Septic Shock

Question 1

Septic shock occurs when

Answer 1

circulatory and metabolic abnormalities are profound, greatly increasing mortality.

Question 2

Multiple Organ Dysfunction Syndrome (MODS)

Answer 2

Altered function of > 1 organ system requiring interventions to achieve homeostasis.

Question 3

Septic Shock causes

Answer 3

vasodilation which leads to pooling of blood in venous system; relative hypovolemia; decrease venous return.

Question 4

Etiology of Septic Shock

Answer 4

Pneumonia
Urinary tract infections
Endocarditis
Abdominal infections
CAUTI
CLABSI

Question 5

Septic Shock Risk Factors

Answer 5

Very old & very young
Chronic illnesses
Malnutrition
Broad spectrum antibiotic overuse
Surgical or invasive procedures
Immunosuppressed patients
Invasive Equipment: IVs & tubes: Foley, peg tube.

Question 6

SIRS

Answer 6

Systemic Inflammatory Response Syndrome

Question 7

Systemic Inflammatory Response Syndrome (SIRS) Parameters

Answer 7

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)

Question 8

SOFA

Answer 8

Sequential Organ Failure Assessment

Question 9

Signs of Organ Dysfunction or Hypoperfusion

Answer 9

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)

Question 10

Normal bilirubin

Answer 10

1.2 mg/dl under age 18, 1mg/dl

Question 11

Normal PT

Answer 11

10-13.5 seconds

Question 12

Normal INR

Answer 12

.8 to 1.2

Question 13

Normal PTT

Answer 13

30-45 sec

Question 14

Normal Lactate level

Answer 14

4.5mg/dl- 19.8mg/dl

Question 15

Calculate MAP

Answer 15

SBP + 2 (DBP) / 3

Question 16

Oliguria

Answer 16

urine of 400ml/24 hours
16ml/hr

Question 17

Anuria

Answer 17

Urine output of 100 ml/24 hr
4ml/hr

Question 18

Septic Shock Symptoms – Early Stage

Answer 18

**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

Question 19

Warm shock

Answer 19

A hyperdynamic state. Warm extremities associated with Septic Shock. But BP and HR similar to most other types of shock.

Question 20

Late Signs & Symptoms

Answer 20

**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

Question 21

Complications of Septic Shock

Answer 21

Disseminated Intravascular Coagulopathy (DIC)
Multi Organ Dysfunction System (MODS)

Question 22

Disseminated Intravascular Coagulopathy (DIC)

Answer 22

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

Question 23

Disseminated Intravascular Coagulopathy (DIC) Treatment

Answer 23

.9NS IVFs; Blood; FFP (plasma) & platelets (if acute)

Question 24

Multi Organ Dysfunction System (MODS)

Answer 24

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%

Question 25

Multi Organ Dysfunction System (MODS) Treatment

Answer 25

Oxygenate via ventilator; Replace Intravascular Volume; IV Antibiotics & Blood as needed

Question 26

Septic Shock Management

Answer 26

Protocols
Prevention (first line of therapy)
CLABSI prevention
CAUTI prevention

Question 27

Management protocols

Answer 27

Screening – “Time is Tissue”
Initiate interventions in FIRST HOUR after identifying sepsis.
Sepsis Alerts on Hospital Software

Question 28

Management Prevention

Answer 28

Handwashing
Aseptic technique
Minimize invasive procedures.

Question 29

Management CLABSI prevention

Answer 29

“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.

Question 30

Sepsis & Septic Shock Medical Management

Answer 30

Labs/lactate
IV fluids
Broad spectrum antibiotics
New interventions

Question 31

When do we remeasure lactate levels?

Answer 31

if elevated > 2 mmol/L

Question 32

IV fluids

Answer 32

weight based (30 mL/kg) for hypotension or lactate ≥ 4 mmol/L
Isotonic fluids

Question 33

Isotonic fluids

Answer 33

Lactated Ringers
Normal Saline

Question 34

What is important about blood cultures?

Answer 34

Blood Cultures x2 and another culture (sputum, urine or wound) prior to starting antibiotics.

Question 35

If fluids do not increase BP (MAP of 65 or >) then?

Answer 35

Use vasopressors (dopamine, norepinephrine)

Question 36

Newer interventions

Answer 36

Vitamin C infusions, angiotensin II, thiamine, steroids

Question 37

Septic Shock Nursing Intervention

Answer 37

• 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

Question 38

Medication administration

Answer 38

Vasopressors
DVT prophylaxis
Gastric Stress ulcer prophylaxis (PPI)

Question 39

Airway management

Answer 39

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.

Question 40

Glycemic control

Answer 40

Check BS: Very ill pts get stress hyperglycemia.

Question 41

Nutritional support

Answer 41

TPN or tube feedings

Question 42

Pt and family education

Answer 42

handwashing/reverse isolation