Sepsis and Septic Shock Overview

Sepsis/Septic Shock: Epidemiology

• Incidence of sepsis in the US: ~1.7 million adults annually; ~270,000 deaths annually
• Increasing incidence attributed to factors like:
  • Increased invasive procedures and monitoring
  • Growing aging population
  • Rise in chemotherapy/immunosuppressive use
  • Growing antimicrobial resistance
• Mortality is decreasing due to improved treatment
• Gram-positive infections more common but gram-negative still substantial
• Fungal infections increasing but still less frequent than bacterial infections

Sepsis/Septic Shock: Definitions and Pathophysiology

• Sepsis 3 definition: life-threatening organ dysfunction caused by a deregulated host response to infection.
• Septic shock: circulatory and metabolic abnormalities, substantially increasing mortality.
• Potential complications: DIC (disseminated intravascular coagulopathy), MODS (multiple organ dysfunction syndrome)
• Pathophysiology: initial immune response activation (innate immunity)
  • Mobilization of macrophages & neutrophils
  • Pro-inflammatory cytokine activation
  • Complement activation
  • Coagulation activation (fibrin mesh for localization)
• Sepsis results from an amplified and uncontrolled systemic inflammatory response
• Normal deactivation process impaired, leading to excessive pro-inflammatory cytokines
• Inflammatory damage to blood vessels, vasodilation, and increased permeability
• Contributing factors: endotoxins and exotoxins from invading organisms (gram-negative & gram-positive)
• Coagulation cascade dysfunction: significant fibrin deposition, impaired fibrinolysis (breakdown of clots), decreased protein C and antithrombin III levels
• Microvascular clots, reduced blood flow and organ dysfunction

Sepsis/Septic Shock: Clinical Manifestations

• Early (hyperdynamic/warm): tachycardia, bounding pulses, warm flushed skin, fever, potentially normal blood pressure (compensatory response).
• Early signs of decreased organ perfusion (confusion, decreased urine output).
• Increased cardiac output (as long as adequate fluid resuscitation).
• Low filling pressures (CVP, PAOP).
• Systemic vascular resistance (SVR) is low due to vasodilation.
• Late (hypodynamic/cold): cool, pale skin, weak/thready pulses, hypothermia, persistent tachycardia,
• Low blood pressure.
• Severe end-organ hypoperfusion (lethargy/coma, anuria).
• Decreased cardiac output.
• Variable filling pressures (dependent on fluid resuscitation).
• SVR may remain low or increase with compensation & drug therapy.
• Low venous oxygen levels (reflecting inadequate tissue oxygen delivery)

Sepsis/Septic Shock: Interprofessional Management

• Surviving Sepsis campaign: standardized care to reduce sepsis mortality.
• Diagnosis: general indicators of infection (fever, WBC count changes in BP/RR/HR), specific infection signs, lab tests (CBC, metabolic panels, cultures), imaging (radiographs, CT, MRI)
• Severity assessment: NEWS, MEWS, SOFA scores
• ICU admission within 6 hours for those needing it

Sepsis/Septic Shock: Medical Management

• Prevention first: hand hygiene, aseptic technique, and minimizing invasive procedures.
• Bundle of care (1 hour): fluid resuscitation, blood work (lactate, blood cultures), antibiotics (after cultures)
• Fluid resuscitation: balanced crystalloid solution, 30 mL/kg over 3 hours
• Vasopressors: norepinephrine as first line if fluids are insufficient
• Antibiotics: within 1 hour of diagnosis, guided by cultures
• Corticosteroids: low-dose only in non-responsive patients to fluid & vasopressors

Sepsis/Septic Shock: Ongoing Monitoring

• Frequent vital signs, peripheral perfusion, and mental status checks.
• Cultures and blood testing (WBC, lactate).
• Hemodynamic monitoring (CVP/PAOP, SvO2/ScvO2); PA catheter use is not standard.
• Cardiac response evaluation (echocardiography after passive leg raise) .
• Capillary refill time monitoring

Sepsis/Septic Shock: Withdrawal of Life Support

• Patient/family discussion fundamental for withdrawal decisions.
• Using “withdrawal of support” instead of “withdrawal of care” to reduce anxiety.
• DNR order.
• Gradual or immediate discontinuation of ventilation, with comfort measures.
• Pain and sedation management driven by patient response, not a schedule
• Discontinuing non-comfort interventions

Sepsis/Septic Shock: Complication - Stress Ulcers

• Common in ICU patients, risk factors include: Mechanical ventilation, coagulopathy, shock, sepsis, major trauma, and head injury.
• Prophylaxis: enteral PPIs or H2 blockers, IV options for those unable to take enteral drugs

Sepsis/Septic Shock: Complication - Disseminated Intravascular Coagulopathy (DIC)

• Enhanced coagulation from procoagulant release during the inflammatory response of sepsis.
• Two phases: thrombotic (clotting) and bleeding, often occurring simultaneously.
• Thrombotic phase leads to microvascular clots, ischemia, and necrosis.
• Bleeding phase caused by impaired fibrinolysis and excessive fibrin degradation products.
• Diagnosis through clinical symptoms and lab tests (decreased fibrinogen, increased fibrin degradation products, D-dimer, decreased platelets, prolonged PT/aPTT, decreased antithrombin III)
• Management: focus on treating underlying sepsis, hypotentions, hypoxemia, and metabolic acidosis. Fluid support, blood products, and clotting factors may be required.

Sepsis/Septic Shock: Complication - Multiple Organ Dysfunction Syndrome (MODS)

• Multifaceted cause:
  • Accelerated apoptosis (programmed cell death)
  • Widespread vascular endothelium damage
  • Microvascular dysfunction
  • Enhanced coagulation
  • Hypermetabolism
  • Mitochondrial toxicity
• Progression typically starts in lungs, then renal, hepatic, and GI systems.
• High mortality rates, especially when 3+ organ systems are affected.

Sepsis/Septic Shock: Nursing Management

• Assessment: neurological status, vital signs, hemodynamic readings, urine output, skin, bleeding.
• Nursing Diagnoses: altered tissue perfusion, excessive clotting, bleeding.
• Interventions: hand hygiene, oxygen, fluid replacement, monitoring lactate, labs (cultures, ABGs, coagulation studies).
• Administer antibiotics after cultures.
• Vasopressors for inadequate blood pressure
• Oral care, nutrition, supportive care, turning to prevent complications.
• Teaching: sepsis prevention, importance of hand hygiene, patient comfort

Sepsis/Septic Shock: Evaluating Outcomes

• Early recognition & swift treatment (antibiotics, fluids)
• Maintaining cardiac output
• Monitor hemodynamics, frequent labs
• Supportive care to prevent complications.
• Evaluating response in blood pressure, cardiac output, and tissue perfusion.

Sepsis/Septic Shock: Delirium Management (Box 14.1)

• Delirium: altered consciousness, impaired focus and memory.
• Common in ICU
• Management: -Orientation aids -Cognitive stimulation -Sleep-wake cycle support -Minimize restraints -Avoid problematic medications (benzodiazepines, opiates, antihistamines)

This quiz covers the epidemiology, definitions, and pathophysiology associated with sepsis and septic shock. Learn about the increasing incidence, contributing factors, and the latest definitions from Sepsis 3. Additionally, explore complications and the immune response mechanisms involved in these critical conditions.