23.3 Septic Shock

Clinical Manifestations

Clinical manifestations vary from insidious to overt presentation based on the individual response of the body and the stage of sepsis. Eventually, all organ systems are affected.

At the onset of septic shock, common manifestations include changes in mental status, high respiratory rate, tachycardia, and hypo- or hyperthermia. Common causes of sepsis are urinary or respiratory infections. If the source of the infection is the urinary system, the patient may complain of low energy levels or urinary retention with a continual urge to void. If the source of the infection is respiratory, the patient may complain of shortness of breath or present with a cough.

As sepsis progresses and brain cells experience decreased perfusion, the patient’s mental status may progress from confusion and agitation all the way to coma. The patient may experience shortness of breath as the fluid shifts into the alveolar space, and renal hypoperfusion may cause a decrease in urinary output. Loss of vascular tone and other components of the infectious process result in variations in skin and body temperature. The patient may exhibit core temperature elevations as the infection progresses and an even greater increase in core temperature as the global inflammatory response ensues. Along with fever, the patient may experience shaking and chills. The skin may be warm and clammy or sweaty with cool, pale limbs.

The terms “warm shock” and “cold shock” are sometimes used to describe where the patient is in the progression of sepsis. In the early stages, usually within the first six to seventy-two hours of sepsis, the patient is often warm as the body responds to the inflammatory process. In this state of warm shock, cardiac output is increased, and systemic vascular resistance (SVR) is decreased.

The dynamic precordium causes the patient to develop tachycardia, bounding peripheral pulses, and skin that is warm to the touch, with decreased capillary refill time. As the shock progresses, the patient deteriorates to the development of cold shock, which is a hypodynamic response of the body. At this point, cardiac output is decreased and SVR is increased. Skin may have purplish discoloration from poor perfusion to the cutaneous tissue. This change, called mottled skin, is a finding associated with septic shock. Some patients exhibit a “septic skin rash,” or clusters of tiny blood spots that look like pinpricks of the skin.

Diagnostics and Laboratory Values

A blood culture is the definitive test for sepsis. It usually takes one to three days to get the results. Consequently, some organizations incorporate the early use of a rapid sepsis screen, but the rapid results are not definitive. Most patients are treated with a broad-spectrum antibiotic if sepsis is suspected. Along with blood cultures, urine, sputum, or wound cultures are obtained to help determine the presence of infection. In some institutions, indwelling catheters such as vascular access devices and Foley catheters are removed and their tops are sent for culture and sensitivity.

Sputum culture helps providers evaluate the respiratory system. Other tools for this purpose include pulse oximetry, imaging studies of the lungs to diagnose pneumonia or other pulmonary infections, and arterial blood gas analysis to analyze the diffusion capacity of the lungs. Strep throat rapid antigen and throat culture as well as rapid influenza diagnostic tests may also be obtained.

A computerized tomography (CT) scan or magnetic resonance imaging (MRI) of the brain may be obtained if meningitis is suspected. Lumbar puncture, also called a spinal tap, may be performed to obtain cerebral spinal fluid (CSF). The provider may order a culture and sensitivity on the collected CSF to definitively diagnose meningitis.

Another test for sepsis is the presence of endotoxins. Under normal conditions, there should be no evidence of endotoxins in the blood. If gram-negative bacteria are present in the bloodstream, then endotoxins are released when the cell disintegrates. Testing for the presence of endotoxins is not a replacement for blood cultures, but it may assist in directing the immediate treatment of the patient.

Procalcitonin (PCY) levels are drawn for the patient with suspected sepsis. This substance is undetectable in patients without infection. Procalcitonin rises rapidly in response to proinflammatory stimuli, especially infection. It will not determine what type of bacteria is present, however. Another test, C-reactive protein (CRP), is sometimes obtained to assist in the diagnosis of sepsis. CRP is elevated with inflammation, which is very high in sepsis.

A complete blood count (CBC) is obtained to determine the baseline status of the patient as well as to plan and evaluate treatment. White blood cell (WBC) (leukocyte) results should be reviewed. A WBC count of 45,000 to 11,000 per microliter is considered normal. A count below 4,000 or greater than 12,000 per microliter is cause for concern. High leukocytes indicate the presence of infection, while low leukocytes indicate risk for infection.

Lactate levels are drawn to assess cellular perfusion. An elevation of lactate is indicative of cellular hypoxia. A lactate of less than 2 mmol/L is considered acceptable; however, a lactate level of greater than 4.0 mmol/L is associated with high mortality. Aggressive volume resuscitation is recommended for lactate levels of 4.0 mol/L (Lat et al., 2021).

Patients with septic shock often develop clotting abnormalities and disseminated intravascular coagulation (DIC). Homeostasis is evaluated through analysis of prothrombin time (PT), partial thromboplastin time (PTT), and platelet count. High PT and PTT times indicate impaired clotting ability of the blood. Low platelet counts may be the result of platelet aggregation and the presence of microclots throughout the vascular system. D-dimer may be used as a marker of microcirculatory failure. It is the most-used fibrinogen-related marker for DIC diagnosis. Almost all patients admitted with sepsis have elevated D-dimer levels related to organ dysfunction and outcome.

Diagnostic tests for sepsis are summarized in Table 23.8.

Recognizing Cues and Analyzing Cues

Any patient who suddenly develops hypotension, unresponsiveness, anuria, or fever is suspected of having sepsis. A sudden change in the level of consciousness is often an early manifestation of bladder infection, especially in older adults. An increase in respiratory rate is also associated with sepsis. As the body attempts to compensate for the buildup of lactic acid and metabolic acidosis, the respiratory rate increases to rid the body of carbon dioxide. As the patient decompensates, the respiratory rate will drop.

Early in the development of sepsis, blood pressure is slightly elevated from sympathetic nervous stimulation. As the shock progresses, blood pressure significantly drops. MAP is the best indicator of cell perfusion: a MAP > 65 mmHg indicates adequate blood pressure to help push life-sustaining nutrients into the cells and tissues.

When caring for patients with sepsis, nurses should also be aware of these cues:

• Hourly urine output of at least 30 mL per hour indicates adequate kidney perfusion. A drop in urine output to less than 30 mL/hour indicates poor renal perfusion.
• Lactate levels greater than 4 mmol/L indicate the need for volume resuscitation.
• Worsening manifestations of dehydration, such as decreased skin turgor and dry mucous membranes, indicate the need for fluid resuscitation.
• Assessment findings of weak to absent extremity pulses, change of skin temperature, and increased capillary refill time indicate hypoperfusion and the need for volume resuscitation.

It is imperative to recognize these cues of sepsis to prevent progression and serious complications such as respiratory failure, heart failure, kidney failure or injury, malfunction of the hematologic system, gangrene of fingers or toes, amputation of extremities, brain damage, and, ultimately, death. In the refractory stage of shock, the nurse is often present for discussions with the family to withdraw care because 30 percent of patients with severe sepsis do not survive.

Prioritizing Hypotheses, Generating Solutions, and Taking Action

Quality nursing care featuring attention to detail, close monitoring, and surveillance with prompt interventions can reduce morbidity and mortality. Any changes in the patient’s status, including trends suggesting progression of the septic state, should be immediately reported for appropriate adjustment in treatment. Indications that the patient is deteriorating include an increase in respiratory rate, an elevated temperature with a quick drop, and a fast heart rate with hypotension.

Identifying and eradicating the infecting organism is essential to reversing the septic shock state. Immediate and timely administration of a first dose of broad-spectrum antibiotics is critical to the patient’s prognosis. Culture and sensitivity are obtained prior to the administration of broad-spectrum antibiotics. When results are available, the antibiotic is often changed based on the identified organism. Some patients require surgical incisions and drainage of the infectious area.

When caring for the patient in sepsis, it is essential to stabilize the patient’s hemodynamic status. Patients with sepsis may require massive volume resuscitation—usually between 6–10 L in the first twenty-four hours of treatment. Due to the massive input of fluid volume, an indwelling Foley catheter is often used to allow for accurate measurement of intake and output. Fluids are first administered to fill the vascular space, followed by a type of drug called a vasopressor, which supplies tone to the vascular system by inducing vasoconstriction and increasing blood pressure. The nurse must assess for complications of volume resuscitation such as pulmonary edema.

Patients with sepsis are at risk for developing complications to multiple organ systems; for example, poor perfusion to the lungs may cause the patient to develop ARDS. The ensuing respiratory failure may require the use of endotracheal intubation and mechanical ventilation to support the respiratory system.

There is an increase in metabolic response during the acute stage of sepsis, increasing the caloric needs of patients. Enteral nutrition may improve clinical outcomes, decrease the length of hospital stays, and reduce mortality in patients with sepsis. These feedings should be rich in protein and essential amino acids. Stress ulcer prophylaxis is also recommended.

Optimal outcomes for sepsis are influenced by regulated glycemic control. Sepsis can be associated with hyperglycemia, which can hinder the body’s healing response. Hypoglycemia can also lead to a much higher mortality risk. Regulated glycemic control has been found to decrease morbidity and mortality in patients with sepsis. To stabilize and normalize serum glucose, the patient’s blood glucose level should be monitored frequently and treated according to agency policy. A blood glucose level between 110 and 150 mg/dL has been associated with positive patient outcomes. Careful observation and assessment of the patient is vital, as patients with sepsis often experience variable glucose levels and insulin requirements, increasing the frequency of hypo and hyperglycemia.

Nurses should maintain urinary catheterization, calculating intake and output. Assessment of hourly urinary output is reflective of the patient’s response to treatment and the status of renal perfusion. Hourly urinary output of less than 30 mL/hour should be reported to the health-care team; this reflects poor perfusion of the kidneys, which may lead to kidney failure.

Figure 23.8 illustrates equipment used to treat a patient with sepsis.

Figure 23.8 The treatment of sepsis often requires care for the patient in a critical care unit. (credit: modification of work from Fundamentals of Nursing. attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Evaluating Outcomes

Evaluation of outcomes includes determining the effectiveness of the current plan of care. Consistent monitoring of blood pressure and urinary output are key indicators of shock and recovery. Evaluation of lactate levels and electrolytes helps in determining the patient’s recovery progress or continual decline. As the nurse continues to evaluate interventions, changes to the nursing care plan can be made as needed.