Septic Shock (Sepsis)


Article Author:
Sidharth Mahapatra


Article Editor:
Alan Heffner


Editors In Chief:
Wanda Wright
Cynthia Oster


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
6/4/2019 2:21:52 PM

Introduction

Sepsis syndromes span a clinical continuum with variable prognosis. Septic shock, the most severe complication of sepsis, carries high mortality. In response to an inciting agent, pro-inflammatory and anti-inflammatory arms of the immune system are activated in concert with the activation of monocytes, macrophages, and neutrophils that interact with the endothelium through pathogen recognition receptors to elaborate cytokines, proteases, kinins, reactive oxygen species, and nitric oxide.[1] As the primary site of this response, the endothelium not only suffers microvascular injury but also activates the coagulation and complement cascades which further exacerbate vascular injury, leading to capillary leak. This cascade of events is responsible for the clinical signs and symptoms of sepsis and progression from sepsis to septic shock. The ability to balance pro-inflammatory responses to eradicate the invading microorganism with anti-inflammatory signals set to control the overall inflammatory cascade ultimately determines the degree of morbidity and/or mortality suffered by the patient. Judicious and early antimicrobial administration, sepsis care bundle use, and early goal-directed therapies have significantly and positively impacted sepsis-related mortality. However, early identification remains the best therapeutic tool for sepsis treatment and management.

Etiology

The 2009 European Prevalence of Infection in Intensive Care (EPIC II study) determined that gram-negative bacterial infections far exceed other etiologies as the most common cause of sepsis syndromes with a frequency of 62%, followed by gram-positive infections at 47%. An increase in the prevalence of the latter may be attributable to the performance of more invasive procedures and increased incidence of nosocomial infections.[2] Predominant micro-organisms isolated in patients include Staphylococcus aureus (20%), Pseudomonas (20%), and Escherichia coli (16%).[3] Predominant sites of infection include respiratory (42%), bloodstream (21%), and genitourinary (10%).[2] These data need to be assessed in the context of knowing that over a third of patients never grow positive cultures.[4]

The influence of bacterial strain and site of infection on mortality was illustrated in a large meta-analysis.[5] In this study, gram-negative infections were overall associated with higher mortality. However, gram-positive bacteremia with Acinetobacter or pneumonia with Staphylococcus carried a 40% mortality with Pseudomonal pneumonia carrying the highest mortality at 70%.

Sepsis syndromes caused by multidrug-resistant bacterial strains (methicillin-resistant Staphylococcus (MRSA), vancomycin-resistant enterococci (VRE)) are on the rise with a current incidence of up to 25%; viruses and parasites cause far fewer cases and are identified in 2% to 4% of cases.[6]

Epidemiology

Annually, the rate of this debilitating condition is rising by almost 9%.[7] The incidence of sepsis and severe sepsis have risen over the past decade from approximately 600,000 to over 1,000,000 hospitalizations per year from 2000 through 2008.[8] Accompanying this trend has been a rise in healthcare expenditure, making sepsis the most expensive healthcare condition in 2009, accounting for 5% of total United States hospital costs.[9] The case-fatality for patients with sepsis has been declining due to advances in sepsis management provided by the Surviving Sepsis Campaign. The United States Nationwide Inpatient Sample (NIS) from 2009 through 2012 showed a mortality rate decline from 16.5% to 13.8%.[10] However, severe sepsis continues to rank amongst the most common causes of death in hospitalized patients.[11] Moreover, up to 25% of patients with severe sepsis and 50% of patients with septic shock will suffer mortality.[2] However, overall mortality from sepsis syndromes can vary from 30% to 50% [12] depending on demographic factors such as age, race, sex, co-morbid conditions, and the presence of organ dysfunction.[13] For example, in-patient mortality was predicted most by number and degree of organ injury with the strongest predictors being respiratory, cardiovascular, hepatic, and neurologic failure.[10]

Pathophysiology

Sepsis is a clinical state that falls along a continuum of pathophysiologic states, starting with a systemic inflammatory response syndrome (SIRS) and ending in multiorgan dysfunction syndrome (MODS) before death. 

The earliest signs of inflammation are heralded by the following:

  1. Fever (temperature higher than 38 C or hypothermia (temperature less than 36 C)
  2. Tachycardia (heart rate more than 90 beats per minute), 
  3. Tachypnea (respiratory rate more than 20 breaths per minute)
  4. Leukocytosis (WBC greater than 12,000/cu mm) / leukopenia (white blood cells (WBC) less than 4,000/cu mm) with or without bandemia (more than 10%).

The presence of two of these four clinical signs is necessary for the diagnosis of systemic inflammatory response syndrome. After that, systemic inflammatory response syndrome with an infectious source suffices the clinical definition for sepsis.[14] 

With the development of hypotension, tissue demands are not adequately met by tissue oxygenation, and the patient is now defined to be in severe sepsis.[14] The decline in peripheral vascular perfusion and oxygenation leads to cellular and metabolic derangements, most notably a shift from aerobic respiration to anaerobic respiration with ensuing lactic acidosis. Tissue hypoperfusion may also be manifested by signs of end-organ damage, such as pre-renal azotemia or transaminitis. The difference in oxygen supply and demand can be monitored during resuscitation by trending the mixed venous oxygen saturation from a central line in the superior vena cava (SVC), when available.[1]

When sepsis-induced hypotension remains refractory to initial management with fluid resuscitation, septic shock ensues.[14] Septic shock is distinguished from other shock states as a distributive type of shock. The action of a combination of inflammatory mediators (histamine, serotonin, super-radicals, lysosomal enzymes) elaborated in response to bacterial endotoxins leads to a marked increase in capillary permeability and a concomitant reduction in peripheral vascular resistance. This translates not only into a reduction in afterload but also in preload from a decline in venous return from third-spacing. The resulting reduction in stroke volume is accommodated initially by an elevation in heart rate, i.e., compensated septic shock. As a result, the patient is in a hyperdynamic state that is characteristic of septic shock.[1]

Clinically, patients, have a dynamic precordium with tachycardia and bounding peripheral pulses. They are warm to the touch and have a reduction in capillary refill (flash cap refill). This is described as warm shock. As shock progresses, elevated catecholamine production leads to an increase in peripheral vascular resistance as the body attempts to shunt blood away from non-vital tissues (gastrointestinal (GI) tract, kidneys, muscle, and skin) to the vital tissues (brain and heart). This is described as cold shock. Understanding the pathophysiology and continuum of septic shock is imperative in initiating appropriate treatment measures.[1]

Functionally, septic shock is defined by persistent hypotension despite adequate fluid resuscitation from 60 ml/kg to 80 mL/kg of either crystalloid or colloid fluid. At this point, the initiation of appropriate vasoactive medications such as beta-adrenergic or alpha-adrenergic drugs is of utmost importance. The progression of organ dysfunction despite high-dose vasoactive administration defines the state of multi-organ dysfunction syndrome (MODS) which carries a mortality as high as 75%. While the exact circumstances predicting poor prognosis and death have been difficult to determine, immunologic dissonance (exaggerated proinflammatory response) versus immunologic paralysis (exaggerated anti-inflammatory response) have been purported to play a role.[15]

History and Physical

Early Signs and Symptoms

Sepsis is defined as systemic inflammatory response syndrome plus an infectious source. Therefore, earlier on in the presentation of sepsis, patients present with the following vital sign changes:

  • Fever, temperature higher than 38 C, or hypothermia, temperature lower than 36 C
  • Tachycardia with a heart rate higher than 90 beats per minute in adult patients or less than two standard deviations for age in pediatric patients
  • Tachypnea with respiratory rate greater than 20 breaths per minute in adult patients or more than two standard deviations for age in pediatric patients

Signs and Symptoms of Severe Sepsis Severe sepsis is defined as sepsis and end-organ dysfunction. At this stage, signs, and symptoms may include: 

  • Altered mental status
  • Oliguria or anuria
  • Hypoxia
  • Cyanosis
  • Ileus

Patients progressing to septic shock will experience signs and symptoms of severe sepsis with hypotension. Of note, at an early "compensated" stage of shock, blood pressure may be maintained, and other signs of distributive shock might be present, for example, warm extremities, flash capillary refill (less than one second), and bounding pulses, also known as warm shock. This stage of shock, if managed aggressively with fluid resuscitation and vasoactive support, can be reversed. With the progression of septic shock into the uncompensated stage, hypotension ensues, and patients may present with cool extremities, delayed capillary refill (more than three seconds), and thready pulses, also known as cold shock. After that, with continued tissue hypoperfusion, shock may be irreversible, progressive rapidly into multiorgan dysfunction syndrome and death.

Evaluation

Laboratory Findings

Findings in sepsis, severe sepsis, and septic shock are as follows [16]

  • Hyperglycemia (glucose more than 120 mg/dL)
  • Leukocytosis (WBC more than 12,000/mm3) or leukopenia (WBC less than 4000/mm3)
  • Bandemia (more than 10%)
  • C-reactive protein or procalcitonin more than 2 SD above normal
  • Mixed venous saturation more than 70%
  • PaO2: FiO2 less than 300
  • Pre-renal azotemia
  • Coagulopathy, INR more than 1.5 or PTT more than 60 sec
  • Thrombocytopenia (platelets less than 100,000/mL)
  • Hyperbilirubinemia (total bilirubin more than 4 mg/dL)
  • Lactic acidosis (more than 2 mmol/L)

Patients should be placed on continuous cardiopulmonary monitoring to allow close observation of vital signs. A thorough assessment of end-organ function and peripheral perfusion should be undertaken to determine where along the pathophysiologic continuum of sepsis they may fall. This should include a Glasgow Coma Scale (GCS) or mental status assessment, urine output measurement, or lactate/mixed venous saturation determination (with central lines). Regardless of where along the continuum patients are, all patients should have drawn a complete blood count with differential (CBC-d), source cultures (blood, urine, tracheal (if intubated), wound), and a urinalysis. Depending on the severity of presentation and age of the patient a lumbar puncture may be indicated, for example, patients with signs of encephalitis or meningitis or febrile pediatric patients under six weeks of age. The addition of C-reactive protein or procalcitonin, both acute phase proteins, may be helpful in distinguishing viral from bacterial sepsis, with the latter showing steeper elevations in these proteins. A complete chemistry panel with liver function test, disseminated intravascular coagulation (DIC) panel, and an arterial blood gas are additional labs that may provide important information on the severity of sepsis syndrome in a patient.

Treatment / Management

Below guidelines are derived from the Surviving Sepsis Campaign Guidelines [17][18]

Source Control

  1. Broad-spectrum antibiotics within one hour of diagnosis for all patients. Initial empiric anti-infective therapy should have activity against all likely pathogens and adequate penetration of source tissue.  
  2. Removal of infected/necrotic tissue, if it is the source of septic shock, i.e. patients with cellulitis, abscess, infected devices, purulent wounds.

Management of Shock [19]

  1. Measures most effective if achieved within the first six hours of diagnosis
  2. Restore central venous pressure (CVP) to 8 mmHg to 12 mmHg
  3. Restore mean arterial pressure (MAP) greater than 65 mmHg
  4. Restore superior vena cava saturation to 70% or mixed venous saturation to 65%
  5. Fluid resuscitation with crystalloid (NS or albumin) and colloid (blood products) up to 80 ml/kg
  6. Mechanical ventilation to reduce metabolic demand
  7. First line vasoactive agents (epinephrine in cold shock versus norepinephrine in warm shock) when fluid-refractoryNote: dopamine as a first line agent has fallen out of favor given its inhibitory effect on the HPA axis, namely prolactin and growth hormone, which can confer immunologic dysfunction [20]

Enhancing Host Response

  1. Corticosteroids indicated in vasoactive-refractory shock and or in patients with low (unstimulated) basal cortisol levels less than 150 ug/L) [21][22]
  2. Addition of vasopressin indicated in vasoactive-refractory shock

While central lines are not required for the resuscitation of patients with septic shock, they provide an accurate means of monitoring CVP and mixed venous the . Remember that CVP and MVO2 are most accurate from a central line that lies within the right atrium; lower extremity central lines do not provide the most accurate data for monitoring these indices of resuscitation. Regarding the need for central venous access for administration of vasoactive agents, a recent study showed that both dopamine, norepinephrine, and phenylephrine at high doses could be safely administered via peripheral venous access.[23] 

Of note, early goal-directed therapy (EGDT) has not been shown to confer a survival benefit in more recent studies.[24] All studies comparing EGDT to standard practice have shown an increase in the administration of crystalloid and packed red blood cells in the first six hours and the placement of central lines. Furthermore, survival was influenced most by the maintenance of blood pressure independent of the type of fluid or vasoactive used and not CVP or MVO2.[25] That said, the Surviving Sepsis Campaign guidelines continue to support EGDT as the standard of practice for management of severe sepsis and septic shock.

The placement of an arterial line becomes important in the management of vasoactive-refractory shock for close monitoring of blood pressure and tissue oxygenation status via regular blood gasses with key attention to lactate levels and pO2.

Enhancing Healthcare Team Outcomes

The management of septic shock is best done with a multidisciplinary team that includes ICU nurses. The key is early diagnosis and resuscitation to maintain end organ perfusion. The type of fluid for resuscitation has little bearing on outcomes but the key is to maintain adequate perfusion pressure.

The outcomes of septic shock depend on patient age, associated comorbidities, renal function, need for dialysis, requiring mechanical ventilation and response to treatment.


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Septic Shock (Sepsis) - Questions

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An adult patient is febrile, has a pulse of 120 beats/min, and a blood pressure of 65/40 mmHg. The patient has been given 4 liters of crystalloids with minimal response. What is the best next treatment for this patient?



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A patient is in the burn unit following a fire at his home. After 2 weeks in the intensive care unit, he still is intubated with 75 percent burns to his body. To what would sepsis in this type of patient most likely be due?



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A patient sustained gunshot wounds to the abdomen. He underwent an exploratory laparotomy and returned to the intensive care unit intubated. Given the need for prolonged nothing-by-mouth status, total parenteral nutrition was started on pod1. Six days later, fever, leukocytosis, and marked hyperglycemia were noted. What is the most likely etiology?



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Which statement concerning septic shock is accurate?



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A patient is in septic shock 5 days after major trauma and has a significant decrease in urine output. Mean arterial pressure is 58 mm Hg, right atrial pressure is 15 mmHg, wedge pressure is 22 mmHg, cardiac output is 8.9 L/min, and cardiac index is 4.5 L/min/m2. What is the most appropriate treatment for this patient?



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A previously healthy 60-year-old woman becomes confused and lethargic 40 hours after arthroplasty. Her blood pressure is 85/40 mmHg, heart rate is 122 beats per minute, respiratory rate is 26 breaths/min, and temperature is 96.8 F. Her skin is pink and warm. The wound is clean and dry, and the peripheral IV site shows no signs of phlebitis. Pulses are bounding. Chest and abdominal exams are within normal limits. Her Foley catheter is draining a small amount of cloudy urine. What is the first step in the management of this patient?



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Which of these is considered to be the earliest sign of sepsis?



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Fluid-refractory shock should trigger the initiation of which of the following?



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What should be the immediate next step in the case of an elderly female who is admitted for pyelonephritis and started on IV antibiotics who becomes tachycardic and hypotensive who is then found to have a fever and to be somnolent with tachypnea?



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A nursing home patient is febrile with blood pressure 60/40 mmHg and pulse 115. What is the likely cause of this condition?



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Which of the following is associated with septic shock?



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A patient is diagnosed with pneumococcal pneumonia and is admitted to the hospital. He develops circulatory collapse and arrests. Blood culture is positive for pneumococcus. Which of the following is the most probable diagnosis?



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A 59-year-old undergoes surgery for rectal cancer. On the 4th day in the hospital, he has a temperature of 39.3 C (102 F), blood pressure of 160/89 mm Hg, a pulse of 112 beats per minute and regular, and respiratory rate of 26 breaths per minute. CT scan of the abdomen reveals a collection in the pelvis. Which of the following is the most likely diagnosis?



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What are initial respiratory signs and symptoms of septic shock?



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What is the cause of septic shock?



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What happens to systemic vascular resistance (SVR) readings in a patient with early septic shock?



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What would a complete blood count with differential in a patient with septic shock reveal?



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What is the most common end-organ dysfunction manifestation of severe sepsis?



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A 3-year-old girl with acute lymphoblastic leukemia who is receiving maintenance chemotherapy is admitted to intensive care unit from the emergency department. Her temperature is 39.3 C, heart rate is 188 beats/min, respiratory rate is 56/min, blood pressure is 67/21 mmHg, and arterial oxygen saturation is 93% on room air. She received a total of 80 mL/kg crystalloid fluid resuscitation in the emergency department and is now receiving another 20 mL/kg of intravenous fluid. Which of the following is the most accurate statement about this patient’s treatment?



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A 2-year-old is admitted to the intensive care unit with septic shock. Which of the following statements about oxygen delivery and consumption is most correct?



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A 7-year-old boy is 48 hours into treatment for septic shock. He is currently ventilated with the following settings: FiO2 is 0.6, peak inspiratory pressure/positive end expiratory pressure ratio is 28:8, and rate is 18 breaths/min. He is receiving a combination of epinephrine (0.1 mcg/kg per min) and norepinephrine (0.1 mcg/kg per min) for circulatory support, and dexmedetomidine for sedation. His vital signs include a temperature of 38.3 C, heart rate of 110 beats/min, blood pressure of 98/65 mmHg, and central venous pressure (CVP) of 10 mmHg. Peripheral perfusion is characterized by 1 to 2+ pulses and 2- to 3-second capillary refill. Urine output is 0.4 mL/kg per hour and has not changed since a bolus of normal saline increased his central venous pressure from 8 to 10 mm Hg. This child’s acidosis has resolved. The fellow is about to start a milrinone infusion. Which of the following is the most accurate statement regarding this patient’s management?



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A 3-year old child with septic shock remains hemodynamically unstable. She has received 160 ml/kg of crystalloid and colloid solutions, and a pulmonary artery catheter was placed 6 hours ago. She is currently receiving epinephrine 0.5 micrograms/kg/min and dopamine 5 micrograms/kg/min. The patient’s blood pressure is 88/50 mmHg, and her heart rate is 178 bpm. Hemodynamics show a cardiac index of 2.3 L/min/m2 and a systemic vascular resistance index of 2150 dyne-sec/cm/m2 (HIGH). Her hematocrit is 33%, and her pulmonary capillary wedge pressure is 14 mmHg (HIGH). Which of the following is most likely to improve this patient’s hemodynamic status?



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A 4-year-old girl with all acute lymphoblastic leukemia is admitted to the pediatric intensive care unit with fever, neutropenia, and hypotension. Her pulse is 205 bpm, blood pressure is 60/30 mmHg, extremities are pink and warm, and capillary refill is 6 seconds. The relative risk is 40 with intermittent grunting, but no retractions and oxygen saturation is 99% to 100% on 40% oxygen by facemask. She is given 100 mL/kg of normal saline and started on dopamine up to 20 mcg/kg/min. Blood pressure increases to 80/40 mmHg and pulse decreases to 185. She is intubated and mechanically ventilated. She is diagnosed with septic shock and has remained anuric. Evaluation shows cardiac index is 2.5 L/min/m2, systemic vascular resistance index is 400 dyne-sec/cm5/m2 (LOW), and central venous pressure is 18 mmHg. Mechanical ventilator settings are as follows: intermittent mandatory ventilation rate 20, PIP 30, PEEP 15, Fi02 0.6, and tidal volume 8 cc/kg. pH 7.39, PaC02 50, Pa02 70. Which of the following is the best therapeutic option to increase this child's urine output?



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A 57-year-old female is admitted for persistent abdominal pain. She is postoperative day 5 from a laparoscopic cholecystectomy. Her vital signs are heart rate 110 bpm, respiratory rate 18/minute, blood pressure 80/55 mmHg, and temperature 39C. On exam, the patient has tenderness over her left upper quadrant, appears lethargic, and is somewhat confused. CT scan shows evidence of an intraabdominal abscess. What are the best first-line interventions?



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A nurse is delivering care to a patient with a history of congestive heart failure, renal failure, diabetes mellitus, myocardial infarction 3 years ago with stents, and hypertension. Current medications are insulin, clopidogrel, furosemide, multivitamin, metoprolol, and a potassium supplement. The patient was admitted yesterday for fever, urinary tract infection with possible pyelonephritis, nausea, vomiting, and hyperglycemia. Admission vitals and assessment were within normal limits. A reassessment today reveals a blood pressure of 80/50 mmHg, heart rate 128 beats/min, temperature 39.8 C (103.8 F), respiratory rate 32, pulse oximetry 95% on room air, and 9/10 right flank pain. Breath sounds are clear, there is no edema, jugular venous distention, or dyspnea, the skin is warm and moist, and there has been no urine output over the past 4 hours. Blood work reveals BUN 32, creatinine 4.1 mg/dL, potassium 4.5 mEq/L, WBCs 38,000/microliter, and lactic acid level 4.8 mmol/L. How does the nurse proceed with the management of care for this patient? Select all that apply.



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A novice nurse is rounding in the medical-surgical unit with her experienced counterpart while on orientation. They receive a report on a client from an off going nurse. The client is reported as stable, confused, lethargic and is slightly tachycardic. The working diagnosis is a ruptured diverticulum. The experienced nurse asks the novice nurse if any of the report warrants concern. The novice nurse wants to see this client immediately to decide if the tachycardia, lethargy, and confusion support the report of a "stable" client by the off going nurse. The new nurse assesses the client and finds a temperature of 101.9 F (38.8 C), heart rate 146 beats/min, respiratory rate 38, blood pressure 80/50 mmHg, and pulse oximetry 90% on room air. The client is lethargic and oriented and complains of 9/10 abdominal pain. Review of lab results reveals a lactic acid level of 5.2 mmol/L and a WBC count of 28,000/microliter. What emergent orders would the novice nurse anticipate from the healthcare provider after notification of the change in condition by the overseeing nurse? Select all that apply.



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Septic Shock (Sepsis) - References

References

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