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Septic Shock

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  Septic Shock: Case analysis:    A 68-year-old man presents to the emergency department with severe acute abdominal pain located in his left lower quadrant for the last 2 days. He has had a fever to 101 F, diarrhea 4 days ago, and now constipation for the last day. He has not vomited, but he has been nauseated and has been unable to take solid food or liquids. He has made little urine in the last day. He reports a history of hypertension controlled with medication. He is unable to give a more complete history because of increasing confusion. His vital signs reveal an elevated temperature to 101.5 F, a pulse of 128, a respiratory rate of 32, and a blood pressure of 74/38 mm Hg. His examination demonstrates an acutely ill appearing man in pain and respiratory distress. He is mildly confused but without focal neurologic findings. He is tachypneic with rapid shallow respiratory efforts but clear lungs. His oxygen saturation is 90% on 60% face mask. His cardiac examination is normal save for his depressed blood pressure and elevated heart rate. His abdominal examination reveals a distended abdomen that is rigid and painful to palpation both generally and especially in the left lower quadrant where there is a suggestion of fullness. His stool is guaiac negative. His extremities are cool with pulses not palpable. Definition:    Shock associated with sepsis; characterized by symptoms of sepsis plus hypotension and hypoperfusion despite adequate fluid volume replacement. Cause:    Infection    Bacteriacemia    Immunusuppresion    Chronic disease Pathophysiology: Stages of septic shock: 1.   Early stage:    BP remains w/n normal limits.    Responsive to fluids but hypotensive    Tachycardia    Hyperthermia    Flushed skin and bounding pulse    Tachypnea    Output is normal    GI status compromised    Hypermetabolism    Inflammatory markers are elevated Microorganism invades tissue Immune response Chemical mediators activates inflammatory response Cascade of physiologic events leads to poor tissue perfusion Inc. capillary permeability Vasodilatation Interruption of ability of body to give essential substances (perfusion, oxygen and nutrients Imbalance of inflammatory response and formation of clots Stages of septic shock    2.   Progressive stage:    Acidotic    Compensation fail    Cardiovascular fail    BP don’t respond to fluids      Temperature elevated    Signs of organ damage 3.   Late stage:    BP drops    Skins become pale and cool    Temperature normalize    Tachycardia and tachypnea    Urine prods. Cease    MOD Diagnostic Test:    CBC    Coagulation test    Urinalysis    Renal and hepatic function test    X-ray Management:    FLUID REPLACEMENT THERAPY Reestablishing tissue perfusion through aggressive fluid resuscitation is the key to management of severe sepsis and septic shock.    PHARMACOLOGIC THERAPY  -broad-spectrum antibiotic agents(Dellinger, et al., 2008; Smith and McInnis, 2007) -administration of recombinant human activated protein C (rhAPC; drotrecogin alfa (Xigris) to patients with end-organ dysfunction and high risk of death (Dellinger et al., 2008)   NUTRITIONAL THERAPY    Nutritional supplementation should be initiated within the first 24 hours after ICU admission (Stapleton, et al., 2007)    Enteral feedings are preferred to the parenteral route because of the increased risk of iatrogenic infection associated with IV catheters. NURSING MANAGEMENT      1. All invasive procedures must be carried out with aseptic technique after careful hand hygiene.    2. Nurses needs to identify patients who are at particular risk for sepsis and septic shock.    3. Nurse collaborates with the health care team to identify the site and source of sepsis and the specific organisms involved. Often obtains culture and sensitivity.    4. Nurse administers prescribed IV fluids and medications including antibiotic agents and vasoactive medications, to restore vascular volume. HYPOVOLEMIC SHOCK Case analysis:    A 42 year old female is transferred from another hospital for chemotherapy. Two days prior to transfer the patient had undergone a laparotomy for a hysterectomy. The procedure was abandoned when the surgeon realized that there was an inoperable tumor present in the pelvis, and there was a considerable amount of blood loss, which continued into the post-operative period. Hours after transfer the patient becomes initially hypoxemic and subsequently hypotensive. Her temperature is 37 degrees Celsius, her heart rate is 140, blood pressure is 80/36, ECG shows a sinus tachycardia, SpO2 is 79%. The patient’s hemoglobin is 10.2g/l.  DEFINITION    syndrome characterized by decreased circulating blood volume (hypovolemia), which results in reduction of effective tissue perfusion pressure and generalized cellular dysfunctions. Forms:      Hemorrhagic shock    Non-hemorrhagic hypovolemic shock CAUSES:    Hemorrhagic:    External blood loss (wounds)    Exteriorization of internal bleeding (hematemesis, melena, epistaxis, hemoptysis,etc.)    Internal bleeding (hemothorax, hemoperitoneum,etc. )    Traumatic shock    Non-hemorrahagic:    Digestive losses (vomiting, diarrhea, nasogastric suction, billiary, digestive fistula, etc )    Renal losses (diabetes mellitus, polyuria caused by diuretics overdose, osmotic substances, polyuric phase of acute renal failure, etc.)    Skin losses (intense physical effort, overheated enviroment, burns, etc.)    Third space losses (peritonites, intestinal oclussion, pancreatits, ascitis pleural effusions, etc.) Pathophysiology Management:    Keep the person comfortable and warm to avoid hypothermia    Have the person lay flat with feet raised to about 12 inches to increase circulation. However, if the patient has a head, back, neck, or leg injury, do not change the person’s position unless he or she is in immediate danger    Do not give fluids by mouth    Replace blood and fluids through IV lines    Medicines such as dopamine, dobutamine, epinephrine, and norepinephrine may be needed to increase blood pressure and the amount of blood pumped out of the heart (cardiac output)    If the patient is not awake, not breathing, and has no heartbeat, it is appropriate to start chest compressions.    Any underlying cause of hypovolemia, such as injury, must also be treated to prevent ongoing fluid losses.    CLASSIFICATION OF HYPOVOLEMIC SHOCK: Class I Class II Class III Class IV Blood loss- ml < 750ml 750-1500ml 1500-2000ml >2000ml Blood loss-% <15% 15-30% 30-40% >40% Pulse rate <100/min < 100/min 120-140/min >140/min BP N N      Pulse wave amplitude N         Capillary refill N + + + Respiratory rate 14-20/min 20-30/min 30-40/min >40/min Urinary output > 30ml/oră  Oliguria Oligoanuria Anuria Mental status Mild anxiety Anxiety Confused Lethargy References: - Ignatavicius, D. D., Workman, M. L. (2010) “Patient Centered Collaborative Care Approach to: Medical - Surgical Nursing” 6 th  Edition Elsevier (Singapore) Pte Ltd.  Vol. 1 Pg.828-841 - Brunner and Suddarth 6 th  edition medical and surgical nursing
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