Shock: Early Recognition and Management☆
Article Outline
Dear Editor:
The clinical article published in the March 2010 issue of the Journal of Emergency Nursing by Wilmont titled “Shock: Early Recognition and Management,”1 though generally well written, is noted to have omitted some very important points regarding the assessment and treatment of patients with sepsis.
After a discussion of the systemic inflammatory response syndrome criteria, as well as their importance in the identification of septic patients and the initial treatment of potentially septic patients, the discussion turns to obtaining appropriate cultures (blood, urine, sputum, and other types as needed). This point, though mentioned briefly, requires further emphasis because this first set of cultures (especially blood) is of utmost importance in directing patient care. This is also an area where confusion exists among many ED staff members (physicians, nurses, and technicians). Inappropriate techniques, such as poor site preparation and drawing multiple cultures from a single site, abound in actual practice and have the potential to impact patient care significantly. It is also mentioned that as soon as potential sources of infection are identified, appropriate antibiotics should be administered. Actual identification of the source may in many cases be difficult, and administration of appropriate antibiotic coverage should be guided by clinical suspicion/presentation as well as local and institutional susceptibility guidelines. This is usually accomplished by broad-spectrum coverage administered within 1 hour of patient identification with severe sepsis or septic shock. In a critically ill patient with suspected infection, administration of antibiotics should never be delayed while awaiting the identification of “potential sources of infection.” A recently published article by Gaieski et al2 in Critical Care Medicine showed a significant relationship between duration of time from triage or time from qualification for early goal-directed therapy (EGDT) to administration of appropriate antibiotics and death in patients with severe sepsis or septic shock who were treated with a uniform, algorithmic resuscitation strategy. A significant reduction in mortality rate was found when appropriate antibiotics were administered within 1 hour of ED triage/qualification for EGDT.
The article by Wilmont1 also discusses various hemodynamic parameters that may be monitored in the septic patient. Central venous oxygen saturation (SCVO2) and central venous pressure (CVP) are briefly mentioned. Although some aspects of the importance of these monitoring parameters are highlighted, no actual values are provided to the reader to allow a better understanding of these very important parameters. The importance of SCVO2 in measuring the body's oxygen consumption is discussed; however, no mention of the expected value (70%) is mentioned nor is any mention made of the factors that influence this value (<70% increased oxygen consumption or decreased delivery and >70% increased delivery or decreased consumption). All of these are important factors that allow correct interpretation of the SCVO2 value. A similar issue occurs in the brief discussion of measurement of the CVP. No normal or expected value is given (0-4 mm Hg in normal “healthy” individuals or the goal for CVP in EGDT of Rivers et al3 of 8 mm Hg in non-intubated patients and 8-12 mm Hg in intubated patients). The correct treatment for hypovolemia and a low CVP is given: vigorous fluid resuscitation.
An additional concern comes from the discussion on mean arterial pressure (MAP).1 The statement is made correlating “shock” with a MAP of less than 60 mm Hg or a drop of 40 mm Hg from baseline. As mentioned in the first paragraph of the article, shock is a lack of adequate tissue perfusion, not hypotension. Blood pressure or MAP only differentiates compensated shock from uncompensated shock. This confusing information, if it leads providers to equate shock with hypotension, may lead providers to miss a whole group of patients who may present in what Rivers et al3 called “cryptic shock,” that is, inadequate tissue perfusion without hypotension. The importance of a serum lactate level—one of the key laboratory parameters that may assist in identifying patients in “cryptic shock”—is also not mentioned. Lactate levels above 4 mmol/L indicate tissue hypoperfusion, even with “normal” vital signs. Early identification leads to more rapid treatment and, in the study of Rivers et al, a significant reduction in mortality rate.
The care of the patient with sepsis and septic shock has significantly evolved over the past several years. Although this article is a good overview of shock in general, any discussion of sepsis and septic shock must clarify the above points for the emergency nurse because many of these more critical care interventions are now routinely being performed in many emergency departments through the world.
References
- . Shock: early recognition and management. J Emerg Nurs. 2010;36(2):134–139
- Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department. Crit Care Med. 2010;38(4):1045–1053
- Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368–1377
☆ Submit all Letters to the Editor online at http://ees.elsevier.com/jen/
PII: S0099-1767(10)00181-9
doi:10.1016/j.jen.2010.04.008
© 2010 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved.
Refers to article:
- Shock: Early Recognition and Management , 26 June 2009
