Septic Shock

Septic shock is a clinical syndrome associated with severe systemic infection. It is a severe critical illness with healthcare costs exceeding $62 billion a year in the United States. Sepsis, a life-threatening organ dysfunction due to an abnormal response to infection, leads to multiple organ dysfunction; it is accompanied by circulatory and metabolic abnormalities associated with an increased risk for death. Septic shock is a sepsis-induced shock with hypotension (mean arterial pressure < 65 mm Hg) requiring vasopressors to maintain blood pressure, despite adequate fluid replacement, and with a serum lactate level greater than 2 mmol/L. Patients have perfusion abnormalities, including lactic acidosis, oliguria (urine output < 400 mL/day), or an acute alteration in mental status. Often septic shock is characterized by decreased organ perfusion, hypotension, and organ dysfunction. Septic shock is the major cause of death in intensive care units; the mortality rate is as high as 20% to 40% depending on the patient population. The incidence has increased during the past 50 years in the United States, probably owing to an increased number of patients who are immunocompromised, the increased use of invasive devices, and a longer life span for older adults.

While the physiology of septic shock is not completely understood, most experts note that it occurs because of a complex interaction between an infecting agent and the patient's immune system. The syndrome usually begins with the development of a local infectious process, but in septic shock, the response is not local but rather systemic. Bacteria from the local infection enter the systemic circulation and release toxins into the bloodstream. Gram-negative bacteria release endotoxins from their cell membrane as they lyse and die, whereas gram-positive bacteria release exotoxins throughout their life span. These toxins trigger the release of cytokines (proteins released by cells to signal other cells) and other mediators such as the interleukins, tumor necrosis factor, interferon, nitric oxide, complement, and platelet-activating factor. They also activate phagocytic cells such as the macrophages. The complex chemical reactions lead to multiple system effects such as disruption to the vascular endothelium, increased vascular permeability, vasodilation, and thrombosis at the organ level. Endothelial damage leads to further inflammatory responsiveness, coagulation, and further organ damage. As the syndrome progresses, blood flow becomes more sluggish, tissues become hypoxemic, and acidosis develops. Ultimately, if the infection is not reversed, the major organ systems (such as the lungs, kidneys, liver, and blood coagulation) fail, which leads to multiple organ dysfunction syndrome and death.

Causes ⬆ ⬇

Respiratory tract, abdominal, urinary tract, and soft tissue infections are the most frequent causes of sepsis. Although any microorganism may cause septic shock, it is most often associated with gram-negative bacteria such as Escherichia coli, Klebsiella pneumoniae, and Pseudomonas. Gram-positive bacteria such as Staphylococcus aureus and Streptococcus pneumoniae can also cause septic shock. A fungal infection causes septic shock in less than 3% of the cases. Lower respiratory infections cause 35% to 50% of the cases of septic shock, urinary tract infections cause 25%, and soft tissue infections cause 15% of the cases.

Common factors or conditions associated with septic shock include diabetes mellitus, chronic kidney disease, malnutrition, alcohol abuse, chronic liver disease, respiratory infections, hemorrhage, cancer, and surgery. People with traumatic injuries with either peritoneal contamination, burns, prolonged IV cannulation, abscesses, or multiple blood transfusions are at particular risk as well. People at greatest risk have an impaired immune system, advanced age, infection with a resistant organism, and poor functional status at baseline.

Genetic Considerations ⬆ ⬇

Studies of genetic epidemiology have indicated that there is a strong genetic component involved in individual responses and outcomes of sepsis. The contributions of candidate inflammatory response genes are being investigated. These include tumor necrosis factor alpha (TNF) and tumor necrosis factor beta (LTA) genes. Additional candidate genes include FOXP3, interleukin 1 receptor associated kinase 3 (IRAK3), IL6, IL10, IL12 receptor, CD14, toll-like receptor 4 (TLR4) and TLR2.

Sex and Life Span Considerations ⬆ ⬇

Septic shock occurs at all ages. Adults over 60 years of age are at high risk because of the immunocompromise associated with the aging process and make up the largest proportion of patients with septic shock. More males than females develop septic shock, and males have a slightly higher mortality rate. In neonates, the most common cause of septic shock is an immature immune system. Clinical manifestations may differ in the adult and pediatric populations. For instance, poor feeding and decreased activity levels may be early indicators of septic shock in infants. Pediatric patients may also maintain vital signs within normal limits for longer periods of time before circulatory failure occurs. Older individuals may never have an increased temperature and may remain hypothermic throughout the course of the disease.

Health Disparities and Sexual/Gender Minority Health ⬆ ⬇

Some epidemiological studies indicate that Black, Hispanic, and Native American persons have a higher prevalence of septic shock, possibly because of decreased access to healthcare and increased prevalence of multiple comorbidities. Epidemiological studies show that the highest risk for sepsis is found in Black men. Experts suggest that gender and sexual minority persons have higher levels of chronic health conditions such as asthma, diabetes, obesity, and rheumatoid arthritis than other groups. They also have higher rates of health behaviors such as tobacco use and heavy drinking. Gender and sexual minority persons are also more likely to delay testing and screening for chronic health conditions because of stigma, lack of healthcare providers' awareness, or insensitivity to the unique needs of this community (Caceres et al., 2019; Downing & Przedworski, 2018). These factors place them at risk for septic shock.

Global Health Considerations ⬆ ⬇

While septic shock occurs around the globe, there are no data on global prevalence.

Assessment ⬆ ⬇

ASSESSMENT

History

Patients with sepsis have nonspecific symptoms such as fever, chills, anxiety, confusion, dyspnea, nausea, vomiting, and fatigue. Patients may also have organ-based symptoms depending on the location of the infection, such as respiratory distress. Because of the severity of patients' condition, you may not be able to interview them for a complete history. You may obtain a great deal of information from the family and from other healthcare providers when the patient is transferred to your care. Because patients with septic shock are among the most critical of all patients treated in a hospital, they are admitted to a critical care unit for management.

Patients often have a history of either an infection or a critical event, such as a traumatic injury, recent major surgery, perforated bowel, or acute hemorrhage. Some patients may also have a longstanding IV catheter or a Foley catheter. Determine the cause for the patient's admission to the hospital and any history of a chronic disease such as cancer, diabetes mellitus, or pneumonia. Note any brief periods of decreased tissue perfusion such as hemorrhage, severe hypotension, or cardiac arrest that may demand emergency management before the development of septic shock. Take a thorough medication history, with particular attention to recent antibiotic administration, immunosuppressive medications, or total parenteral nutrition. Ask if the patient has been exposed to any treatment—such as organ transplantation, radiation therapy, or chemotherapy—that would lead to immunosuppression.

Physical Examination

Common symptoms are fever, tachycardia, fatigue, chills, confusion, agitation, and dyspnea. Three stages have been identified, but all patients do not progress with the same pattern of symptoms. In early septic shock (early hyperdynamic, compensated stage), some patients are tachycardic, with warm and flushed extremities and a normal blood pressure. As shock progresses, the diastolic blood pressure drops, the pulse pressure widens, and the peripheral pulses are bounding. The patient's temperature may be within normal limits, elevated, or below normal, and the patient may be confused or agitated. Often, the patient has a rapid respiratory rate, and peripheral edema may develop. In the second stage (late hyperdynamic, uncompensated stage), widespread organ dysfunction begins to occur. Blood pressure falls, and the patient becomes hypotensive. Increased peripheral edema becomes apparent. Respirations become more rapid and labored; you can hear rales when you auscultate the lungs; and the patient's sputum may become copious, pink, and frothy. In late septic shock, the blood pressure falls below 90 mm Hg for adults, the patient's extremities become cold, and signs of multiple organ failure (decreased urinary output, abdominal distention, absence of bowel sounds, bleeding from invasive lines, petechiae, cardiac dysrhythmias, hypoxemia, and hypercapnia) develop.

Psychosocial

As the syndrome progresses, patients may develop symptoms that change their behavior and appearance and experience situations that increase their anxiety and that of their family members. Ultimately, the family may be faced with the death of a loved one. Continuously assess the coping mechanisms and anxiety levels in both patients and families.

Diagnostic Highlights

Test	Normal Result	Abnormality With Condition	Explanation
Cultures and sensitivities	Negative for pathological bacterial flora or fungi	Positive for pathological bacterial flora or fungi	Identifies infecting organism in blood, urine, sputum, or wounds; note that in less than 50% of patients who develop septic shock, no bacterium is ever identified in cultures
Serum lactate level	0.5–2 mmol/L	>2 mmol/L	Elevated under conditions of anaerobic metabolism due to hypoxemia or decreased perfusion

Other Tests: Tests include complete blood count, serum electrolytes, creatine, blood urea nitrogen, arterial blood gases, serum glucose, liver function tests, albumin level, prothrombin, and partial thromboplastin levels. In the later stages of septic shock, as complications develop, serial chest x-rays are essential to follow the progression of conditions such as pulmonary congestion and adult respiratory distress syndrome (ARDS), abdominal ultrasound, and echocardiography.

Primary Nursing Diagnosis ⬆ ⬇

Diagnosis

DiagnosisRisk for infection as evidenced by increased or decreased temperature, chills, confusion, agitation, hypotension, fatigue, and/or dyspnea

Outcomes

OutcomesImmune status; Infection severity; Knowledge: Infection management; Risk control; Risk detection; Symptom severity; Symptom control; Fluid balance

Interventions

InterventionsInfection control; Medication management; Oxygen therapy; Respiratory monitoring; Medication administration; Fluid/Electrolyte management; Vital signs monitoring; Teaching: Disease process

Planning and Implementation ⬆ ⬇

PLANNING AND IMPLEMENTATION

Collaborative

The primary goals of treatment in septic shock are to identify and treat the infection, maintain oxygen delivery to the tissues, and restore the vascular volume, blood pressure, and cardiac output. IV fluids are administered to increase the volume within the vascular bed; crystalloids (normal saline solution or lactated Ringer's injection) are usually the fluids of choice. Vasopressors, such as dopamine, norepinephrine (Levophed), phenylephrine, or vasopressin may also be required to maintain an adequate blood pressure. The patient is also placed on broad-spectrum IV antibiotics. If the patient's hemoglobin and hematocrit are insufficient to manage oxygen delivery, the patient may need blood transfusions. A pulmonary artery catheter or central venous catheter may be inserted to monitor fluid, circulatory, and gas exchange status.

If complications such as ARDS develop, more aggressive treatment is instituted. Intubation, mechanical ventilation with low tidal volumes, and oxygenation are required for severe respiratory distress or failure. Patients often need ventilator adjuncts, such as positive end-expiratory pressure, pressure-control ventilation, or inverse inspiration-to-expiration ratio ventilation. Airway stabilization and management are essential to allow for ventilator management. An aggressive search for the source of sepsis is an essential part of the treatment. Any indwelling catheters, whether they are urinary, intravascular, intracerebral, or intra-arterial, are discontinued if possible or moved to another location. A surgical consultation may be performed to search for undrained abscesses or to débride wounds.

Total parenteral feeding or enteral feedings may be instituted for patients who are unable to consume adequate calories. Monitor the success of nutritional therapy with daily weights. During supportive care, the entire healthcare team needs to monitor the patient's condition carefully with serial cardiopulmonary assessments, including vital signs, physical assessment, and continuous hemodynamic monitoring. Patients should be attached to a pulse oximeter for continuous assessment of the arterial oxygen saturation. The patient's level of consciousness is important. In children, monitor the child's activity level and the response to parents or significant others.

Pharmacologic Highlights

Medication or Drug Class	Dosage	Description	Rationale
Vasopressors	Varies by drug	First line of care: Dopamine, norepinephrine; second line of care: dobutamine, phenylephrine, vasopressin, synthetic human angiotensin II	Maintain an adequate blood pressure
Broad-spectrum antibiotics	Varies by drug	Examples: Vancomycin, gentamicin, cefotaxime (Claforan), ceftriaxone, cefuroxime (Zinacef), piperacillin and tazobactam (Zosyn), ticarcillin and clavulanate, imipenem and cilastatin (Primaxin), clindamycin, meropenem (Merrem), metronidazole (Flagyl), ciprofloxacin (Cipro), levofloxacin, cefepime	Eradicate bacteria

Other Drugs: Administration of corticosteroid in septic shock remains controversial but is often performed if hypotension is poorly responsive to fluid resuscitation and vasopressor therapy; generally corticosteroids need to be started within 8 hours of onset of severe septic shock.

Independent

Priorities of nursing care for the patient with septic shock include maintaining airway, breathing, and circulation; preventing the spread of infection; increasing the patient's comfort; preventing injury; and supporting the patient and family. Monitor the patient continuously for airway compromise, and prepare for intubation when necessary. Maintain strict aseptic technique when you manipulate invasive lines and tubes. Use universal precautions at all times. Unless the patient is endotracheally intubated, place patients with a decreased level of consciousness in a side-lying position, and turn them every 2 hours to protect them from aspiration. To increase the intubated patient's comfort, provide oral care at least every 2 hours.

Maintain skin integrity by placing the patient on an every-2-hour turning schedule. Post the schedule at the head of the bed to increase the visibility of the routine. Implement active and passive range of motion as appropriate to the patient's condition. Provide the family with information about diagnosis, prognosis, and treatment. Expect the patient and family to have high levels of anxiety and fear given the grave nature of septic shock. Support effective coping strategies and provide adequate time for the expression of feelings.

Evidence-Based Practice and Health Policy

Chinai, B., Gaughan, J., & Schorr, C. (2020). Implementation of the Affordable Care Act: A comparison of outcomes in patients with severe sepsis and septic shock using the National Inpatient Sample. Critical Care Medicine, 48, 783–789.

The authors note that sepsis is the most common and costly diagnosis in U.S. hospitals and yet accounts for more than 50% of hospital deaths. The aim of the study was to evaluate changes in insurance coverage and outcomes in patients with severe sepsis and septic shock as a result of the Affordable Care Act. They used a national data set and examined patients ages 18 to 64 years (N = 361,323) before the Affordable Care Act and after it was implemented.
They found that there was a 5% increase in Medicaid coverage and a 2% decrease in the uninsured in patients with severe sepsis and septic shock. Overall in-hospital mortality decreased from 23% to 19%, and patients with Medicaid had the greatest reduction in mortality. The authors concluded that there was an increase in insured patients post Affordable Care Act initiation, and the improvement in outcomes was likely because of advances in management, earlier presentation, earlier treatment, and patients being less severely ill.

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DRG Information ⬇

Introduction ⬆ ⬇