Sepsis & Shock Flashcards
Sepsis:
Systemic response to infection
Severe Sepsis:
Sepsis with organ dysfunction
Septic Shock:
Sepsis with marked hypotension despite adequate fluid resuscitation
SIRS
Widespread systemic inflammatory response
SIRS Triggers
-Microbial invasion: bacteria, viruses, fungi
-Endotoxin release: gram-negative bacteria
-Global perfusion deficits: post cardiac resuscitation, shock states
-Regional perfusion deficits: distal perfusion deficits
SIRS Associated disorders
Infection
Trauma
Shock
Pancreatitis
Ischemia
SIRS Criteria & S/S
-High Temperature 100.4 (38) or Low Temperature 96.8 (36)
-Heart Rate greater than 90bpm
-Respiratory Rate greater than 20
-WBC less than 4k or greater than 12k
-BG greater then 140 in non-diabetic patient
*Must meet 2 of these criteria and have a known source of infection to be septic
Initial Sepsis One hour bundle
Measure Lactate
-Greater than 4 is critical
Obtain Blood Cultures
-X2 sites, 2 bottles per site (anaerobic and aerobic)
Initial fluid resuscitation: 30ml/kg (run it wide open)
Begin broad spectrum antibiotics
-Zosyn and Levaquin are common
Closely monitor hemodynamics
-B/P Q10-15min,
Repeat Lactate at 2 hour mark
-Lactate should go down
Sepsis Monitoring Labs
Redraw Lactate q4 hours
Sepsis Monitoring Meds
Vasopressors for hypotension persisting after fluids
-Titrate to maintain MAP above 65
Sepsis Monitoring
Place CVC & A-line with monitoring
-Keep CVP between 8 and 12 (12 to 15 if vented)
-Keep SCVO2 above 70%
-A-line continuous B/P monitoring & ABG’s
Sepsis Urine Monitoring
Keep urine output greater than 0.5ml/kg/hr
Sepsis Vented Monitoring
-ensure Vt at 6ml/kg of IBW
-monitor FiO2/PaO2 ratio
-assess for ARDS
-assess for abdominal compartment syndrome (3rd spacing)
How often to assess for sepsis
-At least once per shift
-Ideally twice per shift
Who to test for sepsis
Everyone
Shock
A clinical syndrome
-Life-threatening response to alterations in circulation
-Inadequate tissue perfusion
-Imbalance between cellular oxygen supply and demand
-Impacts all body systems
Shock patho
Shock begins with cardiovascular system failure
Shock Alterations
Alterations in at least one of four components:
Blood volume
Myocardial contractility
Blood flow
Vascular resistance
Classifications of Shock
Hypovolemic
-Absolute (hemmorhage) and Relative (vasodialation)
Cardiogenic
Obstructive
Distributive
-Anaphylactic (allergen)
-Neurogenic Assault on neuro system/directly related to trauma
-septic
4 stages of shock
Initial
Compensatory
Progressive
Refractory
Initial Shock
-Hypoperfusion: inadequate delivery or extraction of oxygen
-Lactic acid begins to build up
-No obvious clinical signs
-Early, reversible
Compensatory Shock
Sustained reduction in tissue perfusion
Initiation of compensatory mechanisms in an attempt to overcome consequences of anaerobic metabolism
-Neural: baroreceptors and chemoreceptors
-Improve cardiac output – BUT increased myocardial O2 demand, so RR goes up
Hormonal: ACTH and ADH
-Increased BG and reduces OU to increase intravascular volume
BioChemical
-Hyperventilation leads to respiratory alkalosis which causes vasoconstriction of cerebral arteries and a decreased CP
Progressive Shock
-shock begins as compensatory mechanisms fail
-Changes in the patient’s mental status are important findings in this stage.
Progressive Shock UPDATE!!
Failure of compensatory mechanisms
Profound cardiovascular effects
Hypoperfusion
Widespread Vasoconstriction
-Extremity ischemia
-Cellular hypoxia
-Anaerobic metabolism
-Lactic acid production (metabolic acidosis)
-Failure Na+/K+ pump
Refractory Shock
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
Shock assessment findings Central nervous system
Most sensitive to early changes
Initial stage
-Anxiety/restlessness
Late stage
-Coma
Shock assessment findings Cardiovascular system
Blood pressure
-Initial compensatory stages
-Slightly elevated
-Narrow pulse pressure
Late stages
-Very low
Pulses
-Progressively become weaker
Shock assessment findings Pulmonary system
Early stages
Rapid, deep respirations
Late stages
Shallow respirations
Poor gas exchange
Shock assessment findings Renal system
Decreased glomerular filtration
Activated renin-angiotensin-aldosterone system
Sodium retention
Water reabsorption
Oliguria
Shock assessment findings Gastrointestinal system
Slowing intestinal activity
Decreased bowel sounds,
distension, nausea, and
constipation
Shock assessment findings Hepatic System
Altered liver enzymes
Clotting disorders
Increased susceptibility to
infection
Shock assessment findings Hematological System
Consumptive coagulopathy
(DIC)
Enhanced clotting/inhibited
fibrinolysis
Depletion of clotting factors
Clotting in the microcirculation
Shock assessment findings Integumentary System
Skin color, temperature,
texture, and turgor
Most will present pale and cool
Septic shock will be warm and
flushed
Cyanosis-late/unreliable sign
General management of shock
Treat underlying cause
Reverse altered circulatory component
-Maintain circulatory volume
Combination therapy
Fluid
Pharmacotherapy
Mechanical therapy
Minimize oxygen consumption
Hypovolemic shock
Inadequate intravascular blood/fluid 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
Hypovolemic Shock Management
Hypovolemic Shock Findings
Hypovolemic Shock Treatment
Cardiogenic Shock Management Pharmacological
Decrease preload
-Diuretics, venous vasodilators
Increase cardiac output
-Positive inotropes
Decrease afterload
-Arterial vasodilators
Cardiogenic Shock Management Mechanical
-IABP – Intra aortic Balloon Pump
-VAD – Ventricle Assistive Device
Cardiogenic Shock Findings
-Tachycardia
-low BP
-narrow pulse pressure
-high RR
-pulmonary edema
Decreased cardiac output; impaired perfusion
Cardiogenic Shock Treatment
Septic Shock
