3. Sepsis and Septic Shock

Question 1

Most acute care settings have developed protocols for the treatment of sepsis and septic shock to provide timely, evidence-based, life-saving treatment for this pt population and to meet the requirements set by the Centers for Medicare & Medicaid Services (CMS).

Answer 1

Whereas older medical studies stressed the importance of CVP and ScvO2 measurements, more recent medical studies that discuss sepsis and septic shock place less importance on those measurements and instead, stress fluid resuscitation, timeliness of obtaining blood cultures and serum lactate level measurements, the administration of antibiotics, and the initiation of vasopressors if necessary.

Question 2

Overview:

Answer 2

There are at least 1.7 million incidences of sepsis in American adults annually, with ~ 270K deaths per yr (as of 9/2021 per CDC).
-Sepsis is the #1 cause of death in the non-coronary ICUs.
-As per the CDC, 1 in 3 pts who die in a hospital have sepsis.
-Numbers are expected to increase due to high incidences of sepsis in the older adult population
-The current Adult CCRN test blueprint expects you to understand sepsis and septic shock.
-SIRS and severe sepsis are not in the latest blueprint and so brief descriptions are provided for them.
-Exam Q will most likely focus on sepsis and septic shock

Question 3

SIRS

Answer 3

Systemic Inflammatory Response Syndrome (SIRS)

-SIRS is systemic inflammatory response to a wide variety of severe clinical insults, manifested by 2 or more of the following:
-temp greater than/equal to 38C or < 36C
-HR > 90 bpm
-RR > 20 breaths/min or PaCO2 < 32 mmHg
-WBC > 12000 or < 4000 OR bands > 10% (shift to left)

-A pt may have SIRS without sepsis (i.e. traumatic injury, pancreatitis, burns).

-Studies have shown that SIRS is a poor predictor of sepsis, thus SIRS was eliminated from the Sepsis -3 definitions.

Question 4

Sepsis is a

Answer 4

-life-threatening organ dysfunction that is caused by an abnormal host response to an infection. Initially, the infection may be “suspected,” rather than “proven,” based on the clinical exam and the pt’s hx.

Question 5

With sepsis, a “suspected” infection in the presence of one or more of the following:

Answer 5

-Positive culture results from blood, sputum, urine, etc.

-Receiving antibiotic, anti fungal, or another anti-infective therapy

-Altered mental status in the elderly

-Possible pneumonia (infiltrate on the chest radiograph)

-Nursing home pt with an indwelling urinary catheter

-Pressure ulcers

-acute abdomen

-infected founders, especially with a hx of diabetes

-immunosuppression

Question 6

sepsis =

Answer 6

infection + organ dysfunction = sepsis

Question 7

Organ dysfunction may be identified by

Answer 7

assessing the pt’s qSOFA score or SOFA score

Question 8

Examples of organ dysfunction

Answer 8

-hypotension

-acute hypoxemia

-acute drop in urine output (<0.5 mL/kg)

-Lactate 2 mmol/L or greater

-abrupt mental status change

-platelets below 100K

-coagulopathy

Question 9

qSOFA

Answer 9

(Quick Sepsis Related Organ Failure Assmt) Score

-The qSOFA score is included in the Sepsis-3 definitions, but not in CCRN exam blueprint (may be added in the future)

-The qSOFA score is a bedside evaluation (without the need for labs) to identify patients with suspected ORGAN DYSFUNCTION

-The qSOFA score evaluates 3 criteria, assigning 1 point for each of the following:
-Systolic bp less than/equal to 100 mmHg
-RR greater than/equal to 22 breaths/min
-Glasgow coma scale < 15 (altered mentation)

-qSOFA score of 2 or 3 indicates high probability for organ dysfunction

Question 10

Severe sepsis

Answer 10

(as defined prior to publication of Sepsis-3 definitions in 2016) is sepsis PLUS markers of organ dysfunction.

-not included in Sepsis-3 definitions; not on Exam.

-see table 5-3 Differences between Sepsis-2 definitions and sepsis-3 definitions

Question 11

Septic Shock

Answer 11

-Of all deaths in hospitals annually, more than 40% are -the result of septic shock

-Clinically identified by an infection, PLUS:
-Vasopressor requirement to maintain a MAP of
greater than/equal to 65 mmHg, despite adequate
fluid resuscitation.
-Serum lactate > 2 mmol/L, despite fluid
resuscitation

Question 12

Q: BP 78/36 before fluids; 102/58 after a 500 mL fluid bolus, BE -5, pH 7.30, lactate 3 mmol/L, acute abdomen.

Answer 12

Pt showing clinical signs of Sepsis

Question 13

Q. BP 110/80, BE -1, pH 7.34, lactate 1.5 mmol/L, temperature 39 C, WBC 15000, acute abdomen

Answer 13

Pt showing clinical signs of Infection.

Question 14

Q. BP 78/40 before fluids, 88/49 after a 500 mL fluid bolus x 4, BE -5, pH 7.31, lactate 6 mmol/L, acute abdomen

Answer 14

Pt showing clinical signs of septic shock.

Question 15

Pathophysiology of sepsis/septic shock

Answer 15

Sepsis/septic shock is a process of malignant intravascular INFLAMMATION

         INFECTING ORGANISM 
                     I
                     I
                     I
                    V Uncontrolled inflammatory response due to release of mediators:

-Vasodilation —-> decreased SVR

-Increased capillary permeability and significant leak
—->decreased vascular volume

-Impaired O2 extraction, utilization —->Anaerobic
Metabolism

-Maldistribution of blood flow —->Anaerobic
Metabolism

-Accelerated coagulation and microemboli formation
–>DIC

-Myocardial Dysfunction –> decreased cardiac output
(late)

-Pulmonary Dysfunction —–> ARDS

Question 16

Pathophysiology of sepsis/septic shock (con’t)

Answer 16

-Activation of coagulation, inflammatory cytokines, complement, and kinin cascades with the release of a variety of endogenous mediators.

-Causative organisms include:
-Gram-negative bacteria
-Gram-positive bacteria
-Fungi, viruses, Rickettsia, parasites

Question 17

Risk Factors for Sepsis:

Answer 17

-Extremes of age
-Chronic health problems
-invasive procedures and devices
-Surgical wounds
-Genitourinary infections
-Prolonged hospitalizations
-Translocation of GI bacteria (NPO)
-Acquired immunodeficiency syndrome (AIDS)
-Use of cytotoxic and immunosuppressive agents
-Alcoholism
-Malignant neoplasm; bone marrow suppression
-Transplantation procedures
-history of a splenectomy

Question 18

Signs/symptoms of early septic shock:

Answer 18

-Tachycardia, bounding pulse
-BP is low, responsive to vasopressors
-Skin is warm, flushed
-Respirations are deep, somewhat fast
-Lactate > 2 mmol/L
-Confusion–>mental status change (esp in elderly)
-Oliguria
-Fever (temperature > 38C)

Question 19

Signs/symptoms of Progressive (Later) Septic Shock

Answer 19

-Hypotension, may not be responsive to pressors
-Tachycardia, pulse is weak and thready
-Lactate 4 mmol/L or greater
-Skin is cool, pale
-Respirations are rapid OR may be slow
-Lethargy, coma
-Anuria
-Hypothermia (temp <36C)

Question 20

Myth

Answer 20

A pt with sepsis or septic shock always has a fever and an elevated WBC.

Question 21

Hemodynamics of Early Septic Shock

Answer 21

-CO/CI increases

-RA, PA, PAOP decreases

-SvO2 increases

-O2 delivery increases

-O2 consumption decreases

Question 22

Hemodynamics of Late Septic Shock

Answer 22

-CO/CI decreases
-RA, PA, PAOP increases
-SVR (variable)
-SvO2 (variable)
-O2 delivery decreases
-O2 consumption decreases

Question 23

Diagnostic Test Results That Indicate Early Septic Shock

Answer 23

-ABGs –>respiratory alkalosis, mild decrease in PaO2, or may have a combined respiratory alkalosis & metabolic acidosis.

-PT, PTT about the same or increased

-Platelets about the same or decreased

-WBC increased, about the same, or decreased

-Bands increased

-Glucose increased

-Lactate increased

-Troponin increased

Question 24

Diagnostic Test Results That Indicate Late Septic Shock

Answer 24

-ABGs–>metabolic acidosis, very decreased PaO2

-PT, PTT very increased

-WBC decreased

-Bands very increased

-Glucose decreased

-BUN, creatinine increased

-Liver enzymes increased

-Lactate increased

-Troponin increased

Question 25

What percent of pt’s who present with sepsis/septic shock have positive blood cultures?

Answer 25

30-50%

Question 26

Treatment for Sepsis/Septic Shock

Initial fluid challenge

Answer 26

should be the administration of 30 mL/kg of crystalloid (2.1 L for a 70 kg or 154 pound person) AS EARLY AS POSSIBLE to achieve the below goals:

-MAP greater than/equal to 65 mmHg
-UO greater than/equal to 0.5 mL/kg/hr
-Decrease in tachycardia

Question 27

If hypotension persists despite fluid resuscitation, start:

(Treatment for Sepsis/Septic Shock)

Answer 27

-Vasopressor: pressor of choice is norepinephrine.

-Norepinephrine (Levophed) is first-line
- Epinephrine (drip) is recommended when a second
vasopressor agent is needed.

Question 28

If the BP does not respond to the high-dose initial pressor and fluids,

(Treatment for Sepsis/Septic Shock)

Answer 28

The pt may have CATECHOLAMINE-REFRACTORY SEPTIC SHOCK, whereby alpha receptors in the arterial bed are not responsive to pressers.

  -Start a VASOPRESSIN drip at 0.03 - 0.04 units/min, 
      generally not titrated.
       -Vaso NOT a first-line agent for hypotension.
       -Used to enhance the effectiveness of the initial 
           pressor that was used for treating septic shock.

   -If vaso not effective, consider extreme metabolic 
    acidosis or corticosteroid insufficiency r/t a critical 
     illness; treatment with sodium bicarb or steroids 
      may be considered, although neither have 
     demonstrated that they can improve mortality     
      rates.

Question 29

Obtain ___ as early as possible:

(Treatment for Sepsis/Septic Shock)

Answer 29

two blood cultures as early as possible that are drawn simultaneously from two different sites prior to antibiotic administration.

Question 30

After blood cultures, begin

(Treatment for Sepsis/Septic Shock)

Answer 30

antibiotic therapy as early as possible after recognizing sepsis/septic shock and AFTER blood cultures are drawn; administration within 3 hours of recognition of sepsis/septic shock (preferably within 1 hour of recognition, if possible).
-In one study, for every hour that the antibiotic administration was delayed, there was an ~12% decrease in the survival probability.

Question 31

Obtain …..as early as possible

(Treatment for Sepsis/Septic Shock)

Answer 31

serum lactate as early as possible and remeasure within 2 - 4 hours if the first lactate is 2 mmol/L or greater.

Question 32

Identify
(Treatment for Sepsis/Septic Shock)

Answer 32

the source of infection ASAP (which may direct antibiotic and/or interventional therapy).

Question 33

If the MAP remains below 65 mmHg OR

(Treatment for Sepsis/Septic Shock)

Answer 33

the lactate is 4 mmol?L or greater, REASSESS THE FLUID STATUS.
-Ask a licensed independent practitioner to complete a focused clinical assessment, OR

-Perform an assessment of 2 of the following:
-measure the CVP;
-assess the pt’s fluid responsiveness with either a
passive leg raise or a fluid challenge;
-perform/assess a bedside ECHO;
-measure the ScvO2.

Question 34

For inotropic therapy–

(Treatment for Sepsis/Septic Shock)

Answer 34

DOBUTAMINE is recommended (by itself or in addition to a vasopressor) for pts with cardiac dysfunction, as evidenced by high filling pressures and low cardiac output, or clinical signs of hypoperfusion after successfully restoring the blood pressure with effective volume resuscitation.

Question 35

Oxygenation goals for septic shock:
(Treatment for Sepsis/Septic Shock)

Answer 35

-Maintain SpO2 95% or greater
-Goal = ScvO2 greater than/equal to 70%
or SvO2 greater than/eqaul to 65%
(when CVP and MAP goals are met)

-If ScvO2 or SvO2 goals are not achieved:
-Consider further fluids
-Dobutamine infusion, max 20 mcg/kg/min
-Consider a transfusion of PRBCs if the Hgb is 7.0 or
less

Question 36

Summary of Therapeutic Endpoints for Septic Shock

Answer 36

-MAP greater than/equal to 65
-Decreased lactate/improved base deficit
-Normalization of HR
-UO greater than/equal to 0.5 mL/kg/hr
-Warm extremities
-Mental status return to baseline
-Source control
-Central venous oxygen saturation (ScvO2) greater than/equal to 70% or SvO2 greater than/equal to 65% (if CVP or PA line is available)
-CVP (if available), 8 - 12 mmHg