Sepsis Flashcards
sepsis
life threatening organ dysfunction caused by dysregulated response to infection occurring when microorganisms invade the body and initiate a systemic inflammatory response
causes of increased prevalence of sepsis
bigger awareness of sepsis/septic shock, aging population ( w/ chronic illnesses), antibiotic-resistance, increase of invasive procedures being done, increased use of immunosuppressant and chemotherapy agents
factors for increased mortality risk
65 +, hyperglycemia on admission, inability to clot, site of infection (if unknown, GI, or pulmonary), type of infection, and restoration of perfusion
“q sofa” screening
GCS less than 15, systolic bp less than 100, and a respiratory rate greater than 22; if you have 2/3 in a pt with a suspected infection, think sepsis
septic shock criteria
vasopressor required to maintain MAP of 65, serum lactate level greater than 2, and absence of hypovolemia
septic shock
a subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality
pathophysiology of sepsis
body’s immune response is triggered in response to pathogen, WBCs release inflammatory mediators and cytokines resulting in vasodilation, capillary leakage (–> third spacing), and blood clotting; there isn’t enough blood to get to organs (hypoperfusion); metabolic acidosis occurs (organs aren’t getting the blood they need and can’t get excrete waste products that are building up and kidneys can’t make enough HCO3 to balance out the blood pH); evolves to septic shock if the patient has received fluid resuscitation but their blood pressure isn’t responding; evolves to MODS when 2 or more organs have failed
SIRS
(not in new definition but still used) temperature greater than 38C (100.4) or less than 36C (96.8), HR above 90 bpm, RR over 20 or PaCO2 less than 32, and WBC greater than 12,000 or less than 4,000; need 2 or more to dx
SIRS –> Sepsis
2/4 SIRS with a suspected or confirmed source of infection
severe sepsis
sepsis + dysfunction of 2 or more organ systems r/t hypoperfusion
organ dysfunction/failure criteria
respiratory usually fails first –> tachypnea or low O2 sat; liver failure –> jaundice, elevated liver enzymes or bilirubin greater than or equal to 4; renal –> decreased UOP (should be 0.5ml/kg/hr), Cr greater than 0.5 from baseline; bone marrow –> plt less than 100 or INR greater than 1.5; CNS –> altered LOC/confusion/delirium; CV –> HR above 90, dysrhythmias, SBP below 90 or decreased 40 from baseline, altered CVP/PAWP; lactate greater than 2, stress ulcers r/t decreased GI perfusion
sepsis –> septic shock
severe sepsis + refractory hypotension (given fluids but not helping bp rise) and lactic acidosis (lactate greater than 2)
septic shock criteria
MAP less than 65 or SBP less than 90/decreased 40 from baseline; no improvement after fluid resuscitation
fluid resuscitation
30ml/kg crystalloid solution within first 3 hrs, additional fluids depend on reassessment of hemodynamics; usually NS, might add albumin
diagnosis of sepsis
2 sets of aerobic and anaerobic testing from different sources, appropriate microbio cultures, gram-stains
antimicrobial therapy
empiric broad-spectrum antibiotics, at least 2 antibiotics within different antimicrobial classes (if septic shock) for 7-10 days, eval procalcitonin levels to know when to de-escalate antibiotic administration
vasoactive therapy
use when fluid resuscitation has not achieved MAP of at least 65; norepinephrine is first choice, might add vasopressin/epinephrine to decrease norepinephrine dosage
corticosteroid therapy
MAP still not sufficient after the use of fluid resuscitation AND vasoconstrictors; hydrocortisone 200mg/day
blood products for sepsis
platelets given if count less than 10,000 and pt is not bleeding, with active bleeding plt count at or above 50,000; PRBC if Hgb less than 7 or s/s of cardiac ischemia/hemorrge
mechanical ventilation with sepsis
development of ARDS –> high levels of PEEP to get PaO2 to tolerable level; prone positioning if PaO2/FiO2 ratio less than 150; TV 6ml/kg (predicted body weight); plateau pressure less than or equal to 30; with spontaneous awakening trials and minimal sedation
glucose control
IV insulin if 2 consecutive blood sugars above 180; goal to keep below 180; recommend using arterial blood for accurate results
renal replacement therapy
continuous –> dialysis, intermittent –> “sled” dialysis at bedside but not for 24 hr+; use if pt hemodynamically unstable r/t fluid balance
VTE prophylaxis
lovenox or mechanical prophylaxis
stress ulcer prophylaxis
PPI or H2 receptor antagonist
nutrition
enteral feedings preferred over parenteral; might give dextrose to supplement
setting goals of care
discuss treatment plan, end-of-life planning, palliative care option, address topics early (w/i 72 hours of ICU admittance)
Surviving Sepsis Campaign (SSC) 1 hour bundle
measure lactate, repeat if above 2; obtain blood cultures prior to antibiotic admin; administer broad-spectrum antibiotics; initiate rapid fluid resuscitation at 30ml/kg for hypotension or lactate greater than or equal to 4; apply vasopressors to increase bp if fluid resuscitation cannot achieve MAP of 65 or greater
potential nursing diagnoses
deficient fluid volume r/t relative loss, decreased cardiac ouput r/t alterations in preload, decreased cardiac output r/t alterations in contractility; impaired gas exchange r/t VQ mismatch or intrapulmonary shunting
