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Chemotherapy infusion can contribute to septic shock by significantly lowering a patient's immune system, making them highly susceptible to infections which can rapidly progress to sepsis and potentially septic shock.

Septic shock develops through an infection that triggers a systemic inflammatory reaction. Through this process, the body releases inflammatory mediators, such as histamine and cytokines, resulting in vasodilation, increased vascular permeability, and leukocyte activation in the tissue.

These changes lay the groundwork for how sepsis progresses throughout the body. The inflammatory mediators circulating the body combined with increased vascular permeability leads to increased tissue and organ damage. Also consider that a consequence for vasodilation is decreased blood pressure which can eventually lead to decreased systemic perfusion. The foundation of sepsis is centered around life threatening organ dysfunction caused by a dysregulated host response to an infection. Through complications that build upon each other, sepsis can be defined through specific stages.

Infection:

A microbial phenomenon characterized by an inflammatory response to the presence of microorganisms or the invasion of normally sterile host tissue by those organisms.

Temp > 38C.

SIRS:

HR> 90

RR> 20 or PaCO2 <32

Temp > 38C or < 36C

WBCs> 12,000 or <4,000 or >10% bands.

If the reaction is triggered in tissue remote from the site of infection and a large inflammatory response is started, this is defined as SIRS.

Sepsis: SIRS + Infection  (Sepsis I)

Suspected or known source of infection AND two or more indicators of systemic inflammation:

HR> 90 beats/min

RR>20breaths/min

Temp >38.3C or <36C

WBC>12 min or <4mm or 10% bands

Severe Sepsis: Sepsis + End Organ Damage (Sepsis II)

Sequential Organ Failure Assessment (SOFA)

Septic Shock: Severe Sepsis + Hypotension (Sepsis III)

Sepsis AND end-organ dysfunction as evidence by two or more of the following:

SBP<90mm Hg or MAP < 65 mm Hg

Urine output < 0.05 mL/kg/h x 2h or creatine > 2.0mg/dL

Creatinine >0.5 mg/dL above baseline if history of chronic kidney disease

Platelets <100,000 mm

INR > 1.5 or aPTT > 60 seconds

Serum Lactate > 4mmol/L or serum lactate > 2mmol/L after fluid resuscitation

New need for noninvasive or invasive ventilation

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Chemotherapy infusion can contribute to septic shock by significantly lowering a patient's immune system, making them highly susceptible to infections which can rapidly progress to sepsis and potentially septic shock (Nates et al., 2024)

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Early s/sx

fever

hypotension

tachycardia

tachypnea

warm, flushed skin

confusion

weakness

decreased urine output

Late s/sx

severe hypotension

pale, cold, or clammy skin

lactic acidosis

anuria

multi-organ failure

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Co-Morbidities and How They Alter the Pathophysiology of the Disease

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Co-Morbidities and How They Alter the Pathophysiology of the Disease

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Risk Factors

Diabetes: Hyperglycemia can promote the growth of bacteria and impair the body's ability to heal wounds. This promotes the risk of infection and can exacerbate the compromised state of the patient.

Neutropenia: With fewer neutrophils the body is less capable of controlling and eliminating infections. Therefore, increasing the likelihood of sepsis and septic shock.

Mucositis: This compromises the natural protective barrier of the digestive tract. Then allowing bacteria and pathogens to enter the bloodstream.

Invasive Devices: These devices are important for treatment but can increase the risk for infection by having a direct pathogen entry.

Malnutrition: Malnourishment compromises the immune system by delaying wound healing and weakening epitheleal barriers and reducing an effective inflammatory response.

Complications of Cancer Induced Sepsis

Kidney Failure: The kidneys normally filter and regulate inflammatory cytokines. Kidney failure can be induced by toxic chemotherapy agents and lead to the accumulation of inflammatory cytokines intensifying systemic inflammation during sepsis. The unchecked cytokine release contributes to organ damage, vascular leakage, and septic shock. Kidney failure also impairs fluid excretion, causing fluid accumulation and tissue edema.

Acute Respiratory Distress Syndrome: Inflammatory cytokines and mediators damage the capillary endothelium, causing gaps between endothelial cells. This allows fluid, proteins, and immune cells to leak from the bloodstream into the alveolar spaces, leading to pulmonary edema and impaired gas exchange.

Liver Failure: Sepsis often leads to hypotension and hypoperfusion of vital organs, including the liver. The liver’s dual blood supply becomes compromised during septic shock. Ischemia damages hepatocytes and impairs liver function causing jaundice, increased ammonia levels, difficulty metabolizing medications and filtering toxins.

GI Bleeds: Due to blood being shunted to vital organs, the acidic contents of the stomach are immobilized and cause ulcerations of the inner lining leading to bleeds.

Altered Mental Status: Sepsis increases the permeability of the blood brain barrier due to endothelial damage and oxidative stress. This allows toxins, inflammatory mediators, and immune cells to enter the brain, further promoting inflammation and neuronal injury. This combined with the “Brain Fog” from chemotherapy can make it difficult to arouse the patient and determine whether perfusion is adequate.

How Co-Morbidities Confound the Disease Process

* Delayed Recognition and Diagnosis of Sepsis

- Symptoms of infection (fever, tachycardia) may be masked or attributed to chemotherapy side effects, delaying treatment.

* Increased Treatment Resistance

- Patients with prior infections may harbour multidrug-resistant organisms, making sepsis harder to treat.

* Higher Mortality Risk

- Co-morbidities reduce physiological reserves, making it harder for patients to recover from septic shock.

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1. Prevent Infection:

Fever, Chills, Elevated heat rate, and changes in blood pressure

Daily assessment of redness, swelling, or drainage on the skin, mucous membranes, or IV sites

Rationale:

Monitoring for signs of infection in a patient with septic shock caused by chemotherapy is critical because chemotherapy weakens the immune system, making the patient more susceptible to infections. Chemotherapy-induced neutropenia significantly impairs the patient to be able to launch an effective immune response. This increases the risk of opportunistic infections that can rapidly escalate to septic shock.

2. Sepsis 1-hour bundle:

Obtain serum lactate, blood cultures

Administer broad spectrum antibiotics

Hypotensive? --> Rapid crystalloid bolus (NS/D5)

MAP < 65? --> Norepinephrine or Vasopressin

MAP < 65 and HF? --> Dobutamine

Rationale:

The 1-hour bundle is crucial in a patient with septic shock caused by chemotherapy. Chemotherapy-induced immunosuppression leaves the patient highly vulnerable to infections, which can escalate rapidly. The 1-hour bundle helps ensure that treatment is started as soon as possible, increasing the likelihood of survival and reducing the long-term complications of septic shock in this vulnerable population.

3. Monitor Organ Function:

Brain, Heart, Lungs, Kidney function, Liver function, and GI function

Rational:

In a patient with septic shock caused by chemotherapy, monitoring organ function is crucial because chemotherapy can already compromise organ systems, making them more vulnerable to the effects of sepsis. Chemotherapy-induced immunosuppression weakens the body’s ability to fight infection, increasing the risk of sepsis and multi-organ dysfunction. Sepsis exacerbates this risk by causing hypoperfusion, inflammation, and tissue damage, which can quickly lead to organ failure, especially in the kidneys, liver, and lungs.

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INTENSIVE CARE MEDICINE ~ The Surviving Sepsis Campaign Bundle: 2018 update

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1. Practice good hygiene - Hand washing is the #1 way to prevent infections.

2. Stay away from sick people - Patients receiving chemotherapy have a weakened immune system, making it much harder to fight infections compared to people with healthy immune systems (ACS, 2024)

3. Monitor for signs of infection - Reporting symptoms of infection (fever, swelling, etc.) early can help prevent them from getting worse.

4. Chemotherapy induced A-Fib - Certain chemotherapy drugs can impact the heart, increasing the risk of irregular heart rhythms.

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What nurses would monitor and prepare for:

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Atrial fibrillation

Thrombosis

Bleeding

Anemia

Hair loss

Stomatitis

Nausea/Vomiting

Constipation/Diarrhea

Chemo brain

Peripheral neuropathy

Infection

Fatigue

Fertility problems

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Risks

Fluids

Fluid overload

Electrolyte imbalance

Antibiotics

Adverse drug reactions

Risk for drug resistance

Vasopressors

Tissue ischemia

Tachyarrhythmias

Ventilator

Oxygen toxicity

Dialysis

Hemodynamic instability

Benefits

Fluids

Corrects hypovolemia

Improves organ function

Antibiotics

Target a wide-range of potential bacteria

Vasopressors

Corrects vascular tone

Improves organ perfusion pressure

Ventilator

Improves gas exchange

Reduces work of breathing

Dialysis

Removes waste from blood

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What nurses would monitor and prepare for:

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Fluids:

Impaired cardiac function

Worsening renal function

Antibiotics:

Increased inflammatory response

C.difficile infections

Further organ dysfunction

Vasopressors:

Increased tachycardia

Increased blood lactate levels

Ventilator:

Further decrease in cardiac output

Ventilator-associated pneumonia

Dialysis:

Worsening systemic infection through vascular access site

Unstable blood pressure fluctuation

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EKG

Heart rate

Blood pressure

Lactate

MOD- AST, ALT, BUN, and creatinine

WBC

ABG

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American Cancer Society. (2020). Chemotherapy Side Effects | American Cancer Society. Www.cancer.org; American Cancer Society. https://www.cancer.org/cancer/managing-cancer/treatment-types/chemotherapy/chemotherapy-side-effects.html

American Cancer Society. (2024). Managing infections and sepsis: Side effects of cancer. Managing Infections and Sepsis | Side Effects of Cancer | American Cancer Society. https://www.cancer.org/cancer/managing-cancer/side-effects/infections/managing-infections-and-sepsis.html

Brown, R. M., & Semler, M. W. (2019a, May). Fluid management in sepsis. Journal of intensive care medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC6532631/

Clark, E. (2015, November 15). Septic shock in chronic dialysis patients: Clinical characteristics, antimicrobial therapy and mortality. U.S. National Library of Medicine. https://pubmed.ncbi.nlm.nih.gov/26607816/#:~:text=Results:%20Septic%20shock%20secondary%20to,shock%20enrolled%20in%20this%20analysis.

Markman , M. (2024, August 13). Oncologist shares the benefits and risks of chemotherapy. City of Hope. https://www.cancercenter.com/community/blog/2021/03/benefits-and-risks-of-chemotherapy

Martínez, M. L., Plata-Menchaca, E. P., Ruiz-Rodríguez, J. C., & Ferrer, R. (2020, March 12). An approach to antibiotic treatment in patients with sepsis. Journal of thoracic disease. https://pmc.ncbi.nlm.nih.gov/articles/PMC7139065/

Nates, J. L., Pène, F., Darmon, M., Mokart, D., Castro, P., David, S., Povoa, P., Russell, L., Nielsen, N. D., Gorecki, G., Gradel, K. O., Azoulay, E., & Bauer, P. R. (2024). Septic shock in the immunocompromised cancer patient: A narrative review. Critical Care, 28(1). https://doi.org/10.1186/s13054-024-05073-0

National Library of Medicine (2019, May). Management of sepsis in neutropenic cancer patients: 2018 guidelines from the Infectious Diseases Working Party (AGIHO) and Intensive Care Working Party (iCHOP) of the German Society of Hematology and Medical Oncology (DGHO). Annals of hematology. https://pmc.ncbi.nlm.nih.gov/articles/PMC6469653/

Russo, A. T. (2022, February 22). Vasopressor-induced ischemia of bilateral feet in a previously healthy 34-year-old female. Foot & Ankle Surgery: Techniques, Reports & Cases. https://www.sciencedirect.com/science/article/pii/S2667396722000416

Shi, R., Hamzaoui, O., De Vita, N., Monnet, X., & Teboul, J.-L. (2020). Vasopressors in septic shock: which, when, and how much? Annals of Translational Medicine, 8(12), 794–794. https://doi.org/10.21037/atm.2020.04.24

Sole, M. L., Klein, D. G., & Moseley, M. J. (2021). Introduction to critical care nursing (8th ed.). Elsevier.

Wallace, H. A. (2023, June 26). Fluid resuscitation. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK534791/#:~:text=Large%20amounts%20of%20intravenous%20fluids,renal%2C%20cardiac%20or%20hepatic%20function.

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Risks

Immunosuppression

Organ dysfunction

Benefits

Reduces tumor size

Prevents cancer progression