Sepsis 3 Flashcards
Sepsis Guidelines: First 3 hrs in ED
1) Start an IV (1 or 2) and draw blood
2) Check O2 via pulse Ox, give 2-4 L of O2
3) Get them on EKG/monitor & Vitals
4) Get a culture from sputum and blood
Need Physician order for:
5) Antibiotics: Vancomycin, Levoquin, Flagyl, Rocephin
6) Normal Saline Solution (2-3 L), want MAP >65 and CVP 8-12
7) Foley to measure urine output
8) CXR or CT (diagnostic test)
Sepsis Guidelines: >6 Hrs (ICU)
1) Put in a hemodynamic catheter (precep Cath: monitors CVP, SCVO2, cardiac output)
2) ART line: give BP and way to draw blood
3) Draw more blood: lactate level, CRP, D dimer (see whats going on), platelet counts
4) Intubate and give PAP or PEEP (increase pressure) PRONE them (turn regardless every 2 hrs)
5) Sedate (precede aka dexmethetomadate)
6) Give Diuretic (Lasix) & Antibiotics for ARDS
7) Give vasopressor (Norepi and vasopressin) for DIC** and heparin for platelets/FFP
8) Nutrition (enteral feedings, glucose control (insulin drip), dialysis (CRRT), Reglan IV
9) Lovenox (to prevent DVT)
normal pCO2
35-45
HCO3
22-26
paO2
80-100
ScVO2
70-80
first phase of septic shock
warm: hyperdynamic
s/s of warm first phase of septic shock
Increased C.O. Peripheral vasodilation Decreased SVR Change LOC Rapid, shallow breathing Decreased urine output Rapid, bounding pulse
second phase of septic shock
Decreased C.O. Vasoconstriction Increased SVR Inadequate tissue perfusion Pale, cyanotic Mottling extremities Absent urine output
treatment of septic shock
*find the cause of infection (do whole panel of lab work and blood cultures (2 cultures: 1) aerobic and THEN 2) anaerobic)
Remove source of infection
Aggressive antibiotics
Vasopressors with Epinephrine or Norepi and Vasopressin
Mechanical ventilation
Sedation- BIS sedation monitor
when do you give antibiotics and fluids if septic shock
before cultures even come back (if suspected/criteria)
what are blood cultures checking for
checking for sepsis: has infection gone from the site of origin to generalized blood stream??
what is often the first indication of DIC
petechiae
sepsis is the _____ most
common principal reason for
hospitalization in the U.S. with
6th
what is sepsis
Way the immune system responds to infection
what can DIC lead to
Become gangrenous and clot off (cause perfusion, lose peripherals/limbs)
6 Steps of Sepsis Protocol: separated into 6 hr time frame
1) High Flow oxygen
2) blood cultures
3) IV antibiotics
4) IV fluid resuscitation (crystalloids)
5) measure lactate
6) measure urine output and strict fluid balance
during the first 6 hours of sepsis what are the goals
1) Oxygen, lab work, etc
2) **GOAL keep CVP up (8-12) and want BP to be good so give 2-3 L of saline
3) Give oxygen at 4 L
4) Systemic venous oxygenation: want 70-80
goals of initial resuscitation
a) CVP 8–12 mm Hg
b) MAP ≥ 65 mm Hg
c) Urine output ≥ 0.5 mL/kg/hr
d) Scvo2 ≥ 70%. Systemic venous oxygenation (still being delivered to organs in body)
what is a presep sepsis catheter
short line, goes in like a swan and measures venous oxygenation and ScvO2
what are crystalloids
saline
Sepsis and septic shock are ___________
medical emergencies
first steps in sepsis diagnosis
Identify SOURCE: use blood cultures, wound, sputum
Start antibiotics IMMEDIATELY before culture comes back
what meds are recommended for sepsis (priority)
combination antibiotics-broad spectrum (usually at least two, anaerobic and aerobic)
what vasoactive agents are given
Norepi because it vasoconstricts and pushes fluid INTO heart and keeps BP up
Add vasopressin next because it stops bleeding (if DIC) and natural ADH
if shock is not resolving quickly…
further hemodynamic assessment (such as assessing cardiac function) to determine the type of shock
what can help guide resuscitation
normalizing lactate levels
frequent assessment of _____ is crucial during resuscitation period.
patients volume status
who is often the screening system for sepsis in the hospital setting
nurses
does sepsis require reporting
yes mandated public reporting
what drugs are not recommended for sepsis and why
Against using corticosteroids- goes against fighting infection
what position should a pt in sepsis (and specifically ARDS*) be in?
- *PRONE positioning: turn patient on their stomach!!
- TURN PT EVERY TWO HOURS regardless
- put sheets over them, and turn onto stomach (bring all junk out of lungs)
- prone allows full expansion of lungs: do it once a shift ( leave them for 4 hrs)
We suggest using ___________ in adult patients with sepsis-induced ARDS.
higher PEEP over lower PEEP
what type of tidal volume should be used with ARDS pt
lower tidal volume to prevent lung capacity damage
what needs to be monitored hourly in sepsis pt
Control blood sugars (hourly glucose monitoring )
Acucheck every hour (can go up to 120, try to keep below that)
Want glucose in system to fight infection! –put pt on insulin drip
Always have_____ in sepsis pt as it is the best way to draw blood
art line
why is reglan given
to keep the stomach empty
why is NG given
to keep stomach decompressed and prevent them from vomiting
complete within 3 hrs
1) Measure lactate level
2) Obtain blood cultures prior to administration of antibiotics
3) Administer broad spectrum antibiotics
4) Administer 30 mL/kg crystalloid for hypotension or lactate 4mmol/L
complete within 6 hrs
5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation)
to maintain a mean arterial pressure (MAP) 65 mm Hg
6) In the event of persistent arterial hypotension despite volume resuscitation (septic
shock) or initial lactate 4 mmol/L (36 mg/dL):
- Measure central venous pressure (CVP)*
- Measure central venous oxygen saturation (ScvO2)*
7) Remeasure lactate if initial lactate was elevated*
*Targets for quantitative resuscitation included in the guidelines are CVP of 8 mm Hg, scVo2 > 70%
