Septic Shock Nursing Guide

Septic Shock Definition 

Infections that cause sepsis can be viral, bacterial, fungal, and also protozoal (Mahapatra & Heffner, 2021). Sepsis can lead to septic shock, which causes organ damage and carries a high risk of mortality if left untreated. 

Once an individual is exposed to a pathogen, the immune system responds by releasing mediators that increase inflammation and coagulation, impair fibrinolysis function, and cause endothelial damage. The increase in inflammation and impairment of fibrinolysis causes altered perfusion, thus forming microthrombi. Endothelial damage causes capillary leaks leading to edema. In addition, a systemic hormonal response to an infection causes the release of specific hormones. The release of catecholamines, glucagon, cortisol, and growth hormone play a critical role in an individual's hemodynamic status. These hormones in the setting of sepsis can cause severe hemodynamic instability. Unfortunately, the immune system may have difficulty fighting off the pathogen for various reasons, ultimately leading to organ damage and increased mortality. 

The rate of sepsis continues to rise, making it one of the most expensive healthcare conditions to treat. New and recent research has reported a decrease in the sepsis mortality rate from 16.5 to 13.8% (Mahapatra & Heffner, 2021). From 2000 to 2008, there have been over 1,000,000 hospitalizations per year due to sepsis (Mahapatra & Heffner, 2021). Furthermore, septic shock, a subset of sepsis, continues to be the top cause of death for hospitalized individuals. Septic shock is a life-threatening emergency, and timely interventions are essential to improve mortality. Specific factors that put individuals at a higher risk for sepsis include: 

• Extended hospitalization 
• Chronic kidney disease (CKD) 
• Major surgery 
• Diabetes 
• Indwelling lines (i.e., catheters, central lines) 
• Burns 
• Immunosuppression 

Septic Shock ICD-10 Code: R65.21

• Severe sepsis with septic shock.

Septic Shock Diagnosis 

According to the Third International Consensus Definitions for Sepsis and Septic Shock, an individual has septic shock when the following criteria are BOTH met (Singer et al., 2016): 

• Need for a vasopressor to maintain a mean arterial pressure of 65 mm Hg or greater AND 
• Serum lactate level greater than 2 mmol/L (>18 mg/dL) even with adequate fluid volume resuscitation. 

Currently, there is no single biomarker for the diagnosis of sepsis. Individuals presenting with signs and symptoms concerning sepsis will initially receive various testing outlined by the  

Surviving Sepsis Campaign. Individuals can present with an array of abnormal lab values, including (Evans et al., 2021): 

• Glucose 
  • Glucose ≥ 120 mg/dL 
• Complete blood count (CBC) 
  • WBC ≥ 12,000/mm3 
  • WBC ≤ 4000/mm3 
  • Platelets ≤ 100,000/mL 
• C-reactive protein and/or procalcitonin 
  • Elevated 
• Mixed venous saturation (SVO2) 
  • ≥ 70% 
• Arterial blood gas (ABG) 
  • Partial pressure oxygen (PaO2): Fraction of inspired oxygen (FiO2) ≤ 300 mmHg 
  • Lactic acidosis (≥ 2 mmol/L) 
• Complete metabolic profile (CMP) 
  • Abnormal electrolytes 
  • Abnormal creatinine 
  • Bilirubin ≥ 4 mg/dL 
  • Elevated liver function tests (LFTs) 
• Coagulopathy 
  • International normalized ratio (INR) ≥ 1.5 
  • Partial thromboplastin time (PTT) ≥ 60 seconds 
• Chest-X-ray 
  • May be normal or can show signs of infiltrates 
• Urinalysis 
  • Can show bacteremia 
• Culture and sensitivity 
  • Blood, wounds, sputum, and other potential sources of infection 
• Serum lactate 
  • Elevated 

Septic Shock Treatment & Management 

Treating sepsis requires multiple interventions. Current recommendations cannot replace a provider's decision-making but can guide decisions based on best practice guidelines (Evans et al., 2021). However, the Surviving Sepsis Guidelines (2021) recommend that the following treatment and resuscitation begin immediately: 

• Antibiotic and/or fungal therapy 
  • Empirical broad-spectrum antibiotic and/or fungal therapy should be initiated within 1 hour of symptom recognition and specific antibiotic therapy when the infection source is identified. 
  • If there is a high suspicion of fungal infection, empiric antifungal therapy should be started. 
  • Currently, there is no specific recommendation on starting antiviral medications. 
• Resuscitation 
  • Administer intravenous (IV) crystalloid fluid at 30 mL/kg bolus within 3 hours of symptom onset. The individual’s volume status should guide the administration of additional fluids. 
  • Assessing fluid status through dynamic measures (i.e., stroke volume [SV], stroke volume variation [SVV], pulse pressure variation [PPV], and/or echocardiogram) is preferred over a physical examination. 
  • In individuals who receive large boluses of crystalloids, it is recommended to use albumin IV. 
• Maintain hemodynamic status 
  • Achieve a mean arterial pressure (MAP) of ≥ 65 mmHg. 
  • Administer vasopressors, initially norepinephrine (Levophed®), if fluid administration fails to restore adequate blood pressure (BP). 
  • If norepinephrine is not successful (i.e., MAPs ≤ 65 mmHg), adding vasopressin (Vasostrict®) instead of increasing norepinephrine is recommended. 
  • Individuals with cardiac abnormalities that are not responding to fluid resuscitation should be started on norepinephrine and an inotrope instead of vasopressin. 
• Maintain glucose levels 
  • Glucose levels may be managed by using insulin. Goals include glucose ≤ 180 mg/dL and no less than 90 mg/dL. 
• Line insertion 
  • Some individuals may require a central line if issues arise with inserting or maintaining peripheral access. Starting pressors via peripheral IV is recommended until a central line is placed. 
  • An arterial line may be placed for monitoring MAPs. 

Nursing Considerations 

Assessment 

Nurses should be vigilant and routinely assess those at risk for sepsis to catch it early and notify the provider so the individual can be treated immediately. An individual with sepsis will have symptoms from multiple organ groups. Typical symptoms can include (Mahapatra & Heffner, 2021): 

• Cardiovascular 
  • Hypotension, tachycardia, dysrhythmias, and fevers 
• Respiratory 
  • Tachypnea and hypoxemia 
• Renal 
  • Oliguria and elevated creatinine 
• Gastrointestinal 
  • Change in bowel sounds 
• Neurological 
  • Change in mental statuses such as confusion, lethargy, and agitation 

Nursing Diagnosis/Risk For 

• Hemodynamic instability 
• Risk for impaired fluid status 
• Risk for impaired gas exchange 
• Risk for hyperthermia 

Interventions 

Hemodynamic stability 

• Monitor vital signs 
  • Place ice packs on the groin, axilla, and neck for hyperthermia. 
• Optimize airway 
  • Titrate high flow nasal oxygen per order. 
  • If the individual is intubated, perform oral care, suction, and manage mechanical ventilator per the organization's protocol. 
• Monitor intake and output 
  • Ensure urine output is ≥ 30 mL/hour. 
  • Insert an indwelling foley if indicated. 

Medication administration 

• Administer antibiotics, antipyretics, and analgesics, as ordered and as needed. 
• Administer IV fluid therapy. 
• Administer fluids, vasopressors, and/or inotropes. 
• Titrate vasopressors and/or inotropes to maintain MAP goal of ≥ 65 mmHg. 

Expected Outcomes 

Septic shock is a life-threatening illness, and despite advanced treatment options, it still has a high mortality rate which can exceed 40% (Mahapatra, Heffner, 2021). Mortality rates rely on multiple factors such as the type of infection and antibiotic therapy and the extent of organ damage. Individuals who require inotropes, pressors, and impaired respiratory compromise have a higher predicted mortality rate. The expected outcomes of septic shock include: 

• Maintain adequate perfusion through the use of inotrope, pressors, and fluids. 
• Maintain thermoregulation. 
• Identify the cause of the organism and implement appropriate antibiotic therapy. 

Patient/Caregiver Education 

• Educate on infection prevention strategies (i.e., hand washing, staying up to date on vaccinations). 
• Continue the antibiotic and/or fungal regimen as prescribed. 
• Educate on signs and symptoms of sepsis 
• If possible, discuss home health options for rehab. 

Content Release Date 

4/1/2022

Content Expiration

12/31/2028

Course Contributor 

The content for this course was created by Zeliha Ozen, MSN, RN, CCRN, CNL. 

Zeliha has extensive experience in critical care nursing in acute care hospitals, including cardiac intensive care and medical intensive care units. She has served in various roles, such as lung transplant coordinator, educator, preceptor, charge nurse, and code nurse. Additionally, Zeliha has worked on many quality initiatives for the ICU, such as infection control, cardiac education, and nursing onboarding. She earned a Bachelor of Science in nursing from Saint John University in Rochester, NY. She has a Master of Science in nursing and a master’s in clinical nurse leadership (CNL) from Queens University in Charlotte, NC. She is also a certified critical care nurse (CCRN). 

Resources 

• Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021 https://doi.org/10.1007/s00134-021-06506-y 

References 

• Evans, L., Rhodes, A., Alhazzani, W., Antonelli, M., Coopersmith, C. M., French, C…Machado, 
• F. R. (2021). Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive care medicine, 47(11), 1181–1247. https://doi.org/10.1007/s00134- 021-06506-y 
• Mahapatra, S., Heffner, AC. (2021). Septic Shock. Stat Pearls Publishing https://www.ncbi.nlm.nih.gov/books/NBK430939/ 
• Singer, M., Deutschman, C.S., Seymour, CW. (2016). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 315(8):801–810. http://doi:10.1001/jama.2016.0287