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Sepsis and Septic Shock. The human body is resilient…. Undergoes many insults daily Survives most One insult is microbial If overwhelming, infection occurs Unchecked, damage occurs at the cellular level Transmits to organ level If damage progresses, shock occurs. What is “shock?”.

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Presentation Transcript
the human body is resilient
The human body is resilient….
  • Undergoes many insults daily
  • Survives most
  • One insult is microbial
  • If overwhelming, infection occurs
  • Unchecked, damage occurs

at the cellular level

  • Transmits to organ level
  • If damage progresses, shock occurs
what is shock
What is “shock?”
  • A state of organ hypoperfusion

causing cellular dysfunction and death

  • Mechanisms include:
    • Decreased volume
    • Decreased cardiac output
    • Vasodilation
  • Symptoms:
    • Life threatening hypotension
    • Decreased urine output
    • Body temperature changes
facts regarding septic shock
Facts regarding septic shock
  • More than half the cases caused by gram-negative bacteria
  • Most common sources are respiratory tract and GI tract
  • Mortality range is 40-70%
important terms
Important terms
  • SIRS—first stage of sepsis, may occur

with or without clinical sepsis

  • Bacteremia—at least 1 positive blood culture
  • Sepsis syndrome—bacteremia + altered organ perfusion
  • Septic shock—sepsis syndrome + reversible hypotension
  • Refractory septic shock—sepsis syndrome + irreversible,

prolonged (>1 hr) hypotension

  • Septicemia—overly used, confusing term, do not use!
systemic inflammatory response syndrome sirs
Systemic inflammatory response syndrome (SIRS)
  • Acute, nonspecific illness
  • First stage of sepsis
  • SIRS may result from
    • Surgery
    • Trauma
    • MI
    • Pancreatitis
    • Burn injury
signs of sirs result from damage occurring at organ level
Signs of SIRS result from damage occurring at organ level
  • SIRS patient must have at least 2 of the following:
  • Systemic inflammation
  • Temperature >100.4F or <96.8F
  • Heart rate >90 bpm
  • Respiratory rate >20 bpm
  • PaCO2 <32 mm Hg
  • WBC >12,000 or <4,000
risk factors for sirs progressing to sepsis
Risk factors for SIRS progressing to sepsis
  • Post operative status
  • Infection
  • Chronic illnesses
  • Long-term immunosuppresive therapy (e.g., chemo)
  • Poor nutritional status
  • Debilitation
the cascade begins with bacteremia
The cascade begins with bacteremia
  • May exist for lengthy time before shock develops
  • At risk populations are
initial result of bacteremia
Initial result of bacteremia
  • Bacteria is present in the blood
  • Endotoxins are present in the bacteria, toxic substances bound to bacterial wall
  • Endotoxins are released when bacterial wall ruptures or disintegrates
  • Endotoxins implicated in activation of multiple inflammatory chemicals
major chemicals in septic shock
Major chemicals in septic shock

IL- Interleukins; TNF-tumor necrosis factor; PAF-platelet-activating factor; MDF/S-myocardial depressant substance

interleukins 1 3
Interleukins 1-3
  • Cause arterial smooth muscle

dilation

  • Cause capillary basement leaks
  • Cause CHO production and uptake
  • Induce fever
  • Initiate complement cascade

(which initiates cell lysis)

  • Stimulate TNF
  • Net effect is fever, vasodilation, hypotension, edema, elevated WBC
tumor necrosis factor tnf
Tumor necrosis factor (TNF)
  • Major chemical responsible for septic shock
  • Produced from macrophages in response to endotoxin and IL
  • Infiltrates complement and coagulation cascades
  • Directly toxic to endothelial cells
  • Causes capillary dilation and leak
  • Changes CHO metabolism
  • Causes fever
platelet activating factor paf
Platelet-activating factor (PAF)
  • Directly toxic on certain organs
  • Heart: coronary artery constriction,

decreased myocardial contractility

  • Lungs: generates pulmonary edema
  • Kidneys: decreases renal blood flow

and urine production

  • GI: causes ulceration
  • If patient able to survive hypotension, he remains at great risk to die from multiple organ failure.
tnf paf
TNF + PAF

Simultaneous clotting and bleeding

Early Later

myocardial depressant substance
Myocardial depressant substance
  • Secreted from WBCs in response to endotoxin
  • Myocardium becomes depressed and dilated
  • Both ventricles involved simultaneously
  • Does not respond to increased

volume if given

  • Due to changes in CHO metabolism,

glucose and glycogen stores are

depleted

  • Hypotension is main cause of death
results signs of septic shock
Results: Signs of septic shock
  • Patches of skin discoloration
  • Decreased urine output
  • Confusion, lethargy
  • Pulmonary edema
  • Abnormal heart function
  • Temp ↑ or ↓
  • Weakness
assessing the patient for sepsis
Assessing the patient for sepsis

On Med-Surg unit, monitor patient for:

  • Changes in oxygenation (earliest sign)
  • Heart rate changes
  • Changes in tissue perfusion
  • Mental status changes The “Sepsis 6”
  • Prior to admission, had there been delayed treatment? Misdiagnosis? Inappropriate antibiotic use?
  • Monitor urine output
  • Screening tool is invaluable!
nursing interventions
Nursing interventions
  • Most patients recover with rest, antibiotics, and hydration
  • Ongoing physical assessment
  • Fluid resuscitation—may need 6-10 L in first 24 hours
  • Fluid challenge may be given rapidly (e.g., 10 minutes)
  • Indwelling catheter
  • Strict I&O
  • CVP monitoring (normal is 5-10 cm H2O)
  • Monitor H&H; transfuse if Hgb <7 g/dL
  • Be knowledgeable and institute algorithms, pathways, and order sets as appropriate