creatinine inc (>44.2)
-thrombocytopenia (plts <100)
-dec cap refill
-inc lactate

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11
Q

what is used to diagnose septic shock

A

SOFA & qSOFA
-lab values (WBC, neutrophils, BUN, lactate, CRP, procalcitonin)
-clinical manifestations
-TREWS

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12
Q

interprofessional care in successful sepsis management

A

-identification of patients at risk for shock and prompt intervention
-integration of the patient’s history, physical exam, clinical fidnings

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13
Q

management of shock

A

-#1 ensure patient airway
-maximize oxygen delivery (inc supply dec demand)
-lab draw/cultures
-large bore iv access and aggressive fluid resus w isotonic crystalloids (30ml/kg)
-art line for BP monitoring, CVAD for pressors
-pressors if non responsive to fluids
-catheter
-PPI or h2 receptor antagonist for stress ulcer prophylaxis
-neuromuscular block for sedation + dec metabolic demand

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14
Q

fluid resus in septic shock

A

-6-10L crystalloids (wont alter electrolytes in plasma but can cause hyperchloremia) and 2-4L colloids (lit doesn’t show inc outcomes) in first 6 hours to get target CVP (30mL/kg)
-after 8L or more can add pressors

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15
Q

how is fluid responsiveness assessed in shock management

A

-clinic assessment (vitals q15, reactive BP, perfusion pressures, cap refill, I&O, Cardiac output, skin temp,
-hemodynamic parameters
-monitor trends in BP
-foley for I&O
-goal: restore tissue perfusion

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16
Q

medications in shock management

A

-broad spectrum ABX AFTERR cultures are drawn, then abx can be changed w sensitivity
-pressors if unresponsive to fluid resus/ achieve & maintain MAP >65
-IV steroids to dec immune response (caution for hyperglycemia)
-stress ulcer prophylaxis (PPI or H2RA)
-DVT prophylaxis with lovenox
-insulin to keep glucose <10

17
Q

nutrition in shock management

A

-intiate enteral feeds within first 24h (ideal)
-initiate parenteral feeds if enteral is not tolerated or they fail to meet caloric requirements
-monitor weight (reflects fluid status mostly), protein, nitrogen balance, BUN, glucose, electrolytes, serum protein

18
Q

assessment when caring for a known septic shock pt

A

-ABCs
-assessments around tissue perfusion:
-vitals q15
-peripheral pulses
-cardio & pulmonary assessment
-LOC
-Cap refill
-skin temp/colour/moisture
-strict I&O
-brief history :(events prior/onset/duration), details of care received before hospitalization, allergies, vaccinations (?source, R/O causative viruses)

19
Q

goals for patient with septic shock

A

-restore adequate tissue perfusion
-normal vital signs, MAP >65
-return/recovery of organ function
-prevention of progress to prolonged states of hypoperfusion

20
Q

acute interventions for septic shock tx

A

-evaluate response to therapies
-identify trends to detect changes in condition
-provide emotional support (pts are usually not sedated)
-collaborate with HC team PRN
-monitor ongoing physical and emotional status to detect subtle changes in pt condition
-plan to implement nursing interventions and therapies

21
Q

implementation of assessment for neuro system in shock

A

orientation
LOC

22
Q

implementation of assessment for cardiac system in shock

A

-continous EKG
-vital signs, cap refill
-hemodynamic parameters
-heart sounds: murmur S3 and S4

23
Q

implementation of assessment for respiratory system in shock

A

-resp rate, depth, rhythm
-breath sounds (pulm edema)
-continous o2 monitor (ear d/t blood shunting)
-ABGs
-intubation/vent assessments if needed

24
Q

implementation of assessment for GI system in shock

A

-NG drainage (if not used for feeds) and stools for occult blood
-I&O, fluid and lytes balance
-oral care if o2 req allow
-passive/active ROM to dec muscle wasting

25
Q

implementation of assessment for pain/anxiety in shock

A

-meds PRN
-talk to pt/family
-request spiritual care
-comfort measures
-privacy
provide call light

26
Q

pts at risk for setpic shock

A

-extremes in age (<1 or >65)
-malnourishment
-debilitating/chronic illness
-immunocompromised
-surgical or accidental trauma

27
Q

what will be seen during evaluation fo a pt recovering from septic shock

A

-normal or baseline, ECG, BP, CVP, and PAOP
-normal temp
-warm, dry skin
-urine >0.5ml/kg/hr
-normal RR and saO2 >90%

28
Q

nursing management of septic shock

A

-early identification and intervention
-temp control
-blood work
-I&O
-fluid replacement
-assessment
-V/S monitoring
-O2 monitoring
-continuous cardiac monitor

29
Q

preventing infection in hospital

A

-hand hygiene
-prevent CVAD infection
-early removal of invasive devices
-programs to prevent VAP
-early ambulation
-debriding wounds
-meticulous aseptic technique
-cleaning equipement and environment

30
Q

“surviving sepsis bundle” within 3 hours

A

-serum lactate
-blood cultures
-broad spectrum ABX
-aggressive fluid resuscitation

31
Q

“surviving sepsis bundle” within 6 hours

A

-vasopressors (if not responsive to fluids)
-measure CVP

advanced concepts (9 decks)

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