1
Q
what type of shock is septic shock?
A
distributive
2
Q
what are the risk factors for sepsis?
A
People with weakened immune systems such as:
- pregnant patients (compensatory mechanism to prevent fetal rejection)
- Oncology patients
- Patients taking steroids chronically
- Asplenic patients
- Pre-existing infections
- Pre-existing co-morbidities (like diabetes or alcoholism)
- Severe injuries (such as large wounds)
- Invasive lines, drains and/or tubes
- Adults older than 65 years of age & the very young
- Patients who have had surgery or invasive procedures
- Hospitalized patients and sepsis survivors
- diabetes (bacteria loves sugar)
3
Q
what organisms cause sepsis?
A
Bacterial
viral
fungal
parasite
4
Q
Sepsis Patho
A
- The body’s overwhelming & life-threatening response to infection which can lead to tissue damage, organ failure & death.
- precipitating event> vasodilation > activation of inflammatory response> vasopermiability >fluid shifts (relative hypovolemia)> decreased venous return= decreased cardiac output> decreased perfusion
5
Q
what Qs should i ask or systems should i look for in order to identify early recognition?
A
- Do I suspect a new or worsening infection?
- Are there two or more SIRS present?
- Are there signs of new organ dysfunction?
6
Q
list the s/s of sepsis
???
A
- Hyperthermia > 38.3°C (100.9°F)
- Hypothermia < 36° C (96.8°F)
- Tachycardia > 90 bpm
- Tachypnea > 20 breaths/minute
- WBC count > 12,000µL or < 4,000µL
- Normal WBC with >10% bands
- increased Lactate
- low urine output
7
Q
sepsis nursing intervention
A
- Initiate cardiac & pulse-ox monitoring
- *VS (full set) q15m until stable
- Administer oxygen as necessary to keep saturation > 92%
- Place second IV for fluid resuscitation/dual antibiotic administration as necessary.
- Complete fingerstick for blood glucose
- Monitor renal function; ensure UOP is > 0.5ml/kg/hr
- Monitor tissue perfusion; ensure capillary refill is < 2 sec.
- lactate monitoring
- Monitor changes in LOC
- blood cultures (2 specimens)
- sterile technique on all procedures
- oral care
- frequent position changes
- nutritional support
8
Q
sepsis medical management
A
- 2 large bore IV
- blood cultures (2 sets)
- broad spectrum/ specific antibiotics
- fluids
- cardiac BP monitoring
- serum Lactate monitoring
- medication (vasopressors if fluid doesn’t work)
9
Q
what is the 1 hour bundle (within 3 hours of admission)
A
- Measure lactate level
- Re-measure if initial lactate elevated >2 mmol/L)
- Obtain blood cultures before administering ABX
- Administer broad-spectrum ABX
- Begin rapid administration of 30 mL/kg crystalloid for hypotension or lactate > 4 mmol/L
- Apply vasopressors if hypotensive during or after fluid resuscitation to maintain MAP > 65 mmHg
10
Q
Interventions after 6 hours
A
- recheck lactate Q2h
- admin vasopressors
11
Q
sepsis RN expectations
A
- Screen Every Patient
- At Triage - On Admit/Discharge/Transfer - Every shift (8h) - - When there is an acute change in the patient’s condition
- Clear, SBAR communication with attending provider
- Call Sepsis Alert/Code Sepsis
- Initiate the Standardized Procedure
- Facilitate Treatment
- Follow Infection Control Measures
12
Q
What Sepsis is NOT:
A
- An infection
- “Blood poisoning”
- Contagious
- Rare
13
Q
Common Infections
A
- lung infection
- a urinary tract infection
- type of gut infection
- a skin infection
14
Q
Sepsis Trajectory
A
- SIRS
- Sepsis
- Severe Sepsis
- Septic Shock
15
Q
Sepsis definition
A
- Infection
- 2 or more SIRS
16
Q
Sepsis cycle
A
- Inflamation
- Vasodilation
- Vasopermeability
- Activation of adhesion molecules
- Coagulation
17
Q
SIRS signs
A
- Hyperthermia > 38.3°C (100.9°F)
- Hypothermia < 36° C (96.8°F)
- Tachycardia > 90 bpm
- Tachypnea > 20 breaths/minute
- WBC count > 12,000µL or < 4,000µL
- Normal WBC with >10% bands
18
Q
What is key to prevention
A
Early recognition
19
Q
Sepsis Screening Practice #1:
80 YOF admitted from ED for ABD pain, weakness, watery diarrhea, fever & chills
Pertinent VS: 38.9C (102F) , 112, 24, 110/70, 94% RA
Pertinent labs: WBC 15.4, Lactate 3.0
A
20
Q
Sepsis Screening Practice #2:
28 YOF arrives in ED, c/o pain in foot. Stumbled off curb the evening before. Trouble walking.
Foot painful, red, swollen & warm. Abrasion/avulsion noted to anterior lateral aspect of fifth metatarsal
Pertinent VS: 38.5C (101.3F), 98, 18, 125/70, 99% RA
Pertinent Labs: WBC 17.1, Lactate 4.0
A
21
Q
Sepsis is a CMS Core Measure
A
“Core Measures” are national standards of care & treatment for common medical conditions
These standards reduce complications & lead to better patient outcomes
The sepsis core measure is called “SEP-1”
22
Q
SEP-1
A
- Focused on adult patients with severe sepsis or septic shock
- Requires completion of time sensitive interventions called “bundles”
- SEP-1is a composite measure, meaning if one element of care is missed, the entire case fails. (i.e. the hospital gets a lower score for compliance)
- Performance is publically reported
23
Q
SCCM Hour-1 Bundle
A
- Measure lactate level
— Re-measure if initial lactate elevated >2 mmol/L) - Obtain blood cultures before administering ABX
- Administer broad-spectrum ABX
- Begin rapid administration of 30 mL/kg crystalloid for hypotension or lactate > 4 mmol/L
- Apply vasopressors if hypotensive during or after fluid resuscitation to maintain MAP > 65 mmHg
24
Q
SEP-1 Requirements for Severe Sepsis & Septic Shock:
Within 3 HOURS from Time of Presentation (TOP):
A
- Measure serum lactate
- Obtain two sets of blood cultures (& source cultures as indicated)
- Administer appropriate antibiotics
- Administer crystalloid fluid bolus(es) for hypotension and/or lactate > 4 mmol/L
25
SEP-1 Requirements for Severe Sepsis & Septic Shock:
Within 6 HOURS from TOP:
- Re-measure elevated lactates every 2h until < 2.0 mmol/L
- Administer vasopressors for hypotension not responding to fluid resuscitation
26
TOP for Severe Sepsis is when a patient has all of the following (within 6 hours):
- Suspected or confirmed infection
- Two or more SIRS
- One or more organ dysfunction criteria
27
TOP for Septic Shock:
- when a patient has a lactate > 4mmol/L or hypotension (two consecutive BPs) following a 30ml/kg IVF bolus.
- TOP can occur at any point in a patient visit.
— Commonly it’s the ED triage time (≈ 80% of patients)
— Usually correlates with a positive sepsis screen
28
Citric Acid Cycle: The Basics
- Normal process in aerobic organisms
- Middle of three major steps in cellular respiration
- Series of chemical reactions which harvest energy for cells to use
- When there isn’t enough cellular oxygen delivery cardiac output is redistributed so more oxygen can be extracted from capillary blood.
- Enough oxygen can’t be extracted from capillaries to support aerobic metabolism so cells begin using anaerobic sources of energy
- Results in lactate production which is why lactate is considered a surrogate marker for tissue hypoxia
29
Lactate & Sepsis
Ranges:
- Normal ≤ 1.0
- > 2.0 is an indication of severe sepsis
- 4 is an indication septic shock
30
Serial lactates more important
- Must re-measure within 6 hours if initial lactate >2 mmol/L
- “Lactime” (duration lactate > 2mmol/L) is predictive of organ failure and mortality
31
Types of Lactic Acidosis
TYPE A
Due to poor tissue perfusion or oxygenation (hypoxic)
- Ischemia
- Hypovolemia
- Cardiac failure/arrest
- Severe asthma, COPD
- Respiratory failure
- Sepsis
32
Types of Lactic Acidosis
TYPE B
No apparent hypoperfusion (non-hypoxic)
- Delayed clearance
- Renal or hepatic failure
- DM
- Malignancy
- Medications
- Seizures
33
Antibiotics
- Communicate with treating provider & obtain order(s) for appropriate antibiotic(s).
- Goal is to administer ABX within the first hour after recognition of sepsis/septic shock.
34
Fluid Resuscitation
- Give 30 ml/Kg crystalloid as a fluid challenge
- Look for hemodynamic improvement.
- Albumin when patients require substantial amounts of crystalloid
35
Post-Bolus Assessment
In the event of persistent hypotension (MAP < 65) after initial fluid administration or initial lactate ≥ 4 reassess & document volume status & tissue perfusion by EITHER:
- Repeat focused exam including:
- VS
- Cardio/pulmonary status
- Cap refill
- Peripheral pulse evaluation
- Skin exam
36
Two of the following:
???
- Measure central venous pressure (CVP)
- Measure central venous oxygen saturation (ScvO2)
- Bedside cardiovascular ultrasound
- Assess fluid responsiveness with passive leg raise or fluid challenge
37
Additional Nursing Interventions
- Initiate cardiac & pulse-ox monitoring
- VS (full set) q15m until stable
- Administer oxygen as necessary to keep saturation > 92%
- Place second IV for fluid resuscitation/dual antibiotic administration as necessary.
- Complete fingerstick for blood glucose
- Monitor renal function; ensure UOP is > 0.5ml/kg/hr
- Monitor tissue perfusion; ensure capillary refill is < 2 sec.
38
Supportive Therapies
- Corticosteroids
- Blood Administration
- Glucose Management
- ARDS management
- VTE Prophylaxis
- Stress Ulcer Prophylaxis
- Renal Replacement Therapy
- Nutrition
- Advanced Care Planning
39
What if the Provider Doesn’t Implement the Guidelines?
- Inform the provider that you are concerned for sepsis & ensure that the provider is aware of the positive sepsis screen
- Document that you have communicated with the provider
- Follow the ‘Chain of Command’ when you have concerns regarding the quality of clinical care
- Continue to monitor the patient for worsening signs/symptoms & repeat the sepsis screen if you notice deterioration in the patients condition
40
During Hospitalization
Patients often experience:
- Sleep deprivation
- Poor nourishment
- Pain & discomfort
- Deconditioning
- Increased risk for sepsis
- ICU Delirium
41
What Might Recovery be Like?
- Many individuals fully recover
- Many others are left with long lasting effects, such as:
- Missing limbs or digits
- Organ dysfunction (like kidney failure)
- Post-Sepsis Syndrome
- Post Traumatic Stress Disorder
42
Post-Sepsis Syndrome
- Affects up to 50% of sepsis survivors
- Effects are less obvious
- Symptoms may include:
— Impaired cognitive functioning
— Difficulty concentrating
— Extreme fatigue
— Muscle/joint pain
— Sleep disturbance
— Nightmares/hallucinations/flashbacks/panic attacks/PTSD
— Loss of self-esteem
43
Case Review
17:18 (Report) 96 YOM recently admitted from ED for failure to thrive & progressive dysphagia. Now presenting with increased SOB, productive cough (thick white sputum) & watery diarrhea (+ c-diff). AOx3 (baseline). PMH includes esophageal stricture, HTN & stroke (six years prior) with residual right arm weakness.
18:02: (VS) 36.8C (98.2F), 102, 23, 152/77(102), 98% RA
18:54: (Pertinent Labs) WBC 14.6
Infection suspected/confirmed?
- Yes: c-diff+, & thick white sputum with cough & dysphagia
Signs/Symptoms Present:
- Three SIRS present: HR, RR, WBC Organ Dysfunction present: None
Sepsis or Septic Shock?
- Undetermined. Patient had positive sepsis screen but a lactate is needed to rule out all organ dysfunction criteria.
18:47: Lactate results at 2.6 mmol/L
- Organ dysfunction now present so this is TOP for severe sepsis.
