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Sepsis and Septic Shock

Sepsis and Septic Shock. The human body is resilient…. Undergoes many insults daily Survives most One insult is microbial If overwhelming, infection occurs Unchecked, damage occurs at the cellular level Transmits to organ level If damage progresses, shock occurs. What is “shock?”.

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Sepsis and Septic Shock

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  1. Sepsis and Septic Shock

  2. The human body is resilient…. • Undergoes many insults daily • Survives most • One insult is microbial • If overwhelming, infection occurs • Unchecked, damage occurs at the cellular level • Transmits to organ level • If damage progresses, shock occurs

  3. What is “shock?” • A state of organ hypoperfusion causing cellular dysfunction and death • Mechanisms include: • Decreased volume • Decreased cardiac output • Vasodilation • Symptoms: • Life threatening hypotension • Decreased urine output • Body temperature changes

  4. Types of shock

  5. Facts regarding septic shock • More than half the cases caused by gram-negative bacteria • Most common sources are respiratory tract and GI tract • Mortality range is 40-70%

  6. Important terms • SIRS—first stage of sepsis, may occur with or without clinical sepsis • Bacteremia—at least 1 positive blood culture • Sepsis syndrome—bacteremia + altered organ perfusion • Septic shock—sepsis syndrome + reversible hypotension • Refractory septic shock—sepsis syndrome + irreversible, prolonged (>1 hr) hypotension • Septicemia—overly used, confusing term, do not use!

  7. Systemic inflammatory response syndrome (SIRS) • Acute, nonspecific illness • First stage of sepsis • SIRS may result from • Surgery • Trauma • MI • Pancreatitis • Burn injury

  8. Signs of SIRS result from damage occurring at organ level • SIRS patient must have at least 2 of the following: • Systemic inflammation • Temperature >100.4F or <96.8F • Heart rate >90 bpm • Respiratory rate >20 bpm • PaCO2 <32 mm Hg • WBC >12,000 or <4,000

  9. Risk factors for SIRS progressing to sepsis • Post operative status • Infection • Chronic illnesses • Long-term immunosuppresive therapy (e.g., chemo) • Poor nutritional status • Debilitation

  10. The cascade begins with bacteremia • May exist for lengthy time before shock develops • At risk populations are

  11. Initial result of bacteremia • Bacteria is present in the blood • Endotoxins are present in the bacteria, toxic substances bound to bacterial wall • Endotoxins are released when bacterial wall ruptures or disintegrates • Endotoxins implicated in activation of multiple inflammatory chemicals

  12. Major chemicals in septic shock IL- Interleukins; TNF-tumor necrosis factor; PAF-platelet-activating factor; MDF/S-myocardial depressant substance

  13. Interleukins 1-3 • Cause arterial smooth muscle dilation • Cause capillary basement leaks • Cause CHO production and uptake • Induce fever • Initiate complement cascade (which initiates cell lysis) • Stimulate TNF • Net effect is fever, vasodilation, hypotension, edema, elevated WBC

  14. Tumor necrosis factor (TNF) • Major chemical responsible for septic shock • Produced from macrophages in response to endotoxin and IL • Infiltrates complement and coagulation cascades • Directly toxic to endothelial cells • Causes capillary dilation and leak • Changes CHO metabolism • Causes fever

  15. Platelet-activating factor (PAF) • Directly toxic on certain organs • Heart: coronary artery constriction, decreased myocardial contractility • Lungs: generates pulmonary edema • Kidneys: decreases renal blood flow and urine production • GI: causes ulceration • If patient able to survive hypotension, he remains at great risk to die from multiple organ failure.

  16. TNF + PAF Simultaneous clotting and bleeding Early Later

  17. Myocardial depressant substance • Secreted from WBCs in response to endotoxin • Myocardium becomes depressed and dilated • Both ventricles involved simultaneously • Does not respond to increased volume if given • Due to changes in CHO metabolism, glucose and glycogen stores are depleted • Hypotension is main cause of death

  18. Results: Signs of septic shock • Patches of skin discoloration • Decreased urine output • Confusion, lethargy • Pulmonary edema • Abnormal heart function • Temp ↑ or ↓ • Weakness

  19. Summary of signs & cellular causes

  20. Summary of signs 2º organ damage

  21. The “sepsis cascade”

  22. Assessing the patient for sepsis On Med-Surg unit, monitor patient for: • Changes in oxygenation (earliest sign) • Heart rate changes • Changes in tissue perfusion • Mental status changes The “Sepsis 6” • Prior to admission, had there been delayed treatment? Misdiagnosis? Inappropriate antibiotic use? • Monitor urine output • Screening tool is invaluable!

  23. Sepsis screening tool

  24. Nursing interventions • Most patients recover with rest, antibiotics, and hydration • Ongoing physical assessment • Fluid resuscitation—may need 6-10 L in first 24 hours • Fluid challenge may be given rapidly (e.g., 10 minutes) • Indwelling catheter • Strict I&O • CVP monitoring (normal is 5-10 cm H2O) • Monitor H&H; transfuse if Hgb <7 g/dL • Be knowledgeable and institute algorithms, pathways, and order sets as appropriate

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