Septic Shock Flashcards
Septic shock occurs when
circulatory and metabolic abnormalities are profound, greatly increasing mortality.
Multiple Organ Dysfunction Syndrome (MODS)
Altered function of > 1 organ system requiring interventions to achieve homeostasis.
Septic Shock causes
vasodilation which leads to pooling of blood in venous system; relative hypovolemia; decrease venous return.
Etiology of Septic Shock
Pneumonia
Urinary tract infections
Endocarditis
Abdominal infections
CAUTI
CLABSI
Septic Shock Risk Factors
Very old & very young
Chronic illnesses
Malnutrition
Broad spectrum antibiotic overuse
Surgical or invasive procedures
Immunosuppressed patients
Invasive Equipment: IVs & tubes: Foley, peg tube.
SIRS
Systemic Inflammatory Response Syndrome
Systemic Inflammatory Response Syndrome (SIRS) Parameters
2 or more of the following
Core temperature below 96.8 °F (36° C) or above 100.4° F (38° C)
Heart Rate > 90 beats/minute
Respiratory rate > 20 breaths/minute
WBC count > 12,000 cells/microliter
Altered mental status.
Blood glucose > 140 mg/dL in the absence of diabetes (stress hyperglycemia)
SOFA
Sequential Organ Failure Assessment
Signs of Organ Dysfunction or Hypoperfusion
Systolic BP <90 or MAP <65 MAP (70-105)
Or a decrease in pts. baseline systolic BP of >40 mmHg (ex:140/80 to 95/65)
**Lactate > 2-4 mmol/L (norm .5-1.0) WHY??
Increasing O2 need/ mechanical ventilator support.
Creatinine > 2.0 mg/dl
Urine output < 0.5 mL/kg/hr. (for at least 2 hours)
Bilirubin > 2 mg/dL
Platelet count < 100,000 µL
Coagulopathy (INR > 1.5 or aPTT > 60 secs)
Normal bilirubin
1.2 mg/dl under age 18, 1mg/dl
Normal PT
10-13.5 seconds
Normal INR
.8 to 1.2
Normal PTT
30-45 sec
Normal Lactate level
4.5mg/dl- 19.8mg/dl
Calculate MAP
SBP + 2 (DBP) / 3
Oliguria
urine of 400ml/24 hours
16ml/hr
Anuria
Urine output of 100 ml/24 hr
4ml/hr
Septic Shock Symptoms – Early Stage
**known as warm shock: Due to Initial Inflammatory Response. Hyperdynamic state
SVR is low due to vasodilation.
**Warm, flushed skin extremities.
Fever, Hyperthermia
Tachycardia
Tachypnea
BP initially normal to low
CO initially increased R/T hyperdynamic state
**Decreased urine output.
Change in mental status (LOC) from time of admission.
May be subtle… listen to family!
State of relative hypovolemia
Warm shock
A hyperdynamic state. Warm extremities associated with Septic Shock. But BP and HR similar to most other types of shock.
Late Signs & Symptoms
**Late (cold shock) Unable to Compensate
Signs/symptoms related to specific organ failure.
Tachycardia & Hypotension
Decreased CO
Weak and thready pulses
Confusion and decreased LOC
Cool and pale extremities
Hypothermia & Peripheral cyanosis
Petechiae flat tiny red spots and/or purpura (rash of purple spots) & skin mottling
Complications of Septic Shock
Disseminated Intravascular Coagulopathy (DIC)
Multi Organ Dysfunction System (MODS)
Disseminated Intravascular Coagulopathy (DIC)
1st stage of DIC lasts hours to days.
A hematological disorder most often caused by sepsis.
Abnormal clots form inside blood vessels that effect the body’s clotting factors & cause massive bleeding in other areas.
Acute DIC: Clotting stage followed by bleeding stage.
Chronic DIC: Clotting
Disseminated Intravascular Coagulopathy (DIC) Treatment
.9NS IVFs; Blood; FFP (plasma) & platelets (if acute)
Multi Organ Dysfunction System (MODS)
Excessive inflammation related to severe injury or sepsis
First organ affected= Lungs. Acute Resp. Distress Syndrome (ARDS)
Other organs affected= Kidney, Liver and GI systems affected
Mortality rate for MODS= 40%
If neuro & cardiovascular systems affected, mortality rate increase to 100%
Multi Organ Dysfunction System (MODS) Treatment
Oxygenate via ventilator; Replace Intravascular Volume; IV Antibiotics & Blood as needed
Septic Shock Management
Protocols
Prevention (first line of therapy)
CLABSI prevention
CAUTI prevention
Management protocols
Screening – “Time is Tissue”
Initiate interventions in FIRST HOUR after identifying sepsis.
Sepsis Alerts on Hospital Software
Management Prevention
Handwashing
Aseptic technique
Minimize invasive procedures.
Management CLABSI prevention
“Scrub the Hub”: Scrub the hub refers to cleaning the ports of the IV tubing with alcohol swab. Alternative is to replace the port with a new port hanging in strip on IV tubing.
Sepsis & Septic Shock Medical Management
Labs/lactate
IV fluids
Broad spectrum antibiotics
New interventions
When do we remeasure lactate levels?
if elevated > 2 mmol/L
IV fluids
weight based (30 mL/kg) for hypotension or lactate ≥ 4 mmol/L
Isotonic fluids
Isotonic fluids
Lactated Ringers
Normal Saline
What is important about blood cultures?
Blood Cultures x2 and another culture (sputum, urine or wound) prior to starting antibiotics.
If fluids do not increase BP (MAP of 65 or >) then?
Use vasopressors (dopamine, norepinephrine)
Newer interventions
Vitamin C infusions, angiotensin II, thiamine, steroids
Septic Shock Nursing Intervention
• Monitor VS & hemodynamic trends closely.
• Maintain IV fluids.
• Assess IV sites (18g or >)
• Medication administration
• Airway management
• Skin Assess for breakdown & necrosis.
• Assess for bleeding R/T DIC
• Glycemic Control
• Nutritional Support
• Meticulous handwashing
• Patient/ Family education
Medication administration
Vasopressors
DVT prophylaxis
Gastric Stress ulcer prophylaxis (PPI)
Airway management
Monitor pt. on ventilator.
Assess for VAP (vent. associated pneumonia)
Mouthcare every 4 hour to prevent VAP: ventilator associated protocols provide very good mouth care.
Glycemic control
Check BS: Very ill pts get stress hyperglycemia.
Nutritional support
TPN or tube feedings
Pt and family education
handwashing/reverse isolation
