Shock, Sepsis, and Multi-

Organ Dysfunction
Syndrome
(NCM 118)
Jomar P. Ronquillo, MD
Associate Professor
 Table of contents

01 02 03
SYSTEMIC MULTI-ORGAN
INFLAMMATORY DYSFUNCTION
SHOCK RESPONSES SYNDROME(MODS)
SYNDROME(SIRS)
 01
SHOCK
Shock is a clinical syndrome characterised by a systemic imbalance between
oxygen supply and demand. This imbalance results in a state of inadequate
blood flow to body organs and tissues, causing life-threatening cellular
dysfunction. (Pearson, 2017)
Overview of c e llula r homeostasis and
haemodynamics
FOUR PHYSIOLOGIC COMPONENTS:

1. A sufficient cardiac output

2. An uncompromised vascular system
3. A sufficient volume of blood
4. Tissues that are able to extract and use the oxygen delivered through the
capillaries.
 Stages of Shock
- Happens with continued hypoperfusion, cellular death and injury are ongoing
- These effects at the cellular level, if untreated, will lead to compromise of
function at the organ system level

Progressive Stage
2

Irreversible Stage
Compensatory Stage • Further hemodynamic derangement and
the body can compensate for the initial cardiovascular collapse from persistent
loss of blood volume via the hypoperfusion
neuroendocrine response to maintain • Volume resuscitation fails to reverse due to
hemodynamics extensive parenchymal and microvascular injury
Compensatory
stage of shock
Progressive
stage of shock
 • Profound hypotension and
hypoxemia
• Tachycardia worsens
• Decreased coronary blood flow
• Cerebral ischemia
Failure of one system affects
Refractory Stage
•
others
• Recovery unlikely
Of Shock
 baSIC HEMODYNAMICS
■ BP = CO x SVR (Systemic Vascular Resistance)

● Stroke volume (SV) is the amount of blood pumped

into the aorta with each contraction of the left ventricle.

■ Cardiac output (CO) is the amount of blood pumped per

minute into the aorta by the left ventricle.

CO = SV × HR
 baSIC HEMODYNAMICS
■ Mean arterial pressure (MAP) is the product of cardiac
output and systemic vascular resistance (SVR):
MAP = CO × SVR
MAP normal range = 70 to 110

■ Sympathetic tone.
Increased sympathetic stimulation increases
vasoconstriction and SVR; decreased sympathetic
stimulation allows vasodilation which decreases SVR.
 baSIC HEMODYNAMICS
■ Central Venous Pressure (CVP) is the blood pressure in
the right atrium or in the superior vena cava
normal range = 4-10cm H20 / 3-8 mm Hg

■ Pulmonary Capillary Wedge Pressure (PCWP)

An indirect measure of left atrial pressure and,
therefore, an estimation of for preload.
normal range: 4-12 mm Hg
 pathophysiology

Altered Hemodynamics

Inadequate tissue perfusion

SHOCK

SYSTEMIC INFLAMMATORY RESPONSE SYNDROME( SIRS)

MULTIPLE ORGAN DYSFUNCTION SYNDROME(MODS)

SHOCK: GENERAL MANAGEMENT
STRATEGIES

● Respiratory support
● Fluid replacement
● Vasoactive medications
● Nutritional support
FLUID REPLACEMENT: CRYSTALLOIDS AND COLLOIDS
VASOACTIVE AND INOTROPIC MEDICATIONS
SHOCK: NUTRITIONAL SUPPORT

● >3000 calories = general caloric

requirement of shock patients
● Parenteral or enteral feeding must be
started as soon as possible
● Administer drugs as ordered to prevent
stress ulcers
SHOCK CLASSIFICATIONS

● CARDIOGENIC shock
● Hypovolemic shock
● distributive/vasogenic
● Anaphylactic shock
● Neurogenic shock
● Septic shock
● Obstructive shock
 assessment
SHOCK MANIFESTATIONS

HYPOtension - TACHYcardia- TACHYpnea

01

Cardiogenic SHOCK
Cardiogenic shock manifestations

● Blood pressure: hypotension

● Pulse: rapid, thready; distension of veins of
hands and neck
● Respirations: increased, laboured; crackles
and wheezes; pulmonary oedema
● Skin: pale, cyanotic, cold, moist
● Mental status: restless, anxious, lethargic
progressing to comatose
● Urine output: oliguria to anuria
● Other: dependent edema; elevated central
venous pressure (CVP); elevated pulmonary
capillary wedge pressure; arrhythmias
CARDIOGENIC SHOCK:
ASSESSMENT AND DIAGNOSTIC
FINDINGS

● CBC
● Blood Chemistry
● Cardiac biomarkers and biomarkers for
ventricular dysfunction
● 2D echo
● ECG
● CXR
● Angiography
CARDIOGENIC SHOCK:
MANAGEMENT

● Correction of Underlying Cause

-coronary: thrombolytics, PCI, CABG,
IABP, VAD
-noncoronary: replacement of impaired
valve, correction of arrhythmia,
electrolyte imbalance, etc.
● Fluid therapy
● Pharmacologic therapy
-dobutamine
-nitroglycerine
-dopamine
02

hypovolemic SHOCK
is caused by a decrease in intravascular
volume of 15% or more (Huether & McCance,
2013)
 Hvs manifestations

1 . INIT IA L STAGE
2. COMPENSATORY
3. PRORESSIVE STAGES
4. IRREVERSIBLE/refractory STAGE
 HYPOVOLEMIC
SHOCK:
MANAGEMENT
● Treatment of underlying cause
● Fluid and blood replacement
-2 large-guage IVs
-3:1 replacement ratio rule
-massive transfusion protocol
● Redistribution of fluid
● Pharmacologic therapy
 Distributive/
vasogenic shock

- includes several types of shock that result from

widespread vasodilation and decreased peripheral
resistance.
- Because the blood volume does not change,
relative hypovolemia results.

- Examples of distributive shock include septic,

neurogenic and anaphylactic shock.
- Treatment is based on the underlying
pathogenesis.
 03

anaphylactic SHOCK

Is the result of a widespread hypersensitivity

reaction (called anaphylaxis).
 Anaphylactic
Shock

-A type of distributive shock caused by

a severe allergic reaction to an
antigen for which the body has already
produced antibodies against
-IgE-mediated
Results in release of vasoactive
substances that causes widespread
vasodilation and increased capillary
permeability
 Anaphylactic
Shock

-THREE DEFINING
CHARACTERISTICS:
1. Acute onset of symptoms
2. Presence of two or more symptoms
(reduced BP, GI distress,
skin/mucosal irritation
3. Cardiovascular compromise after
exposure to the antigen
 Anaphylactic
Shock

-MANAGEMENT:
Removal of the cause
Stabilize airway
O2
Fluid resuscitation
EPINEPHRINE!
Diphenhydramine and albuterol
Anaphylactic
shock
 04

neurogenic SHOCK
Neurogenic shock is the result of an
imbalance between parasympathetic and
sympathetic stimulation of vascular smooth
muscle.
 Neurogenic
Shock

• vasodilation that occurs as a result of

loss of balance between
parasympathetic and sympathetic
stimulation
• There is a predominant
parasympathetic stimulation
• Leads to low BP and inadequate
perfusion
• Causes: SCI, spinal anesthesia,
nervous system damage
neurogenic
shock
 Neurogenic
Shock:
Management
• Depends on the cause
• Restore sympathetic tone
• Fluid resuscitation
• Vasopressors, atropine
• Monitoring and supportive care
 05

septic SHOCK
Septic shock, the leading cause of death for
people in critical care units, is one part of a
progressive syndrome called systemic
inflammatory response syndrome (SIRS).
 Septic Shock

- The most common type of distributive shock

-Sepsis: Life-threatening organ dysfunction caused
by a dysregulated host response to infection
-common cause of death in ICUs
–Septic shock is a subset of sepsis
Septic Shock
Septic Shock
Septic Shock
Septic
Shock
 Septic Shock:
Medical
Management
-Rapid identificatio and elimination of
the cause of infection
-primary tx: isotonic fluids
-inotropes and vasopressors
-glucocorticoids
-broad spectrum antibiotics
-supportive meds
-nutritional support
 Septic Shock:
Nursing
Management
-Asepsis
-Monitoring
 Septic shock:
Complications

• ARDS
• Disseminated intravascular coagulation
• (DIC)
• ARF
• MODS
 06

obstructive SHOCK
is caused by an obstruction in the heart or
great vessels that either impedes venous
return or prevents effective cardiac pumping
action.
 Obstructive
Shock

• Causes:
• Pulmonary embolism
• Cardiac tamponade
• Tension pneumothorax
 obstructive
shock
● Jugular vein distension
● Pulsus paradoxus
 Diagnostic studies
● Hx and PE
● labs ● 12 leads ecg
● Continuous ecg
monitoring
● Chest x-ray, mri, ct scan
● Cont. pulse oximetry
● Invasive and
non=invasive
hemodynamic monitoring
 shock Interprofessional care

Focus (COP) Interventions (MOxFEm)

Treating the underlying Cause Medications
Increasing arterial Oxygenation Oxygen therapy
Improving tissue Perfusion Fluid Replacement
Emergency care measures
 shock medications
adrenergics vasodilators
vasoconstrictors
inotropes Nitroglycerine
Adrenaline Dopamine, (Glycerol trinitrate)
Noradrenaline Dobutamine,
Aramine Isoprenaline Nitroprusside(Nipride)
Sodium
diuretics
bicarbonate
Oxygen therapy
 Fluid resuscitation

● Crystalloid Solutions (Isotonic or Hypotonic)

● Colloid Solutions (Plasma Expanders)
● Blood and Blood Products
Nursing assessment
ABC’s:
Airway
Breathing
Circulation
Tissue perfusion
 Nursing diagnosis
Includes:
● Decreased cardiac output
● Ineffective tissue perfusion
● Anxiety
 nursing interventions
Decreased cardiac
output
Assess and monitor cardiac anxiety
function Assess cause of anxiety
Measure and record I&O Administer pain meds
Monitor bowel sounds Increase comfort and
Maintain bed rest and calm envi. reduce restlessness
Provide support
Ineffective tissue
perfusion
Monitor skin color, temp,
turgor, moisture
Assess LOC
Monitor body
temperature
 02
Systemic
Inflammatory response
syndrome
Generalized inflammation in organs remote
from the initial insult characterizes SIRS.
Many different mechanisms can trigger SIRS.
These incl ude:
• Mechanical tissue traum a: burns, crus h injuries, surgical
procedures
• Ischemic or necrotic tissue: pancreatitis, vascular disease, MI
• Microbial invasion: bacteria, viruses, fungi, parasites
• Endotoxin release: gram-negative and gram-positive
bacteria
• Global perfusion deficits: post cardiac resuscitation, shock
states
• Abscess formation: intraabdominal, extremities
• Regional perfusion deficits: distal perfusion deficits
 03
Multiple organ
Dysfunction syndrome
(mods)
is the failure of 2 or more organ systems in an
acutely ill patient such that homeostasis cannot
be maintained without intervention.
 Clinical
manifestations
OF SIRS AND MODS
CLINICAL MANIFESTATIONS
of
SIRS AND MODS
RESPIRatory C●NSAcute changes to
Neurological status
● Development of
(confusion,
ARDS
disorientation,
delirium, fever, etc.)

cardiovascular endocrine

● Biventricular Failure ● hyperglycemia->hypoglycemia

CLINICAL MANIFESTATIONS
of
SIRS AND MODS
REnal system Hepatic
● Prerenal - Renal
hypoperfusion
● Intrarenal - acute ● Bilirubin > 2 mg/dl,
tubular necrosis jaundice

Gi system hematologic
● GI bleeding, mucous ● Bleeding times, PT, PTT
ischemia ● Platelet count
Sequential organ failure assessment
(sofa)

● can be used to ● is a mortality prediction ● It is believed to

determine level of score that is based on the provide a better
organ dysfunction degree of dysfunction of six stratification of the
and mortality risk in
organ systems mortality risk in ICU
ICU patients
patients
 Nursing interventions
ABC’s:
Airway (optimize O2 delivery, minimize consumption, MV)
Blood (volume management to increase preload,
vasopressors, optimize cerebral blood flow, monitor bleeding)
Continuous ECG monitoring, Calcium channel blockers
Decrease cerebral O2 requirements
Enteral nutrition, stress ulcer prophylaxis, dietician consult
Factors being lost, replace(platelets)
 lesson highlights

shock Sirs
early sign of shock is
Characterized by
a change in the level
generalized
of consciousness, with
inflammation in
restlessness being a
common symptom of organs remote from
cerebral hyp o xia. the initial insult
types Mods
Cardiogenic the failure of 2 or
Hypovolemic more organ systems
Anaphylactic in an acutely ill patient
Neurogenic
Septic
Obstructive
 “
“I attribute my success to this, I never gave nor took
any excuse.”

—florence nightingale
 “I attribute my success to this, I
never gave nor took any excuse.”
—florence nightingale
Thanks!
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