Septic Shock

Septic shock is a potentially lethal drop in blood pressure due to the presence of bacteria in the blood. Septic shock is a possible consequence of bacteremia, or bacteria in the bloodstream. Bacterial toxins, and the immune system response to them, cause a dramatic drop in blood pressure, preventing the delivery of blood to the organs. Septic shock can lead to multiple organ failure including respiratory failure, and may cause rapid death. Toxic shock syndrome is one type of septic shock.

Causes and symptoms

During an infection, certain types of bacteria can produce and release complex molecules, called endotoxins, that may provoke a dramatic response by the body's immune system. Released in the bloodstream, endotoxins are particularly dangerous, because they become widely dispersed and affect the blood vessels themselves. Arteries and the smaller arterioles open wider, increasing the total volume of the circulatory system. At the same time, the walls of the blood vessels become leaky, allowing fluid to seep out into the tissues, lowering the amount of fluid left in circulation. This combination of increased system volume and decreased fluid causes a dramatic decrease in blood pressure and reduces the blood flow to the organs. Other changes brought on by immune response may cause coagulation of the blood in the extremities, which can further decrease circulation through the organs. Septic shock is seen most often in patients with suppressed immune systems, and is usually due to bacteria acquired during treatment at the hospital. The immune system is suppressed by drugs used to treat cancer, autoimmune disorders, organ transplants, and diseases of immune deficiency such as AIDS. Malnutrition, chronic drug abuse, and long-term illness increase the likelihood of

succumbing to bacterial infection. Bacteremia is more likely with preexisting infections such as urinary or gastrointestinal tract infections, or skin ulcers. Bacteria may be introduced to the blood stream by surgical procedures, catheters, or intravenous equipment. Toxic shock syndrome most often occurs in menstruating women using highly absorbent tampons. Left in place longer than other types, these tampons provide the breeding ground for Staphylococcus bacteria, which may then enter the bloodstream through small tears in the vaginal lining. The incidence of toxic shock syndrome has declined markedly since this type of tampon was withdrawn from the market Risk factors for septic shock include:

Diabetes Diseases of the genitourinary system, biliary system, or intestinal system Diseases that weaken the immune system such as AIDS Indwelling catheters (those that remain in place for extended periods, especially intravenous lines and urinary catheters and plastic and metal stents used for drainage)

Leukemia Long-term use of antibiotics Lymphoma Recent infection Recent surgery or medical procedure Recent use of steroid medications

Symptoms
Septic shock can affect any part of the body, including the heart, brain, kidneys, liver, and intestines. Symptoms may include:

Cool, pale extremities High or very low temperature, chills

Lightheadedness Low blood pressure, especially when standing Low or absent urine output Palpitations Rapid heart rate Restlessness, agitation, lethargy, or confusion Shortness of breath Skin rash or discoloration

Septic shock may progress to cause "adult respiratory distress syndrome," in which fluid collects in the lungs, and breathing becomes very shallow and labored. This condition may lead to ventilatory collapse, in which the patient can no longer breathe adequately without assistance.

Diagnosis
Diagnosis of septic shock is made by measuring blood pressure, heart rate, and respiration rate, as well as by a consideration of possible sources of infection. Blood pressure may be monitored with a catheter device inserted into the pulmonary artery supplying the lungs (Swan-Ganz catheter). Blood cultures are done to determine the type of bacteria responsible. The levels of oxygen, carbon dioxide, and acidity in the blood are also monitored to assess changes in respiratory function.

Treatment
Treatment may include:

Breathing machine (mechanical ventilation) Drugs to treat low blood pressure, infection, or blood clotting Fluids given directly into a vein (intravenously) Oxygen Surgery

There are new drugs that act against the extreme inflammatory response seen in septic shock. These may help limit organ damage. Hemodynamic monitoring -- the evaluation of the pressures in the heart and lungs -- may be required. This can only be done with special equipment and intensive care nursing. Septic shock is treated initially with a combination of antibiotics and fluid replacement. The antibiotic is chosen based on the bacteria present, although two or more types of antibiotics may be used initially until the organism is identified. Intravenous fluids, either blood or protein solutions, replace the fluid lost by leakage. Coagulation and hemorrhage may be treated with transfusions of plasma or platelets. Dopamine may be given to increase blood pressure further if necessary.

Prognosis
Septic shock is most likely to develop in the hospital, since it follows infections which are likely to be the objects of treatment. Because of this, careful monitoring and early, aggressive therapy can minimize the likeli-hood of progression. Nonetheless, death occurs in at least 25% of all cases. The likelihood of recovery from septic shock depends on may factors, including the degree of immuno-suppression of the patient, underlying disease, promptness of treatment, and type of bacteria responsible. Mortality is highest in the very young and the elderly, those with persistent or recurrent infection, and those with compromised immune systems.

Prevention
The risk of developing septic shock can be minimized through treatment of underlying bacterial infections, and prompt attention to signs of bacteremia. In the hospital, scrupulous aseptic technique on the part of medical professionals lowers the risk of introducing bacteria into the bloodstream.

Nursing Management

Assessment Techniques Timeliness and precision of very early care in septic shock can make a big difference. Attention to details of oxygen consumption and other hemodynamic variables seems critical for positive outcomes in the first hours of sepsis. Keys to determining an accurate diagnosis are a detailed patient history and psychosocial evaluation, physical examination, and diagnostic assessment. Patient History To begin with, record any of the definitive criteria present for sepsis and septic shock. Be sure to discuss with patients any behavioral or lifestyle changes that may have impacted their current health status. Ask whether individuals have intravascular devices - a major factor in nosocomially-acquired sepsis. And find out if they have recently suffered from CNS, head and neck, chest or pulmonary, abdominal and GI, pelvic or genitourinary, or bone and soft tissue infections. By identifying localized symptoms, such as sinus pain, dyspnea, or swollen joints, providers can determine which organs may be affected. When taking histories, be prepared for patients to present with multiple sites of infection. Studies have shown that this scenario occurs in six to 15 percent of people. Respiratory and urinary tract infections, followed by those originating in the abdomen and soft tissue, are the most common causes of sepsis. Not surprisingly, septic shock presents in 25 percent of patients with lower RTIs and 25 percent with UTIs. Soft tissue infections promote septic shock in 15 percent of cases, as do GI tract infections. Research also shows that 10 percent of patients with this disorder have reproductive system infections, while five percent attribute the illness to fungi and other pathogens. Physical Examination

In addition to examining individuals with regard to typical manifestations of septic shock - such as tachypnea, hypotension, bounding pulses, and confusion - qualified professionals should assess cardiac output. Early in the process, levels increase due to vasodilation - resulting in warm, flushed skin - then fall in late-stage disease. Perhaps the most important element of the assessment process is ruling out other types of shock including hypovolemic, obstructive, distributive, and cardiogenic. Keep in mind that clinical signs may be insensitive to the earliest phases of shock development and to its correction. However, many indications of organ dysfunction accompany a critical depression in core perfusing pressures and should be confirmed in all patients considered for a shock diagnosis. In addition to a decrease in measured blood pressure, look for confirmatory physical symptoms such as CNS abnormalities (obtundation or agitation), renal hypoperfusion (oliguria), and redistribution of blood flow away from the skin (cool, mottled periphery). Diagnostic Assessment A CBC with differential and tests for serum electrolyte levels and renal and hepatic function are just some of the studies recommended. Coagulation status, as calculated by prothrombin time and activated partial thromboplastin time, can reflect the potential for DIC, which requires additional investigation. The use of blood cultures is the main method for diagnosing intravascular infections and bacteremia, while arterial blood gas (ABG) analysis measures the amount of oxygen, carbon dioxide, and acidity. Elevated serum lactate levels indicate the presence of hypoperfusion, with higher figures equating to greater degrees of shock and mortality rates. Urinalysis and culturing can be used to rule out the presence of UTIs. Gram staining may not only document bacterial infection, but also influence the type of initial antibiotic therapy chosen. Other diagnostic assessments include imaging studies, such as x-rays, ultrasonography, CT scans, and lumbar punctures. Hemodynamic Support

By carefully monitoring hemodynamics, mobile practitioners can assess tissue perfusion and assist in restoring levels . A mean arterial pressure of less than 60 mm Hg or a decrease of 40 mm Hg from baseline defines septic shock at the bedside. Another level to watch is mixed venous oxyhemoglobin (MVO2) saturation - an indicator of oxygen delivery and consumption. Decreased tissue perfusion exists when saturation levels are less than 65 percent. Since patients with septic shock may have artificially elevated MVO2 levels, it is necessary to evaluate perfusion in multiple ways - including organ function. With intravascular volume resuscitation, large amounts of fluids - either isotonic crystalloid or colloid solutions - are infused based on patients' volume needs and cardiovascular status. Adequate resuscitation can be gauged by improvements in mental state, heart rate, urine output, and mean arterial pressure. If patients do not respond to volume infusion - or if volume overload occurs, causing dyspnea and pulmonary edema, among other symptoms - vasopressor supportive therapy becomes necessary. Providers can utilize vasoconstrictive agents, such as dopamine, norepinephrine, epinephrine, and phenylephrine, to optimize pressure and cardiac function so tissue oxygenation improves. Those individuals who are unresponsive even with fluid resuscitation and high doses (20 mcg/kg/min) of dopamine may need to receive norepinephrine to reverse septic shock. The use of this drug is controversial, with some studies noting positive outcomes, while others suggest this vasopressor potentiates end-organ hypoperfusion and injury. Because thrombocytopenia and disseminated intravascular coagulation may arise, especially in patients with meningococcal sepsis, hematological monitoring and clinical assessment of bleeding throughout the course of disease are essential. Replacement with vitamin K, fresh frozen plasma, and platelet transfusions should correct most coagulopathies. Antibiotic Therapy Empirical antimicrobial therapy should be instituted early on in the care of septic shock patients as soon as cultures have been obtained, prior to sensitivity results being available. Selection of

initial broad-spectrum regimens will vary depending on age, focus of infection, and underlying disease. Examples of antibiotics administered intravenously are cefotaxime (Claforan), ceftriaxone (Rocephin), cefuroxime (Zinacef), ticarcillin and clavulanate (Timentin), and piperacillin.