1. SHOCK/SEPSIS NUR 351/352 Diane E. White RN MS CCRN PhD (c)

2. Shock  Syndrome characterized by inadequate tissue perfusion  Classifications: Hypovelmic Shock: inadequate volume Cardiogenic Shock: ineffective pump Obstructive Shock: compression Distributive Shock: neurogenic, anaphylactic, & septic

3. Stages of Shock  Initial Stage: CO SNS  Early or Compensatory Stage  Progressive Stage: systemic vasoconstriction, shunting of blood, cellular blood flow, hypoxia which leads to anaerobic metabolism causing acidosis. Microcirculation dilates to maintain blood flow however capillary pressure pushing fluid from capillaries to interstitial spaces causing edema and capillary permeability forcing less venous return and CO

4. Stages of Shock  Refractory or Irreversible Shock:  Multiple organ dysfunction & death  Increased blood pooling  Decreased blood flow to all organs

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

6. Definitions  Sepsis = SIRS + Infection  Severe Sepsis = Sepsis + Multi organ dysfunction  Septic Shock = severe sepsis + refractory hypotension

7. Pathophysiology  Inflammatory response initiated by insult  Damage prevented by antioxidants  When inflammatory response becomes overwhelmed tissue damage results  Massive systemic reaction  Leads to multiple organ dysfunction

8. Pathophysiology  Disruption of endothelial layer: capillary permeability, venodilation, hypovlemia  Coagulation activated: tissue factor released and production of Thrombin  Fibrinolysis suppressed: caused by protein C  Activation of CNS, Endocrine systems  Defect in peripheral extraction of Oxygen

9. Clinical Manifestations  CNS – early sign  Cardiac - HR, CO/CI, BP, SVR, CVP, PCWP, LVSV  Respiratory - RR early, crackles, pO2, pCO2 early, and HCO3  Renal - UO, Creatinine  Hepatic – jaundice, LFT’s  Skin – pink, warm, flushed, Temp

10. Treatment  GOAL – recover function at the microcirculatory level!!!  Fluid Therapy  Vasopressor Therapy  Mechanical Ventilation  Tight Glycemic Control  Treat & Prevent Infection  Gluccocorticoid Steroids & Xigris

11. Nursing Care  Early Recognition!!!  Reduce Exposure  Administration of Antibiotics, Fluids, and Pressors  Correct fluid volume deficit  Increase CO  Adequate nutrition  Improve gas exchange