Sepsis

Question 1

What is the definition of sepsis?

Answer 1

Defined; a life threatening condition that arises when a body’s response to an infection injures its own tissue and organs. - Sir William Osler 1904

Question 2

Sepsis patients that are treated within the first hour have an __% survival rate. After 6 hours that rate drops down to __%.

Answer 2

80

30

Question 3

What is the 4 step progression for SIRS and at what point does treatment need to begin?

Answer 3

The progression is SIRS => Sepsis => Severe Sepsis => Septic Shock
The condition needs to be identified and treatment needs to be initiated at the point of sepsis.

Question 4

What does SIRS stand for? What is it?

Answer 4

SIRS- Systemic Inflammatory Response Syndrome: The clinical syndrome that results from a deregulated inflammatory response or to a non-infectious insult

Question 5

what is the SIRS criteria? (5)

Answer 5

Temp above 101F (38.3C) or less than 96.8F (36.0C)
Heart Rate greater than 90 BPM
Respirations greater than 20 per minute
WBC count greater than 12,000 per ml or less than 4000 per ml or 10% bands (immature WBC)
Sepsis is the presence of 2 or more SIRS criteria AND a known or suspected infection.

Question 6

What is severe sepsis?

Answer 6

Severe sepsis: the presence of sepsis along with any one sepsis induced organ dysfunction.

Question 7

Severe sepsis is the presence of sepsis along with any one sepsis induced organ dysfunction. Name 8 clinical indicators

Answer 7

Hypoperfusion 
Lactate greater than 2mmol/dl 
Decreased urinary output
Decreased platelets. 
Acute altered mental status 
Decreased capillary refill 
Increased creatinine 
Increased coagulopathy

Question 8

What is septic shock?

Answer 8

Septic shock: severe sepsis AND tissue hypoperfusion despite fluid administration

Question 9

Name three clinical indicators of septic shock.

Answer 9

SBP less than 90 or a decrease greater than 40mmhg from baseline
MAP less than 65
Lactate greater than 4 mmol/dl

Question 10

WHAT is time zero?

Answer 10

Time Zero- The time when the patient meets all of the criteria for severe sepsis is called Time Zero

Question 11

What is the criteria for severe sepsis?

Answer 11

Known or suspected infection AND 2 or more SIRS criteria AND Organ dysfunction = Severe sepsis

Question 12

WHEN is time zero?
How should the RN respond?
(6)

Answer 12

Known or suspected infection AND 2 or more SIRS criteria AND Organ dysfunction = Severe sepsis
If the patient arrives with all criteria met then triage time is Time Zero
Time Zero is when the clock starts for 3 hour and 6 hour bundles
Time Zero and source of infection should be documented by the physician or advanced practice clinician.
ED and admitting physician should be communicate sepsis and time zero during handoff
Nursing will use the “PURPLE” sepsis alert sheet to communicate tasks completed from ER to floor or from floor to floor.

Question 13

Severe Sepsis/Septic shock Early Management Bundle (SEP-1). What is it?

Answer 13

3 Hour bundle: Required for severe sepsis to be completed within 3 hours of time zero

Question 14

What does the 3 hour bundle consist of?

5

Answer 14

Measure lactate level; it is a tissue hypoperfusion marker
Order “Initial Sepsis” and it will automatically re-order in 5 hours, if the result is greater than 2 mmol/l
Obtain Blood cultures prior to administration of antibiotics
Administer 30ml/kg crystalloid BOLUS
Administer broad spectrum antibiotics (first than combo of needed)
Document input and output
- Sepsis protocol Order set required.

Question 15

What does the 6 hour bundle consist of?

9

Answer 15

Broken down in other cards

• Re-measure lactate level, if initial lactate is elevated. Order will be automatically generated if the first result was greater than 2mmol/L
• Document reassessment of volume status and tissue perfusion after initial fluid resuscitation. (Must complete “A” or 2 from “B”)
• Repeat focused exam (vital signs, cardiopulmonary, capillary refill, pulse and skin findings)
• Measure CVP, Measure ScvO2, cardiovascular ultrasound, dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge. (Must complete 2)
• Consider administering subsequent crystalloid fluid CHALLENGE
• Apply vasopressors: hypotension that does not respond to initial fluid resuscitation, maintain a MAP greater than 65mmHg
• Begin vasopressor therapy immediately of two consecutive post bolus BP’s are less than 90mmHg or MAP is less than 65.
• **Sepsis protocol Order Set Required
• Physician must also document “I have completed a Sepsis Perfusion Exam”

Question 16

Part of the 6 hour bundle is repeating this level automatically generated with a value greater than 2.

Answer 16

Re-measure lactate level, if initial lactate is elevated. Order will be automatically generated if the first result was greater than 2mmol/L

Question 17

In the 6 hour bundle, what are three things that should be documented?
(4)

Answer 17

• Document reassessment of volume status and tissue perfusion after initial fluid resuscitation. (Must complete “A” or 2 from “B”)
• Repeat focused exam (vital signs, cardiopulmonary, capillary refill, pulse and skin findings)
• Measure CVP, Measure ScvO2, cardiovascular ultrasound, dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge. (Must complete 2)
• Physician must also document “I have completed a Sepsis Perfusion Exam”

Question 18

In the six hour bundle, when should you consider vasopressors?

Answer 18

Apply vasopressors: hypotension that does not respond to initial fluid resuscitation, maintain a MAP greater than 65mmHg
-Begin vasopressor therapy immediately of two consecutive post bolus BP’s are less than 90mmHg or MAP is less than 65.

Question 19

If physician or Advanced Practice Clinician identifies / documents that a patient has severe sepsis or septic shock they MUST do these 4 things:

Answer 19

Document Time Zero
Source of infection
Use the IHN Sepsis protocol order set.
If a positive qualifier is used while documenting, the Sepsis Protocol order set must be followed to meet CMS standards