Sepsis & Shock

Question 1

Sepsis:

Answer 1

Systemic response to infection

Question 2

Severe Sepsis:

Answer 2

Sepsis with organ dysfunction

Question 3

Septic Shock:

Answer 3

Sepsis with marked hypotension despite adequate fluid resuscitation

Question 4

SIRS

Answer 4

Widespread systemic inflammatory response

Question 5

SIRS Triggers

Answer 5

-Microbial invasion: bacteria, viruses, fungi
-Endotoxin release: gram-negative bacteria
-Global perfusion deficits: post cardiac resuscitation, shock states
-Regional perfusion deficits: distal perfusion deficits

Question 6

SIRS Associated disorders

Answer 6

 Infection
 Trauma
 Shock
 Pancreatitis
 Ischemia

Question 7

SIRS Criteria & S/S

Answer 7

-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

Question 8

Initial Sepsis One hour bundle

Answer 8

 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

Question 9

Sepsis Monitoring Labs

Answer 9

Redraw Lactate q4 hours

Question 10

Sepsis Monitoring Meds

Answer 10

Vasopressors for hypotension persisting after fluids
-Titrate to maintain MAP above 65

Question 11

Sepsis Monitoring

Answer 11

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

Question 12

Sepsis Urine Monitoring

Answer 12

Keep urine output greater than 0.5ml/kg/hr

Question 13

Sepsis Vented Monitoring

Answer 13

-ensure Vt at 6ml/kg of IBW
-monitor FiO2/PaO2 ratio
-assess for ARDS
-assess for abdominal compartment syndrome (3rd spacing)

Question 14

How often to assess for sepsis

Answer 14

-At least once per shift
-Ideally twice per shift

Question 15

Who to test for sepsis

Answer 15

Everyone

Question 16

Shock

Answer 16

A clinical syndrome
-Life-threatening response to alterations in circulation
-Inadequate tissue perfusion
-Imbalance between cellular oxygen supply and demand

-Impacts all body systems

Question 17

Shock patho

Answer 17

Shock begins with cardiovascular system failure

Question 18

Shock Alterations

Answer 18

Alterations in at least one of four components:
Blood volume
Myocardial contractility
Blood flow
Vascular resistance

Question 19

Classifications of Shock

Answer 19

Hypovolemic
-Absolute (hemmorhage) and Relative (vasodialation)
Cardiogenic
Obstructive
Distributive
-Anaphylactic (allergen)
-Neurogenic Assault on neuro system/directly related to trauma
-septic

Question 20

4 stages of shock

Answer 20

Initial
Compensatory
Progressive
Refractory

Question 21

Initial Shock

Answer 21

-Hypoperfusion: inadequate delivery or extraction of oxygen
-Lactic acid begins to build up
-No obvious clinical signs
-Early, reversible

Question 22

Compensatory Shock

Answer 22

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

Question 23

Progressive Shock

Answer 23

-shock begins as compensatory mechanisms fail
-Changes in the patient’s mental status are important findings in this stage.

Question 24

Progressive Shock UPDATE!!

Answer 24

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

Question 25

Refractory Shock

Answer 25

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

Question 26

Shock assessment findings Central nervous system

Answer 26

 Most sensitive to early changes  Initial stage -Anxiety/restlessness  Late stage -Coma

Question 27

Shock assessment findings Cardiovascular system

Answer 27

Blood pressure -Initial compensatory stages -Slightly elevated -Narrow pulse pressure  Late stages -Very low Pulses -Progressively become weaker

Question 28

Shock assessment findings Pulmonary system

Answer 28

Early stages  Rapid, deep respirations Late stages  Shallow respirations  Poor gas exchange

Question 29

Shock assessment findings Renal system

Answer 29

Decreased glomerular filtration Activated renin-angiotensin-aldosterone system  Sodium retention  Water reabsorption  Oliguria

Question 30

Shock assessment findings Gastrointestinal system

Answer 30

Slowing intestinal activity  Decreased bowel sounds, distension, nausea, and constipation

Question 31

Shock assessment findings Hepatic System

Answer 31

Altered liver enzymes Clotting disorders Increased susceptibility to infection

Question 32

Shock assessment findings Hematological System

Answer 32

Consumptive coagulopathy (DIC)  Enhanced clotting/inhibited fibrinolysis  Depletion of clotting factors  Clotting in the microcirculation

Question 33

Shock assessment findings Integumentary System

Answer 33

Skin color, temperature, texture, and turgor  Most will present pale and cool  Septic shock will be warm and flushed  Cyanosis-late/unreliable sign

Question 34

General management of shock

Answer 34

Treat underlying cause Reverse altered circulatory component -Maintain circulatory volume Combination therapy  Fluid  Pharmacotherapy  Mechanical therapy Minimize oxygen consumption

Question 35

Hypovolemic shock

Answer 35

Inadequate intravascular blood/fluid volume

Question 36

Cardiogenic shock

Answer 36

Heart fails to act as an effective pump

Question 37

Obstructive shock

Answer 37

Physical impairment to adequate circulating blood flow

Question 38

Distributive shock

Answer 38

Widespread vasodilation and decreased vascular tone resulting in a relative hypovolemia -Neurogenic -Anaphylactic -Septic

Question 39

Hypovolemic Shock Management

Question 40

Hypovolemic Shock Findings

Question 41

Hypovolemic Shock Treatment

Question 42

Cardiogenic Shock Management Pharmacological

Answer 42

Decrease preload -Diuretics, venous vasodilators Increase cardiac output -Positive inotropes Decrease afterload -Arterial vasodilators

Question 43

Cardiogenic Shock Management Mechanical

Answer 43

-IABP – Intra aortic Balloon Pump -VAD – Ventricle Assistive Device

Question 44

Cardiogenic Shock Findings

Answer 44

-Tachycardia -low BP -narrow pulse pressure -high RR -pulmonary edema Decreased cardiac output; impaired perfusion

Question 45

Cardiogenic Shock Treatment

Question 46

Septic Shock