Sepsis Lecture Flashcards
Labs values across the SIRS and Sepsis spectrum
CBC
CMP
ABG
Procalcitonin
Lactate
Prothrombin time ( PT)
C reactive protein ( CRP)
Creatine Phosphokinase
CBC
WBC
Platelets
H&H
When do we transfuse
When h&h is less than 7
CMP
Electrolytes
Potassium
Sodium
ABG
What our body is balancing
Acidic or alkalosis?
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.
Lactate
Goes up when there is no o2
Body starts producing this
Prothrombin time (PT)
How fast do they clot?
About 12 seconds is normal
Less than 5 ..too fast
Takes a minute.. thin
C reactive protein (CRP)
Measures how much inflammation ..higher it is the more inflammation
CPK
Measures muscle injury .. goes up when there is muscle injury
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
Vitals that we look at in SIRS that must have 2 of the following
Temp (high or low)
HR
RR
Paco2
WBC count & bands
Temp requirement for SIRS
Greater or equal to 100.5F
OR
Less or equal to 96.8F
HR requirement for SIRS
Greater than or equal to 90 bpm
RR requirement for SIRS
Greater than or equal to 20 bpm
Paco2 requirement for SIRS
Less than or equal to 32 mmhg
WBC count for SIRS /bands
> or equal to 12,000
Or < or equal to 4,000
OR
Greater than 10% bands
Nursing management when it comes to maintaining tissue oxygenation
Monitor labs (hemoglobin >7)
Sleep
Low stimulation
Administer sedation as ordered
Nursing management for prevention and treating infection for SIRS
Advocate for removal of lines ASAP
Urinary catheters
CVL
Mobility nursing management for SIRS
How we can promote tissue oxygenation we want to encourage movement to move secretions
active ROM
Passive ROM
Nutritional support with SIRS
Start tpn or tube feedings within 24 hours
Parenteral or enteral
NGT or OGT
SIRS med treatment variety
Antibiotic ( broad, narrow)
Anti fungal
Fluid for dehydration
RA meds
DM control
Gluccosteriods
Antipyretics
Sepsis clinical criteria “SOFA”
Sepsis related
Organ
Failure
Assessment
>2
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)
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
