Learning Outcome

1. Recall the causes of septic shock
2. Describe the presentation of septic shock
3. Summarize the treatment of septic shock
4. List the nursing management role in septic shock

Introduction

Sepsis syndromes span a clinical continuum with variable prognoses. Septic shock, the most severe complication of sepsis, carries a high mortality. In response to an inciting agent, pro-inflammatory and anti-inflammatory arms of the immune system are activated in concert with the activation of monocytes, macrophages, and neutrophils that interact with the endothelium through pathogen recognition receptors to elaborate cytokines, proteases, kinins, reactive oxygen species, and nitric oxide.[1] As the primary site of this response, the endothelium not only suffers microvascular injury but also activates the coagulation and complement cascades which further exacerbate vascular injury, leading to capillary leak. This cascade of events is responsible for the clinical signs and symptoms of sepsis and progression from sepsis to septic shock. The ability to balance pro-inflammatory responses to eradicate the invading microorganism with anti-inflammatory signals set to control the overall inflammatory cascade ultimately determines the degree of morbidity and/or mortality suffered by the patient. Judicious and early antimicrobial administration, sepsis care bundle use, and early goal-directed therapies have significantly and positively impacted sepsis-related mortality. However, early identification remains the best therapeutic tool for sepsis treatment and management.

Nursing Diagnosis

• Ineffective healing
• Imbalance in body fluids
• Inadequate oxygenation and breathing
• Impaired body defense mechanisms
• Altered mental status

Causes

The 2009 European Prevalence of Infection in Intensive Care (EPIC II study) determined that gram-negative bacterial infections far exceed other etiologies as the most common cause of sepsis syndromes with a frequency of 62%, followed by gram-positive infections at 47%. An increase in the prevalence of the latter may be attributable to the performance of more invasive procedures and increased incidence of nosocomial infections.[2] Predominant micro-organisms isolated in patients include Staphylococcus aureus (20%), Pseudomonas (20%), and Escherichia coli (16%).[3] Predominant sites of infection include respiratory (42%), bloodstream (21%), and genitourinary (10%).[2] These data need to be assessed in the context of knowing that over a third of patients never grow positive cultures.[4]

The influence of bacterial strain and site of infection on mortality was illustrated in a large meta-analysis.[5] In this study, gram-negative infections were overall associated with higher mortality. However, gram-positive bacteremia with Acinetobacter or pneumonia with Staphylococcus carried a 40% mortality with Pseudomonal pneumonia carrying the highest mortality at 70%.

Sepsis syndromes caused by multidrug-resistant bacterial strains (methicillin-resistant Staphylococcus (MRSA), vancomycin-resistant enterococci (VRE)) are on the rise with a current incidence of up to 25%; viruses and parasites cause far fewer cases and are identified in 2% to 4% of cases.[6]

Risk Factors

Annually, the rate of this debilitating condition is rising by almost 9%.[7] The incidence of sepsis and severe sepsis have risen over the past decade from approximately 600,000 to over 1,000,000 hospitalizations per year from 2000 through 2008.[8] Accompanying this trend has been a rise in healthcare expenditure, making sepsis the most expensive healthcare condition in 2009, accounting for 5% of total United States hospital costs.[9] The case fatality for patients with sepsis has been declining due to advances in sepsis management provided by the Surviving Sepsis Campaign. The United States Nationwide Inpatient Sample (NIS) from 2009 through 2012 showed a mortality rate declined from 16.5 to 13.8%.[10] However, severe sepsis continues to rank amongst the most common causes of death in hospitalized patients.[11] Moreover, up to 25% of patients with severe sepsis and 50% of patients with septic shock will suffer mortality.[2] However, overall mortality from sepsis syndromes can vary from 30% to 50% [12] depending on demographic factors such as age, race, sex, co-morbid conditions, and the presence of organ dysfunction.[13] For example, in-patient mortality was predicted most by number and degree of organ injury with the strongest predictors being respiratory, cardiovascular, hepatic, and neurologic failure.[10]

Assessment

Early Signs and Symptoms

Sepsis is defined as systemic inflammatory response syndrome plus an infectious source. Therefore, earlier on in the presentation of sepsis, patients present with the following vital sign changes:

• Fever, temperature higher than 38 C, or hypothermia, temperature lower than 36 C
• Tachycardia with a heart rate higher than 90 beats per minute in adult patients or less than two standard deviations for age in pediatric patients
• Tachypnea with respiratory rate greater than 20 breaths per minute in adult patients or more than two standard deviations for age in pediatric patients

Signs and Symptoms of Severe Sepsis Severe sepsis is defined as sepsis and end-organ dysfunction. At this stage, signs, and symptoms may include: 

• Altered mental status
• Oliguria or anuria
• Hypoxia
• Cyanosis
• Ileus

Patients progressing to septic shock will experience signs and symptoms of severe sepsis with hypotension. Of note, at an early "compensated" stage of shock, blood pressure may be maintained, and other signs of distributive shock might be present, for example, warm extremities, flash capillary refill (less than one second), and bounding pulses, also known as warm shock. This stage of shock, if managed aggressively with fluid resuscitation and vasoactive support, can be reversed. With the progression of septic shock into the uncompensated stage, hypotension ensues, and patients may present with cool extremities, delayed capillary refill (more than three seconds), and thready pulses, also known as cold shock. After that, with continued tissue hypoperfusion, shock may be irreversible, progressive rapidly into multiorgan dysfunction syndrome and death.

Evaluation

Laboratory Findings

Findings in sepsis, severe sepsis, and septic shock are as follows [14]: 

• Hyperglycemia (glucose more than 120 mg/dL)
• Leukocytosis (WBC more than 12,000/mm3) or leukopenia (WBC less than 4000/mm3)
• Bandemia (more than 10%)
• C-reactive protein or procalcitonin more than 2 SD above normal
• Mixed venous saturation more than 70%
• PaO2: FiO2 less than 300
• Pre-renal azotemia
• Coagulopathy, INR more than 1.5 or PTT more than 60 sec
• Thrombocytopenia (platelets less than 100,000/mL)
• Hyperbilirubinemia (total bilirubin more than 4 mg/dL)
• Lactic acidosis (more than 2 mmol/L)

Patients should be placed on continuous cardiopulmonary monitoring to allow close observation of vital signs. A thorough assessment of end-organ function and peripheral perfusion should be undertaken to determine where along the pathophysiologic continuum of sepsis they may fall. This should include a Glasgow Coma Scale (GCS) or mental status assessment, urine output measurement, or lactate/mixed venous saturation determination (with central lines). Regardless of where along the continuum patients are, all patients should have drawn a complete blood count with differential (CBC-d), source cultures (blood, urine, tracheal (if intubated), wound), and a urinalysis. Depending on the severity of presentation and age of the patient a lumbar puncture may be indicated, for example, patients with signs of encephalitis or meningitis or febrile pediatric patients under six weeks of age. The addition of C-reactive protein or procalcitonin, both acute-phase proteins, may be helpful in distinguishing viral from bacterial sepsis, with the latter showing steeper elevations in these proteins. A complete chemistry panel with liver function test, disseminated intravascular coagulation (DIC) panel, and an arterial blood gas are additional labs that may provide important information on the severity of sepsis syndrome in a patient.

Medical Management

Below guidelines are derived from the Surviving Sepsis Campaign Guidelines [15][16]

Source Control

1. Broad-spectrum antibiotics within one hour of diagnosis for all patients. Initial empiric anti-infective therapy should have activity against all likely pathogens and adequate penetration of source tissue.  
2. Removal of infected/necrotic tissue, if it is the source of septic shock, i.e. patients with cellulitis, abscess, infected devices, purulent wounds.

Management of Shock [17]

1. Measures most effective if achieved within the first six hours of diagnosis
2. Restore central venous pressure (CVP) to 8 mmHg to 12 mmHg
3. Restore mean arterial pressure (MAP) greater than 65 mmHg
4. Restore superior vena cava saturation to 70% or mixed venous saturation to 65%
5. Fluid resuscitation with crystalloid (NS or albumin) and colloid (blood products) up to 80 ml/kg
6. Mechanical ventilation to reduce metabolic demand
7. First line vasoactive agents (epinephrine in cold shock versus norepinephrine in warm shock) when fluid-refractoryNote: dopamine as a first line agent has fallen out of favor given its inhibitory effect on the HPA axis, namely prolactin and growth hormone, which can confer immunologic dysfunction [18]

Enhancing Host Response

1. Corticosteroids indicated in vasoactive-refractory shock and or in patients with low (unstimulated) basal cortisol levels less than 150 ug/L) [19][20]
2. Addition of vasopressin indicated in vasoactive-refractory shock

While central lines are not required for the resuscitation of patients with septic shock, they provide an accurate means of monitoring CVP and mixed venous saturations. Remember that CVP and MVO2 are most accurate from a central line that lies within the right atrium; lower extremity central lines do not provide the most accurate data for monitoring these indices of resuscitation. Regarding the need for central venous access for administration of vasoactive agents, a recent study showed that both dopamine, norepinephrine, and phenylephrine at high doses could be safely administered via peripheral venous access.[21] 

Of note, early goal-directed therapy (EGDT) has not been shown to confer a survival benefit in more recent studies.[22] All studies comparing EGDT to standard practice have shown an increase in the administration of crystalloid and packed red blood cells in the first six hours and the placement of central lines. Furthermore, survival was influenced most by the maintenance of blood pressure independent of the type of fluid or vasoactive used and not CVP or MVO2.[23] That said, the Surviving Sepsis Campaign guidelines continue to support EGDT as the standard of practice for the management of severe sepsis and septic shock.

The placement of an arterial line becomes important in the management of vasoactive-refractory shock for close monitoring of blood pressure and tissue oxygenation status via regular blood gasses with key attention to lactate levels and pO2.

Nursing Management

• Monitor vital signs
• Assess neurovitals
• Obtain cultures (blood, urine, sputum)
• Administer antibiotics
• Check labs for electrolytes, renal and liver function
• Ensure patient has DVT and pressure sore prophylaxis
• Consult with dietitian regarding feeding
• Assess oxygenation and ventilation
• Provide oxygen if saturations lower than 92%
• Optimize fluid status
• Measure Ins and outs
• Weigh the patient
• Assess lung sounds for rales, crackles
• Encourage hand washing
• Limit patient visitors
• Educate the family about septic shock
• Prevent aspiration by elevating the head of the bed
• Check labs for culture results and antibiotic sensitivity
• Check chest x-ray report for pneumonia or ARDs

When To Seek Help

• Hypotension
• Unresponsive
• Anuria
• Fever

Outcome Identification

Septic shock is a serious illness and despite all the advances in medicine, it still carries high mortality which can exceed 40%. Mortality does depend on many factors including the type of organism, antibiotic sensitivity, number of organs affected, and patient age. The more factors that match SIRS, the higher the mortality. Data suggest that tachypnea and altered mental status are excellent predictors of poor outcomes. Finally, prolonged use of inotropes to maintain blood pressure is also associated with adverse outcomes. Even those who survive are left with significant functional and cognitive deficits.

Coordination of Care

The management of septic shock is best done with an interprofessional team that includes ICU nurses. The key is early diagnosis and resuscitation to maintain end-organ perfusion. The type of fluid for resuscitation has little bearing on outcomes but the key is to maintain adequate perfusion pressure. Patients with sepsis are prone to many complications which have high mortality. Thus, close monitoring and prevention of these complications are vital. Primary disorders like diabetes, renal or liver failure must be treated. Drugs that affect the immune system should be discontinued. The dietitian should be consulted as there is good evidence that early enteral nutrition is beneficial. The nurse should ensure DVT and pressure sore prophylaxis. The nurse should also monitor all catheters for infection and remove those that are not needed. The pharmacists should follow culture results and ensure that the patient is on organism-sensitive antibiotics. Clinicians should maintain aseptic techniques during procedures and hand washing should be practiced. The entire team should communicate with each other to ensure that the patient is receiving optimal care.

The outcomes of septic shock depend on patient age, associated comorbidities, renal function, need for dialysis, requiring mechanical ventilation and response to treatment.