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>> To understand the
labs of septic shock,

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let's first go ahead and
recall what septic shock is.

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So really briefly, remember,

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septic shock is infected
material that you see

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in blood vessels, and white
blood cells mount a response

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to this septic material,
and in mounting a response,

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they release all these
different immune molecules

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that can cause damage
to blood vessels

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and increase blood vessel
diameter, and the permeability

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of blood vessels, and
so on and so forth.

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So what's the first thing you
think you would want to do

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in a patient who
might have shock?

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Well, first of all, we
want to diagnose it, right?

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So what can we do
to diagnose shock?

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Well, we have a couple of
lab tests that we can use.

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So the first thing you
want to do is check,

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you know, what's going on?

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A patient comes in who
has fevers, chills,

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they're sweating, they're
very flushed, and you notice

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that their blood
pressure is dropping.

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So you're thinking,
maybe septic shock.

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So the first thing
you want to do,

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aside from checking
your temperature

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and checking their vital signs
is you want to check, you know,

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maybe they have an
infection in their blood.

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Maybe there's infective
material in their blood.

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So you can do that now by
getting blood cultures.

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Because you want to grow out
whatever is in the blood,

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and see if it's a fungus
or a bacteria or a virus.

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So blood cultures will
allow you to figure

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out what organism is
in the bloodstream.

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Next, you should probably figure
out how severe the shock is,

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and if in fact it is shock.

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You know, are the organs
damaged, or what's going on?

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So you'll get values such as
lactic acid or serum lactate,

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and serum lactate is important

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because it shows you
tissue perfusion.

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When cells of the body are
no longer getting oxygen,

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so these little orange
boxes are cells,

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when these guys are no
longer getting oxygen,

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they have to resort to
another way to produce energy,

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and that other way is
anaerobic metabolism.

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Metabolism without oxygen.

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And a byproduct of that
is lactate or lactic acid.

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So measuring the levels of serum
lactate will tell you just how

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oxygen starved these cells are.

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Next, you could also get an
ABG, or arterial blood gas.

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That will tell you how much
oxygen is in the blood,

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and it will also tell you
things like the carbon dioxide,

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different blood gases.

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And then you'll get
some other lab tests

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that are maybe organ specific.

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So for example, you might want
to get a BUN or a creatinine.

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And these are specific
tests for the kidney.

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So I'm only going to write down
these tests for the kidney,

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but you might want to get
tests for other organs as well.

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Now, the lab values for the
kidney are especially important

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because if the kidneys
are deprived of oxygen

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for just a little while,
they cab actually be damaged.

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So they're more readily
injured by lack of oxygen.

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So these are good labs to get.

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Now, once all these
labs are in the works,

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the next logical step is to
immediately treat this patient.

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And treatment is
associated with mortality.

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The sooner the patient is
treated, the more likely it is

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that they will survive.

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So they will have
decreased mortality

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if they're treated more quickly.

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And the treatment usually starts

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with just very broad
spectrum antibiotics.

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Broad spectrum antibiotics.

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Now, why broad spectrum?

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Well, when you first
treat sepsis,

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you will have drawn
a blood culture,

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but you won't have the results
back yet, so you have to start

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with an antibiotic that can
treat many different types

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of infections-- gram
positive, gram negative,

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many different types
of bacteria.

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And if the patient does
not really get better

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with broad-spectrum antibiotics,

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use of anti-fungals
may also be indicated,

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because there may be
a fungal infection.

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But usually you start here,
broad-spectrum antibiotics,

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and then you'll check the
blood cultures afterwards,

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and once those cultures return,
the patient can e switched

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to a more tailored antibiotic
therapy to provide an antibiotic

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or anti-microbial that the
organisms is susceptible to.

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Now, remember, not only is
there an infection going on,

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but as a byproduct
of this infection,

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the patient has a drop
in blood pressure,

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so treatment will
also include IV fluids

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to restore blood
pressure as well

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as a medication called
"pressors."

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And what pressors do is they
help squeeze down blood vessels

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to allow an increase in
systemic vascular resistance,

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or resistance of blood vessels,

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which helps restore the
blood pressure as well.

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So both of these will
increase blood pressure.

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So treatment will likely
take days to weeks,

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and in the meantime, while
the patient is recovering,

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what do you think the
next logical step is?

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You know, the patient has been
diagnosed with septic shock,

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they're being treated for it.

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So the next step is really
to see how the progress

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of the patient is, what's the
progress of the infection?

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To check the progress, you
know, you might continue

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to get lactate, ABG,
BUN and creatinine

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to monitor the patient, but
you can also get other labs,

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such as a CRP or an ESR.

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Now CRP stands for C-reactive
protein, and ESR stands

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for erythrocyte sedimentation
rate.

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Really, the names of these
are somewhat inconsequential.

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The main idea here is you
can track inflammation.

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So these allow you to
track inflammation,

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and when a patient is first
diagnosed with septic shock,

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these values are going
to be very elevated,

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possibly up around
100, each of these.

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And just to give you an idea the
normal values, the normal value

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of CRP should be less
than 1 mg per deciliter,

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and the normal ESR
really depends on age,

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but it will be probably below 20

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or maybe 25 millimeters
per hour.

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That's the units of ESR,
erythrocyte sedimentation rate.

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And so CRP and ESR,
as I was saying,

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may be drastically elevated.

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So resolution of septic shock
will show these values starting

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to go back down to normal.

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Searching for a down-trend
of these elevated lab values.

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So really, that's it
with septic shock.

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And it all makes sense based
off of what is going on.

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Infective material
in the bloodstream.

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Let me make a couple
final points.

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You always want to start

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with blood cultures before
you do antibiotic therapy.

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This is very important,
so that the organism

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in the patient's
bloodstream can be discovered.

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If broad-spectrum antibiotics
are started before blood

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cultures are obtained,

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there will be antibiotics
in the blood.

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So when a lab technician
goes to culture it,

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those antibiotics might
interfere with the growth

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of the blood cultures.

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So always-- blood cultures
first, and then antibiotics.

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But also another great thing

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to know is these
should not be delayed.

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Because remember delay
in treatment can lead

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to increased mortality.

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And last of all, many hospitals,

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we might hear the term
two large-bore IV lines

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for IV fluid treatment.

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Essentially that's establishing
two lines in either arm,

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in which fluids can
get to the patient,

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and they'll be called large-bore
because they'll be very large

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in diameter, these tubes will
have a very large diameter,

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and this allows for
fluid, IV fluid,

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to get to the patient quicker.

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So that blood pressure can
be increased very quickly.

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So remember the steps--
diagnosis, treatment,

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and then tracking
progression of septic shock.