Sepsis Lecture Flashcards by Elizabeth Gausin

Labs values across the SIRS and Sepsis spectrum

CBC
CMP
ABG
Procalcitonin
Lactate
Prothrombin time ( PT)
C reactive protein ( CRP)
Creatine Phosphokinase

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CBC

WBC
Platelets
H&H

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When do we transfuse

When h&h is less than 7

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CMP

Electrolytes
Potassium
Sodium

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ABG

What our body is balancing
Acidic or alkalosis?

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Procalcitonin

Comes up when an infection is present
Anytime inflammation starts there is swelling.
That’s what happens when we have an infection , inflammation starts so that’s what causes Procalcitonin goes up. Leave is typically less than 0.1.

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Lactate

Goes up when there is no o2
Body starts producing this

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Prothrombin time (PT)

How fast do they clot?
About 12 seconds is normal
Less than 5 ..too fast
Takes a minute.. thin

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C reactive protein (CRP)

Measures how much inflammation ..higher it is the more inflammation

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CPK

Measures muscle injury .. goes up when there is muscle injury

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Bands

Immature leukocytes.. babies
More than 10% bands shows us our body has used up all of its mature leukocytes
Very sick pt and has been sick for awhile

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Vitals that we look at in SIRS that must have 2 of the following

Temp (high or low)
HR
RR
Paco2
WBC count & bands

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Temp requirement for SIRS

Greater or equal to 100.5F
OR
Less or equal to 96.8F

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HR requirement for SIRS

Greater than or equal to 90 bpm

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RR requirement for SIRS

Greater than or equal to 20 bpm

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Paco2 requirement for SIRS

Less than or equal to 32 mmhg

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WBC count for SIRS /bands

> or equal to 12,000
Or < or equal to 4,000
OR
Greater than 10% bands

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Nursing management when it comes to maintaining tissue oxygenation

Monitor labs (hemoglobin >7)
Sleep
Low stimulation
Administer sedation as ordered

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Nursing management for prevention and treating infection for SIRS

Advocate for removal of lines ASAP
Urinary catheters
CVL

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Mobility nursing management for SIRS

How we can promote tissue oxygenation we want to encourage movement to move secretions
active ROM
Passive ROM

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Nutritional support with SIRS

Start tpn or tube feedings within 24 hours
Parenteral or enteral
NGT or OGT

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SIRS med treatment variety

Antibiotic ( broad, narrow)
Anti fungal
Fluid for dehydration
RA meds
DM control
Gluccosteriods
Antipyretics

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Sepsis clinical criteria “SOFA”

Sepsis related
Organ
Failure
Assessment
>2

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S/s of sepsis

PaO2/Fio2- 200 or less
Hypotension Or vasopressors
Platelets <150,000
Glasgow coma scale 3-8
Billiruben - increased
Creatine increase , oliguria ( decrease UO)

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How much urine out put we want in the ICU

0.5 mL/kg/Hr

How we figure out the fluid resuscitation?

30mL/kg

How many hours is fluid resuscitation done over for a sepsis patient

Over 3 hours

How many hours is a fluid resuscitation done over for a septic shock patient?

Over one hour

What CVP do we want a septic patient at

8-12 mmHg

What do we want our MAP to be over for septic pt

I over 65 mmHg

Two labs we are monitoring for sepsis pt to see if progressing?

Pro calcitonin and lactic acid

Criteria for a septic shock pt

SIRS plus confirmed infection MAP <65 mmHg Serum lactate > or equal to 2 molecules/l Vasopressors Organ dysfunction

Serious organ dysfunction occurs in

Heart , lungs, liver, kidneys

Lactic acid lab in septic shock

Repeat if > or equal to 2 mmol/l

ABG in septic shock pt

Pao2 <60

Sign of kidney failure in septic shock

Creatine >2.0 or urine output <0.5/mL/kg/hr

Liver lab septic pt

Bilirubin >2 mg /dL

Hematology labs septic shock

Platelets <100,000 INR >1.5 or PTT >60 seconds CRP and ESR

What do we want to maintain the paO2 in septic shock treatment

Pao2 >75 preferably 80

DIC lab values

Decrease fibroses Decrease platelet count Increase activated PTT and PT Increase D-dimer

Types of blood products

Plasma Platelets Cryo RBC Albumin

Which blood products need a consent form

Plasma, platelets, cryo, RBC

Why should you give blood with NS

Lactated ringers will clot the blood

PRBC

No clotting factored Give for strictly hemoglobin to increase o2 status

What is important to do before giving blood products

Assessing vitals such as fever to assess baseline

Why should we stay with the pt after giving blood

Assess for allergic reaction

If pt starts complaining they feel funny after receiving blood products what do you do

Stop the infusion , d/c the line and call the doc

Platelets blood product

From multiple or single donor Does have coag If low on platelets give this

FFP

Albumin , givin for volume and for time?

Cryo blood products

Has clotting factors

When giving blood what do we keep in mind about tubing

Use the one with special filter When priming the line put NS down first then the blood

3 main focus on labs

CRP Lactic acid Procalcitonin

106 F

Not compatible with life

Improper thermoregulation

Hypothermic

When a pt has a picc line what is important to assess

Touch the site, compare arm lengths and check for swelling or s/s of infection

Tube feeding go through

NG , OG tube, enteral You should never insert through IV line

TPN

Through line, picc line, central line Parenteral

How do we know fluid resusitation is effective in sepsis

Increase BP Cap refill comes back Skin temp - warm ( not too warm or cold) Urine output greater than 0.5mL /kg/hr CVP - 8-12mmhg MAP greater than 65

Lab to monitor in sepsis

Lactic acid

What is it important to maintain in sepsis

Bed rest , we want to maintain tissue oxygenation with pt Keep them sedated

If you are having problems with pt staying acidotic

NS is acidotic..see if you can change the fluid to d5 if you are trying to get the ptt out of being acidotic

Sepsis treatment in orrrder

1)Administer crystalloid bolus for hypotension 2)Blood cultures 3)Antibiotics (within 3 hrs ) , continue until WBC is less than 10,000 4)measure lactate level -repeat >or equal to 2 Vasopressors if not responsive to fluid resusitation

How quick to have antibiotics for pt in septic shock

Within 1 hr

In sepsis treatment we administer vasopressors if the pt is not responsive to fluid .. what is our first in line we administer?

We would pick norepinephrine and a vasopressin (antidiuretic) to hold fluid to increase volume We would not pick dopamine because it is like the incredible hulk

Since respiratory blood vessels get damaged in septic shock.. what do we see in this?

Acute respiratory distress syndrome Severe hypoxemia Need to be mechanically ventilated

When assessing a pt with septic shock- what cardiac vitals are we looking out for?

SBP <90 / and or MAP <65 We are looking for hypotension

When drawing lactic acid.. what is important to keep in mind ?( septic shock nursing management slide but same as before)

Repeat if > 2 mg/dL Put it on ice and take it to lab yourself

Organ specific lab

Kidneys creatine >2.0 or urine output <0.5mL/kg/hr

Vasopressors medication

Norepinephrine Vasopressin Pnenylephrine Dopamine

What kind of shock is DIC

Obstructive

DIC leads to excessive bleeding such as

Bleeding from various sites Petechiae Hematuria Oozing from IV sites GI bleeding oozing gums

DIC changes from obstructive shock to

Hypovolemic shock

What makes a clot

Fibrinogen and platelet Which is why it is decreased in DIC

How can we identify early bleeding in DIC

Assess pt for bleeding Thrombocytopenia Petechiae Bruising Black tarry stools Black or coffee grounds emesis Black or bloody sputum or urine Headache change in Vision Cap refill prolong

What can we teach pt with DIC management

Report pain in the extremity Avoid meds that can prolong bleeding Avoid garlic Do not blow nose forcefully Do not bed down head lower than waist Do not use a suppository , enema ,or tampon Mom at risk Lovonox- as prevention Consent form (plasma , platelets , cryo , RBC)

Goal for DIC

Prevent or control hemorrhage

What can be given as prevention for DIC

Lovonox

What are things that can indicate DIC in assessment

Cap refill is unequal on both sides If one arm is warm and the other is cold

If pt is in the bleeding stage in DIC we should teach

Not to be taking ibuprofen , aspirin Are they eating garlic?

Why should someone at risk for DIC bend their head lower than the waist

Increase ICP and could cause hemorrhagic bleed in the brain

RBC product MUST

Use blood tubing w filter and primed w 0.9% sodium chloride Must be cross matched No plasma no platelets

AFH - blood transfusion reaction

Allergic Febrile Hemolytic

“A”-allergic- mild

Mild Facial flushing Hives/rash

A - allergic -severe

Increased anxiety Wheezing Decrease BP

F- febrile

Headache Tachycardia Tachypnea Fever/chills Anxiety

H- hemolytic

Decrease BP Increased RR Hemoglobulinuria Chest pain

Albumin

Does not require consent form Pulls into the intravascular space

What happens first typically when MODS is present

Pulmonary/resp dysfunction

BROAD SPECTRUM

Broad spectrum - levofloxacin, piperacillin/tazobactam, ceftriaxone, meropenem, cefepime

What do we maintain oxygenation at for sepsis shock

>75 prefer 80

What do we want our blood sugar at for SIRS

180 or less