SHOCK/SEPSISSHOCK/SEPSIS

NUR 351/352NUR 351/352

Diane E. White RN MS CCRN Diane E. White RN MS CCRN

PhD (c)PhD (c)

ShockShock

Syndrome characterized by inadequate Syndrome characterized by inadequate tissue perfusiontissue perfusion

Classifications:Classifications:Hypovelmic ShockHypovelmic Shock: inadequate volume: inadequate volumeCardiogenic ShockCardiogenic Shock: ineffective pump: ineffective pumpObstructive ShockObstructive Shock: compression: compressionDistributive ShockDistributive Shock: neurogenic, : neurogenic, anaphylactic, & septicanaphylactic, & septic

Stages of ShockStages of Shock

Initial StageInitial Stage: CO SNS: CO SNS Early or Compensatory StageEarly or Compensatory Stage Progressive StageProgressive Stage: systemic vasoconstriction, : systemic vasoconstriction,

shunting of blood, cellular blood flow, hypoxia shunting of blood, cellular blood flow, hypoxia which leads to anaerobic metabolism causing which leads to anaerobic metabolism causing acidosis. Microcirculation dilates to maintain acidosis. Microcirculation dilates to maintain blood flow however capillary pressure blood flow however capillary pressure pushing fluid from capillaries to interstitial pushing fluid from capillaries to interstitial spaces causing edema and capillary spaces causing edema and capillary permeability forcing less venous return and permeability forcing less venous return and COCO

Stages of ShockStages of Shock

Refractory or Irreversible Shock:Refractory or Irreversible Shock: Multiple organ dysfunction & deathMultiple organ dysfunction & death Increased blood poolingIncreased blood pooling Decreased blood flow to all organsDecreased blood flow to all organs

SepsisSepsis

Systemic Inflammatory Response Syndrome Systemic Inflammatory Response Syndrome (SIRS)(SIRS) Fever + LeukocytosisFever + Leukocytosis Core Temp > 38 or < 36 degrees CelsiusCore Temp > 38 or < 36 degrees Celsius Heart rate > 90Heart rate > 90 RR > 20RR > 20 pCO2 < 32mm HgpCO2 < 32mm Hg WBC > 12,000 or < 4, 000WBC > 12,000 or < 4, 000 > 10% immature neutrophils> 10% immature neutrophils

DefinitionsDefinitions

Sepsis = SIRS + InfectionSepsis = SIRS + Infection Severe Sepsis = Sepsis + Multi organ Severe Sepsis = Sepsis + Multi organ

dysfunctiondysfunction Septic Shock = severe sepsis + Septic Shock = severe sepsis +

refractory hypotensionrefractory hypotension

PathophysiologyPathophysiology

Inflammatory response initiated by insultInflammatory response initiated by insult Damage prevented by antioxidantsDamage prevented by antioxidants When inflammatory response becomes When inflammatory response becomes

overwhelmed tissue damage resultsoverwhelmed tissue damage results Massive systemic reactionMassive systemic reaction Leads to multiple organ dysfunctionLeads to multiple organ dysfunction

PathophysiologyPathophysiology

Disruption of endothelial layerDisruption of endothelial layer: capillary : capillary permeability, venodilation, hypovlemiapermeability, venodilation, hypovlemia

Coagulation activatedCoagulation activated: tissue factor : tissue factor released and production of Thrombinreleased and production of Thrombin

Fibrinolysis suppressedFibrinolysis suppressed: caused by : caused by protein Cprotein C

Activation of CNS, Endocrine systemsActivation of CNS, Endocrine systems Defect in peripheral extraction of OxygenDefect in peripheral extraction of Oxygen

Clinical ManifestationsClinical Manifestations

CNS – early signCNS – early sign Cardiac - HR, CO/CI, BP, SVR, CVP, Cardiac - HR, CO/CI, BP, SVR, CVP,

PCWP, LVSVPCWP, LVSV Respiratory - RR early, crackles, pO2, Respiratory - RR early, crackles, pO2,

pCO2 early, and HCO3pCO2 early, and HCO3 Renal - UO, CreatinineRenal - UO, Creatinine Hepatic – jaundice, LFT’sHepatic – jaundice, LFT’s Skin – pink, warm, flushed, TempSkin – pink, warm, flushed, Temp

TreatmentTreatment

GOAL – recover function at the GOAL – recover function at the microcirculatory level!!!microcirculatory level!!!

Fluid TherapyFluid Therapy Vasopressor TherapyVasopressor Therapy Mechanical VentilationMechanical Ventilation Tight Glycemic ControlTight Glycemic Control Treat & Prevent InfectionTreat & Prevent Infection Gluccocorticoid Steroids & XigrisGluccocorticoid Steroids & Xigris

Nursing CareNursing Care

Early Recognition!!!Early Recognition!!! Reduce ExposureReduce Exposure Administration of Antibiotics, Fluids, and Administration of Antibiotics, Fluids, and

PressorsPressors Correct fluid volume deficitCorrect fluid volume deficit Increase COIncrease CO Adequate nutritionAdequate nutrition Improve gas exchangeImprove gas exchange