Septic shock is a clinical continuum from sepsis. It’s characterized by the dropping of a patient’s blood pressure to a life-threatening point after an infection (which may be caused by any bacteria; or rarely by viruses and fungi).
Quick Facts
- A severe complication of sepsis is septic shock
- Early identification and treatment is the best management of sepsis; this will stop sepsis from progressing into septic shock
- Gram-negative bacteria are the cause of sepsis
- The effects are reversible when treated at an early stage
- It may be caused by hospital infections also known as nosocomial infections
- Multidrug-resistant bacteria called MRSA (methicillin-resistant Staphylococcus) may also cause septic shock
Predisposing Factors to Sepsis
- Diabetes
- Malignancy
- Chronic kidney and liver disease
- Use of corticosteroids
- Immunosuppressed state
- Burns
- Major surgery
- Trauma
- Presence of indwelling catheters
- Prolonged hospitalization
- Hemodialysis
- Extremes of age
Signs and Symptoms
Early Stage
- Fever or hypothermia: temperature may rise to 38 degrees Celsius. It may go lower to 36 degrees Celsius.
- Fast heartbeat (tachycardia): heart rate goes up to 90 beats per minute in adults
- Fast breathing (tachypnea): fast breathing that goes up to 20 breaths per minute in adults
- White blood cells higher than 12,000/cu mm; or white blood cells lower than 4,000/cu mm
These are clinical signs for diagnosing Systemic Inflammatory Response Syndrome (SIRS).
Severe Sepsis
- Anuria or oliguria
- Altered mental status
- Hypoxia
- Ileus
- Cyanosis
Stages of Shock
Early Stage of Shock (Compensated stage)
Here are the signs and symptoms that a patient may experience in the early stage of shock. This is also called warm shock.
- Blood pressure is maintained
- Warm extremities
- Flash capillary refill (refills less than one second)
- Bounding pulse
Uncompensated Stage of Shock
When not treated, the early stage will progress. It will go down to an uncompensated stage, also called cold shock. Here are the signs and symptoms:
- Hypotension
- The patient has cool extremities
- Delayed capillary refill (three seconds or more)
- Thready pulse
Diagnosis
- Blood tests: taken to check for evidence of infection, abnormal liver or kidney function, electrolyte imbalance
- Urinalysis
- Xray: lungs can be assessed if there are any infections
- Ultrasound: this is useful to check the infections in the bladder and kidneys
- Computed tomography: this will assess infection in the abdominal organs. Examples are the liver and the pancreas
- Magnetic resonance imaging
Treatment and Medications
- Antibiotic: the use of broad-spectrum antibiotics given within 1 hour of diagnosis
- Intravenous fluids: Normal saline or albumin is used for fluid replacement. Blood products if in need of blood may be up to 80 ml/kg
- Vasopressor: vasopressin is indicated for vasoactive-refractory shock
- Surgery: To remove the part that causes the infection such as an abscess or infected device
- First-line vasoactive agents: epinephrine is for cold shock. Norepinephrine is for the treatment of warm shock. Dopamine is not given anymore. This is due to its effect that inhibits growth hormone and prolactin. These hormones help in the immune response of the patient.
Management of Shock
- Manage within the first six hours to achieve the most desired health outcomes
- The patient needs mechanical ventilation to lessen the demand for metabolism
- Restoration of the CVP (central venous pressure) from 8mmHg to 12mmHg
- Restore vena cava saturation to 70 percent
- Central lines such as CVP (central venous pressure) are the most effective way to check venous status. This is the best way to know when to resuscitate a patient.
- The survival of the patient is based on the maintenance of the blood pressure and not on the CVP.
Laboratory findings for patients that progressed from sepsis to septic shock
- Leukocytes: white blood cells are more than 12,000/mm3 or less than 4000/mm3
- Glucose level is more than 120 mg/dL
- Bandemia
- The level of mixed saturation is higher than 70 percent
- PaO2:FiO2 is less than 300
- Prerenal azotemia
- Platelets are less than 100,000/mL
- The bilirubin level is more than 4 mg/dL
- The level of the lactic acidosis is 2mmol/L or more
Nursing Intervention
- Assess mental status
- Check vital signs and report to the team if there are any changes
- Administer antibiotics as prescribed
- Check laboratories for renal, liver, and electrolytes function
- Consult a dietician for the patient’s diet
- Assess oxygenation and ventilation of the patient
- Provide oxygen for oxygen saturation that is lower than 92%
- Measure the urinary output and input
- Weigh the patient and if there are any changes, report to the team
- Assess the lungs for sounds or crackles and rales
