1.A BRIEF RESUME OF THE INTENDED WORK
1.1 INTRODUCTION
“Health is not valued till sickness comes”
In humans, health is the general condition of a person's mind, body and spirit, usually meaning to be free from illness, injury or pain (as in “good health” or “healthy”). It is also a level of functional or metabolic efficiency of an individual. Health continues to be a neglected entity despite service. At the individual level, it cannot be said that health occupies an important place; it is usually subjected to other needs defined as more important, e.g., wealth, power, prestige, knowledge, security.1
Health is believed to be the complete wellbeing of a person in all aspects.The World Health Organization (WHO) defined health in its broader sense in 1946 as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.2
Study says that diseases mostly occur due to bad hygienic practices.One of the most challenging clinical problems in critical care is caring for the patient in septic shock.The clinical syndrome of shock is one the most dramatic,progressive,and life threatening condition faced by medical staff in the critical care setting.
In 1914, Schottmueller wrote, “Septicemia is a state of microbial invasion from a portal of entry into the blood stream which causes sign of illness.” The definition did not change much over the years, because the terms sepsis and septicemia referred to several ill-defined clinical conditions present in a patient with bacteremia. Shock is a life-threatening condition that occurs when the body is not getting enough blood flow. This can damage multiple organs. Shock requires immediate medical treatment and can get worse very rapidly.3
Septic shock is a medical emergency caused by decreased tissue perfusion and oxygen delivery as a result of severe infection and sepsis, though the microbe may be systemic or localized to a particular site. It can cause multiple organ dysfunction syndrome (formerly known as multiple organ failure) and death. Its most common victims are children, immunocompromised individuals, and the elderly, as their immune systems cannot deal with the infection as effectively as those of healthy adults.4
A better pathophysiologic knowledge and the apparition of international recommendations allowed an improvement of septic shock’s prognosis. Numerous factors are associated to mortality in septic shock. Early recognition of these factors can help to identify the most critical situations and to provoke a more aggressive resuscitation.
In patient in the intensive care unit(icu), sepsis has the highest incidence of any other major disease, including congestive heart failor, breast and colon cancer,trauma,and acquired immunodeficiency syndrome(AIDS).Shock is a clinical syndrome characterized by inadequate tissue perfusion that results in end-organ Sepsis has a worldwide incidence of more than 20 million cases a year, with mortality due to septic shock reaching up to 70 percent even in industrialized countries.5
Severe sepsis is typically characterized by initial cytokine-mediated hyperinflammation. Whether this hyperinflammatory phase is followed by immunosuppression is controversial. Animal studies suggest that multiple immune defects occur in sepsis, but data from humans remain conflicting severe sepsis and septicaemic shock are the syndromes of overwhelming response of the body to severe infections. At times, it can be protective to body but at times it can lead to sequential multi-organ failure leading to death. The incidence of sepsis is increasing and it is as high as the incidence of myocardial infarctions (heart attacks).6
The reasons for this growing incidence likely include an increasingly elderly population, increased recognition of disease, increased performance of invasive procedures and organ transplantation, increased use of immunosuppressive agents and chemotherapy, increased use of indwelling lines and devices, and increase in chronic diseases such as end-stage renal disease and HIV. Of note, in 1987, gram-positive organisms surpassed gram-negative organisms as the most common cause of sepsis, a position they still hold today.Signs that you may have septic shock include shaking chills, an abnormally high or low body temperature, weakness, rapid breathing, a quickened heart beat, and a drop in blood pressure.7
Treatment primarily consists of Volume resuscitation ,Early antibiotic administration,Early goal directed therapy,Rapid source identification and control, Support of major organ dysfunction.8Among the choices for vasopressors, norepinephrine is superior to dopamine in septic shock. Both however are still listed as first line in guidelines. Antimediator agents may be of some limited use in severe clinical situations however are controversial.9Low dose steroids (hydrocortisone) for 5 – 7 days led to improved outcomes. Recombinant activated protein C (drotrecogin alpha) in a 2011 Cochrane review was found not to decrease mortality and thus was not recommended for use.10
Severe sepsis and septic shock are life-threatening conditions that pose high morbidity and mortality rates for critically ill patients. Moreover, the complexity of this syndrome is still not fully understood and requires continuous research. The treatment of sepsis is time-sensitive, which may be improved through the use of a sepsis protocol. Current research on the initiation of measures designed for early recognition and treatment of sepsis have shown improved outcomes. These interventions with education about the risk factors, manifestations of the illness, and pathophysiology may promote better patient care in the critical care setting. The critical care nurse plays a leading role in early detection, monitoring, and treatment of patients with these conditions. Thus, with education, use of protocols and healthcare professionals working together should positively impact critically ill septic patients.11
1.2 NEED FOR STUDY
The worldwide burden of septic shock is tremendous.Septic shock is a complex and generalized process that involves all organs systems. In united states, there are approximately 750,000 new episodes of sepsis each year and an associated 200,000 death.There has been an increase in the rate of septic shock deaths in recent decades, which is attributed to an increases in invasive medical devices and procedures, increases in immunocompromised patients, and an overall increase in elderly patients. Tertiary care centers (such as hospice care facilities) have 2-4 times the rate of bacteremia than primary care centers, 75% of which are nosocomial infections.It is estimated that there are approximately 400,000 to 500,000 septic episodes each year in the United States
Sepsis and septic shock are frequently encountered conditions in today's hospital environment. The incidence appears to be increasing despite our growing armamentarium of antibiotics and our enhanced knowledge of the pathophysiologic processes at play. The clinical presentation may take a variety of forms, especially in patients at the extremes of age and in the immunocompromised population. A high index of suspicion and prompt institution of appropriate antimicrobial treatment is mandatory for a successful outcome. It is hoped that adoption of uniform definitions will aid in research and in effective communication concerning sepsis and its adverse sequelae.12
A Dutch surveillance study examined the incidence, causes, and outcome of sepsis in patients admitted to a university hospital. The investigators reported that the incidences of sepsis syndrome and septic shock were, respectively, 13.6 and 4.6 cases per 1000 persons.13
A prospective, multicentre, observational study, recently conducted to evaluate the epidemiology of Sepsis and other characteristics of Intensive Care Unit patients in European countries (called the SOAP study) was endorsed by the European Society of Intensive Care Medicine.This observational study showed a marked difference in the frequency of sepsis between countries, and higher frequencies of sepsis were mirrored by higher mortality rates. 13
Fig 1: Incidence of Sepsis in European Countries
There was a direct relationship between the number of organs failing and the Intensive Care Unit mortality. Patients with no organ dysfunction on admission had mortality rates of 6% whereas those with four or more organ failures had mortality rates of 65 %.26 (Fig. 2)
Fig 2: The SOAP study
In most patients with sepsis, a source of infection can be identified, with the exception of patients who are immunocompromised with neutropenia, where an obvious source often is not found. Multiple sites of infection may occur in 6-15% of patient.
The number and rate per 10,000 population of hospitalizations for septicemia or sepsis more than doubled from 2000 through 2008.14
Compared with younger patients, elderly patients are more susceptible to sepsis, have less physiologic reserve to tolerate the insult from infection, and are more likely to have underlying diseases; all of these factors adversely affect survival. In addition, elderly patients are more likely to have atypical or nonspecific presentations with sepsis.
Indian data related to sepsis revealed high admission rates and mortality in patients admitted to intensive care units. Presently, the diagnosis and management of patients with sepsis is based on clinical and laboratory data with poor accuracy. Given this substantial mortality and economic costs, a basic understanding of pathogenesis and the immune alterations in sepsis may help to direct therapy. 15
A study of National Hospital Discharge Survey (NHDS) data identified organ failure in 19.1 per cent of sepsis patients from 1979 to 1989 and 30.2 per cent from 1990 to 2000. Comparing data from the five-year time frame between 1979 and 1984 with a span from 1995 to 2000, the number of patients who had dysfunctional organs more than doubled (2.7 per cent to 7.1 per cent), and the number of patients who had at least three dysfunctional organs more than tripled (0.5 per cent to 1.9 per cent). Though we do not have exact statistics from India, the incidence and mortality from sepsis could be worse in India.
Cardiovascular dysfunction is common in severe sepsis or septic shock. Although functional alterations are often described, the elevated serum levels of cardiac proteins and autopsy findings of myocardial immune cell infiltration, edema and damaged mitochondria suggest that structural changes to the heart during severe sepsis and septic shock may occur and may contribute to cardiac dysfunction.16
Risk factors for septic shock includes,Diabetes,diseases of biliary system, or intestinal system, chronic liver disease, chronic renal failure, and the use of immunosuppressive agents diseases that weaken the immune system such as AIDS Indwelling catheters (those that remain in place for extended periods, especially intravenous lines and urinary catheters and plastic and metal stents used for drainage Leukemia, Long-term use of antibiotics.
Based on the above facts, figures and investigator`s personal experience motivated to conducted the present study. And added, in the view of above aspects are clearly highlights that septic shock is a life threatening medical emergency and its effect is devasting The clinical syndrome of shock is one the most dramatic,progressive,and life threatening condition faced by medical staff in the critical care setting. In this concern study has been taken focusing on knowledge regarding management of septic shock among staff nurses.
1.3 REVIEW OF LITERATURE
Review of literature is one of the most important steps in the research process.It is a description of the literature relevant to a particular filed or topic.It is an account of what is already known about a particular phenomenon.
The related literature has been organized under the following
1. Review related to organ dysfunction due to septic shock
2. Review related to Management of Septic Shock
1. Review related to organ dysfunction due to septic shock
A study was conducted Myocardial dysfunction in sepsis.In this study Myocardial dysfunction appears in 25% of patients with severe sepsis and in 50% of patients with septic shock. It is characterized by a reduction in left ventricle ejection fraction, that reverts at the seventh to tenth day of evolution. Right ventricular dysfunction and diastolic left ventricular dysfunction can also appear.Right ventricular dysfunction and diastolic left ventricular dysfunction can also appear.Since there is no specific treatment for myocardial dysfunction, its management requires an adequate multi systemic support to maintain perfusion pressures and systemic flows sufficient for the regional and global demands.17
A study was conducted on Markers of endothelial damage in organ dysfunction and sepsis.The objective of the study is to review the literature on direct and indirect markers of endothelial activation and damage in patients with sepsis and systemic inflammation and to assess their clinical usefulness for diagnosis and outcome.The data extraction and synthesis from published research and review articles related to these parameters, with special emphasis on clinical studies.The conclusion of the study is endothelial activation and damage occur early during sepsis and play a major role in the pathophysiology of systemic inflammation. Various markers of endothelial activation are increased during sepsis and systemic inflammation, and in most studies, the level of markers such as soluble intercellular adhesion molecule, vascular cell adhesion molecule, and E selectin correlate well with the severity of inflammation and the course of the disease.In addition, it is evident that markers of endothelial activation and coagulation parameters lack specificity for infection-induced endothelial damage and organ dysfunction.18
German Prevalence Study conducted on Acute Renal Failure In Patients With Severe Sepsis And Septic Shock.A prospective cross-sectional one-day prevalence study was carried out in a representative sample of German ICUs, divided into five strata (< 200 beds; 201-400 beds; 401-600 beds; > 600 beds; university hospitals). 3877 patients were screened of whom 415 had severe sepsis and septic shock.The result of the study was fourteen patients were excluded from analysis because of pre-existing CKD requiring regular haemodialysis (HD) . Of the remaining 401 patients, 166 (41.4%) patients were diagnosed to have ARF.Inthis representative survey in patients with severe sepsis/septic shock, prevalence of ARF is high with 41.4%. ARF represents a significant independent risk factor for mortality in these patients. 19
2. Review related to Management of Septic Shock
A study was conducted in America to evaluate fever control by external cooling reduces early mortality and vasopressor requirements in sedated patients with septic shock.The multicenter trial included 200 febrile adults with septic shock (70% with pneumonia) who were sedated on mechanical ventilation and receiving vasopressor treatment. Patients were randomly assigned to receive either 48 hours of external cooling (n = 101) to achieve normothermia (36.5°C - 37°C) or no cooling (n = 99). Both groups had vasopressors tapered to maintain a mean arterial pressure target of 65 mm Hg or more.The main outcome measure was the percentage of patients with a 50% decrease in vasopressor dose from baseline to the end of the 48-hour study period.20