 Hi, welcome to Nursing School Explained and this video on sepsis and septic shock. So first of all, let's look into this here. Sepsis usually occurs from a local infection that can occur anywhere in the body that spreads into the bloodstream. And I written down here, those can be gram-positive as well as gram-negative bacteria, but also fungi can be the offensive organism. Most of the time the source originates from either the respiratory or the urinary symptom. So this could be a common carbon cold that turns into an ammonia that turns the patient septic or maybe a UTI or a kidney infection that spreads from the urinary tract into the bloodstream. So let's look at the pathophysiology. Once the bacteria spread from the localized area into the bloodstream, the bacteria release toxins and that triggers an inflammatory response and recall from physiology that there are a lot of different inflammatory markers or inflammatory cells that come to the aid in the immune system. And these are cytokines and look-ins tumor necrosis factor as well as platelet activation factor. All this immune response causes an increase in the vascular as well as capillary permeability, meaning that now the blood vessels get dilated and as the blood vessels themselves open up, fluid leaks out of the blood vessels causes massive vasodilation as well as thrombosis because we have the platelets that have been activated. Then all these mechanisms cause further inflammatory response and now we have more of the cytokines, interleukins, TNF and platelet activation factor responding to the site. And now because we have these platelets coagulation occurs. So and then now we have the sluggish blood flow because the platelets are aggregating and the fluid is leaking out of the blood vessels which leads to massive hypertension. When there is low blood pressure, certain organs are at risk or are not getting perfused leading to tissue hypoxia and then acidosis follows and so patients who are septic many times will be in metabolic acidosis. So for signs and symptoms, basically we need to vigilantly and be very mindful of monitoring patients who are admitted with any type of infection. Certainly patients who have certain risk factors or comorbidities such as underlying lung issues, maybe cancer, diabetes, hypertension, who have all these underlying issues are at higher risk of developing sepsis from a let's say pneumonia or urinary tract infection. And so when we monitor them we can identify early symptoms and those would be an increase in heart rate because as the blood vessels dilate the heart in response will increase the rate to ensure the perfusion to the cells and the tissues. And initially early the blood pressure might be normal or it might be a little bit on the low side. The patient might sow symptoms of decreased level of consciousness or start to be a little bit confused as the brain might not be being perfused as it would normally. And then the patient would maybe have warm of flesh skin with an elevated temperature because the body is trying to fight this offensive organism with raising the body temperature. And then as the basic dilation occurs and the blood the fluid seeps out from the blood vessels from the scapulary and vascular permeability the urine output will decrease because the body is trying to hang on to every drop of fluid it has to stabilize the blood pressure. This sometimes is also referred to as warm sepsis so with that warm flesh skin and a fever. However if we don't recognize these early symptoms or if the patient does not come in early enough then they might present with these late signs and symptoms. So now again the heart rate will be elevated because we're dealing with this massive fluid loss and the blood pressure will be really low so the patient will be significantly hypotensive and their level of consciousness now might be really depressed ranging from lethargy all the way to the patient becoming unresponsive. And this now turns into cold sepsis where the patient will have cool pale skin because of this massive vasodilation the limbs are not being perfused and also as the kidneys are losing perfusion because we now can't maintain the blood pressure the patient will turn and uric meaning they won't produce urine at all which would be a tell-tale sign that there's some issue with perfusion in the patient. And then there is an acronym called SOFA which stands for Sequential Organ Failure Assessment and these are basically diagnostic criteria that the experts have come up that will help us to identify patients at risk for sepsis so septic shock. And these are a temperature of greater than 100.9 or less than 97 so again that warm or cold sepsis here heart rate greater than 90 respiratory rate greater than 22 systolic blood pressure greater or equal than 100. So these vital signs if you really look at them they are not significantly different from what normal vital signs would look like if we're thinking of systolic blood pressure could be anywhere from 100 to 120 normal heart rate of 90 is usually normal but like to have that upper limit of 100 and the respiratory rate of 22 is not significantly elevated but as these passive physiological mechanisms occur the patient will start to show a trend in their vital signs so we need to be very very carefully monitoring them for these symptoms to develop. Then specifically here this respiratory rate greater than 22 and what that relates to it is now the patient is falling into this what developing metabolic acidosis and if you recall if the body becomes too acidotic the respiratory and renal system work together and by increasing the respiratory rate the patient is trying to blow off the acids that are building up in the system by expelling CO2 through the respiratory tract because we're dealing with the acidosis on the metabolic side. And then other diagnostic criteria here altered level of consciousness like we saw here in both early and late symptoms as well as an elevated blood sugar level in a patient who has no history of diabetes and that again is because the stress response is kicking in so the patient will really see more cortisol leading to elevated blood sugar levels. Diagnostic tests for a patient who is septic or maybe developing septic shock are complete blood count to look at those things and remember the platelets are part of that. CMP to check the patient's electrolytes as well as kidney and liver function and certainly we need blood cultures times two because now we have the local infection that has spread into the bloodstream so we want to collect that two different blood samples usually from the upper extremities and collect the blood sample hoping that as the blood is circulating through the body we can catch the offending organism and then grow it out in a blood culture and always remember that that has to be done before antibiotics are given if that is possible at all. Procosatonin has been a marker that's been coming into favor which can usually indicate an early sign of a bacterial infection if elevated and then lactate levels will be elevated as the patient is moving into this acidosis stage where the body now is switching from aerobic to anaerobic metabolism and recall that lactate is the byproduct. Certainly we want to get a urinalysis of the urine culture because remember that urinary tract infections are many times the offending organism or the offending source. We want to do a chest x-ray to check for respiratory causes of the infection as well as cultures of suspected origin so this would be a patient who for example had a wound a diabetic foot also a surgical wound any kind of injury that now could be the localized cause of the systemic infection. PT, INR and APTT so all the coagulation studies that we'll need to look at because the patient is at risk with that platelet activation factor and the thrombosis here and then fibrin which also plays a big role in the coagulation cascade. Now treatment for sepsis are IV fluids IV fluids IV fluids because recall that we have this massive vasodilation and the blood is seeping through the blood vessels in the interstitial space now we don't have that intravascular volume to sustain the patient's blood pressure and so typically we give the patient isotonic fluids normal saline or lactated ringers to maintain the mean arterial pressure greater than 65 and that means that the patient will get fluid boluses anywhere from 30 to 50 milliliters per kilo and I wrote an example out here if this patient weighed 180 pounds which creates approximately 82 kilos this would mean a fluid bolus of 2450 all the way to 4000 milliliters and that is four big bags of normal saline or lr so typically that would scare us because we don't want to put the patient in fluid volume overload because we know that too much fluid given too fast in the intravascular space especially if the patient has a history of maybe not being able to clear the fluid well due to heart or renal issues we want to be very careful but in this case when we are suspecting that the patient is septic fluid resuscitation is the number one thing we need to do for the patient to help them maintain their blood pressure to keep the organs and the tissues perfused to prevent the patient from hopefully turning into septic shock here and then sometimes also colloids are used so our human is administered after this initial resuscitation phase with crystalloid IV solutions and recall that our human pulls the fluid from that interstitial space back into the intravascular space to help stabilize their blood pressure and certainly wanting to give the patient antibiotics if there is a bacterial cause of the infection and the patient will be started on a broad spectrum antibiotic to treat the patient while we're waiting for all these cultures to result that can take somewhere 40 to 72 hours and then if the fluid resuscitation is not enough or the patient has these chronic issues with the kidneys or the heart then they will be put on vasopressors and the most common one currently is used is norepinephrine which is also called labofed and the literature here varies um labofed has been in and out of favor currently the standard is labofed is typically number one treatment for vasopressor for patients who are accepted and then because of this platelet activation thrombosis and coagulation we're dealing with we want to put the patient on anti-coagulant such as lobenox or heparin and sometimes the patient's heart will need a little bit of support in order to improve the contractility and the positive inotrope such as dubidum it helps with improving that contractility of the heart to help with the cardiac output which will in turn help with the blood pressure certainly this is a major offense to the patient's body system so we'll need to prevent stress ulcers by the administration of ppi such as protonics or age two bloggers such as famotidine raditidine any of those and then antipyretic certainly if the patient has a fever now for nursing care we need to frequently assess the patient i cannot stress enough how important this is so that we can find these diagnostic criteria that might just be very subtle changes here and identify the patient who is at risk for either sepsis or septic shock that will follow if we don't identify this early enough so frequent assessment of vital signs as well as their level of consciousness and then the peripheral pulses because recall as the vessels dilate the body will basically shunt fluids away from the not important parts such as the skin and the peripheral pulses will decrease as the blood pressure decreases the patient might need to have hemodynamic monitoring such as the central line for central venous pressure monitoring and recall that central venous pressure gives us an idea of the patient fluid status and please watch my other video about that we need to assess the patient's respiratory status specifically their osat or tooth sad which might be decreasing their respiratory rate that we talked about over here that might be increasing even so slightly and then their breath sounds while first of all it might be of origin of respiratory origin the sepsis but also when we administer patients large amounts of IV fluids we have to be very carefully assessing the lung sounds to make sure that the fluid doesn't settle there and now we're putting them in pulmonary edema so very carefully monitoring the patient here is super important and then of course we have to assess their ABGs other labs such as lactate levels kidney function all those things that we typically monitor and ABGs because of this acidotic state that the patient is developing and then also we have to be very vigilant about monitoring the patient's urine output because again as the kidneys are not being perfused they're not going to be functioning so they won't be producing any urine and a telltale sign or a very good way of doing this is to monitor urine output and usually if the urine output is less than one half a million per kilo per hour that means that there's decreased renal perfusion the patient is in this decreased urine maybe early septic stage and we need to intervene and again the way to do that is giving them IV fluids and then certainly skin and oral care are super important because now the patient has decreased peripheral circulation so they would risk for skin ulcers plus most likely there being intensive care units so skin care is important as well as oral care because many times these patients will end up intubated and then certainly emotional support for the patient as well as the family is important and if sepsis develops so into the bloodstream infection and the lower the blood pressure drops and the patient will be in shock so usually if they require vasopressors that means that they've now developed this septic shock kind of state but complications can even go further and the patients can develop multiple organ dysfunction syndrome called nods or disseminated intravascular coagulopathy which basically means that now we're turning from a coagulation state into more of a bleeding state so please watch my other videos on mods and DIC. Thanks for watching this video on sepsis and septic shock I hope it has helped you gain a better understanding of these disorders and remember these are the most important telltale signs here to tell about early and late sepsis and keep the patient from suffering bad health consequences. Thanks for watching Nursing School Explained see you soon