Sepsis powerpoints
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ASSESSMENTUncomplicated Sepsis, Severe Sepsis,
& Septic Shock
Susie Brishaber, RNAugust, 2012
AssessmentClinical Manifestations All Sepsis categories hold
the same general clinical manifestations
Hyperthermia (>38 degrees Celsius)
Hypothermia (<36 degrees Celsius)
Difficulty Breathing (Tachypnea, >20 BPM)
Tachycardia (HR > 90) Warm skin, possibly
rash Generalized Weakness High WBC count
(>12,000 µL-1) Low WBC count
(<4,0000 µL-1) Coagulation Imbalance
Severe Sepsis – in addition to general clinical manifestations
Is categorized by having one or more vital organs affected
◦ Lungs
◦ Heart
◦ Kidney
◦ Liver
◦ Central Nervous System
Assessment Clinical Manifestations
Severe Sepsis –
RENAL SYSTEM:
Serum Creatinine level > /= 177 µ mol/L
Oliguria (Output of < 0.5 ml/Kg/ hr., if adequate fluid resuscitation)
CARDIOVASCULAR:
Hypotension (Systolic < 90 mm Hg, Diastolic < 60mm Hg)
Atria or Ventricular Rhythms
MAP < 65
Assessment Clinical Manifestations
LIVER◦ Jaundice◦ Increased levels of Hepatic Enzymes
AST > 48 U/L ALT > 55 U/L PT > 10.8 seconds INR > 1.5 PTT > 60 seconds
IMMUNILOGICAL◦ Nosocomial Infection development◦ Increase Leukocytosis◦ Fever (>100.0)
AssessmentClinical Manifestations
NEUROLOGICAL
◦ Altered LOC
◦ Altered CNS function
◦ Encelopathy
ENDOCRINE
◦ Hyperglycemia (in absence of Diabetes, >140)
◦ Weight loss
◦ Cachexia (Muscle atrophy)
AssessmentClinical Manifestations
Skin
◦Poor tissue perfusion
Lactic Acid Level (>5 mmol/L)
Edema (With fluid management)
Assessment Clinical Manifestations
Activity Intolerance
Acute Pain
Anxiety
Chronic Pain
Decreased Cardiac Output
Impaired Gas Exchange
Nursing Diagnosis
Process of PES
P = Problem statement/diagnostic label/definition
E = Etiology/related factors/causes
S = Defining characteristics/signs and symptoms
Nursing Diagnosis
Etiology/Related Factors/Causes
Sepsis can be caused from many different
infections in different areas of the body. With
each body system, bacteria has a place to
grow if given the chance.
The lungs are the major source of infection in severe sepsis (especially with hospital-acquired infections), with sepsis usually associated with pneumonia.
Lungs
Infection in the abdomen, eg, appendicitis, bowel problems, gallbladder infections. When the outer surface of the abdominal organs (called the peritoneum) is involved in the infection, it is called "peritonitis.“
Diabetic patients are also at increased risk of urinary infections leading to sepsis. Sometimes this is referred to as "urosepsis" which just refers to sepsis related to a urinary tract infection.
(Surviving Sepsis Campaign)
Bowels and Kidney
Bacteria enter the skin through wounds and skin inflammations; they also enter the skin and blood through an opening provided by intravenous ("IV") catheters (small tubes for dripping fluids), which are required for the administration of fluids and/or medicines.
Skin
Surviving Sepsis Campaign◦ Setting Aims◦ Establishing Measures◦ Creating a Protocol◦ Enhancing Reliability◦ Testing Changes
PlanningWhat do we do?
PlanningSepsis Algorithym (Surviving Sepsis Campaign)
The goal is to perform all indicated tasks 100%of the time within the first 6 hours of identification of severe sepsis.
The tasks are: 1. Measure serum lactate 2. Obtain blood cultures prior to antibiotic
administration 3. Administer broad-spectrum antibiotic, within 3 hrs.
of ED admission and within 1 hour of non-ED admission
PlanningSepsis Resuscitation Bundle
4. In the event of hypotension and/or a serum lactate > 4 mmol/L◦ a. Deliver an initial minimum of 20 ml/kg of crystalloid or an
equivalent◦ b. Apply vasopressors for hypotension not responding to initial fluid
resuscitation to maintain mean arterial pressure (MAP) > 65 mm Hg 5. In the event of persistent hypotension despite fluid
resuscitation (septic shock) and/or lactate > 4mmol/L◦ a. Achieve a central venous pressure (CVP) of > 8 mm Hg◦ b. Achieve a central venous oxygen saturation (ScvO2) > 70 % or
mixed venous oxygen saturation (SvO2) > 65 %
(Surviving Sepsis Campaign)
Planning Sepsis Resuscitation Bundle
Efforts to accomplish these goals should begin immediately, but
these items may be completed within 24
hours of presentation for patients with severe sepsis or septic
shock.
1. Administer low-dose steroids for septic shock in accordance
with a standardized ICU policy. If not administered, document why
the patient did not qualify for low-dose steroids based upon the
standardized protocol.
PlanningSepsis Resuscitation Bundle (Surviving Sepsis Campaign)
2. Administer drotrecogin alfa (activated) in
accordance with a standardized ICU policy. If not
administered, document why the patient did not
qualify for drotrecogin alfa (activated).
3. Maintain glucose control > 70, but < 150 mg/dl
4. Maintain a median inspiratory plateau pressure (IPP)*
< 30 cm H2O for mechanically ventilated patients
Sepsis Resuscitation Bundle Cont.
Apache II Score
Measure Serum Lactate Levels
Blood cultures
Initiate IV Antibiotic Therapy
Treatment of Hypotension
Keep oxygen saturation stable/Ventilator
Implementation
Broad Spectrum Antibiotics should be administered within 3 hours of suspected Severe Sepsis or Septic Shock
Blood cultures need to be drawn before antibiotics are started
Implementation
Treat Hypotension
If presenting with hypotension and/or lactate level of
>4 mmol/L give 20mL/kg of crystalloid solution
◦ Lactated Ringer’s
◦ Normal saline
Fluid administration to reach a CVP of >8mm Hg
Implementation
When patients do not respond to initial fluid resuscitation, use vasopressor therapy to maintain a MAP > 65mm Hg◦ Dopamine◦ Norepinephrine
◦ Titrate according to protocol
Implementation
Blood cultures should be re-evaluated in 48 hours to determine specific antibiotic therapy
Continue monitoring patient’s vital signs till hemodynamically stable
Follow protocols for PICC dressing, hand washing, dressing changes, and peri care
Evaluation
http://www.survivingsepsis.org/What_You_Should_Know/Pages/default.aspx
http://www.nigms.nih.gov/Education/factsheet_sepsis.htm
http://www.merckmanuals.com/professional/critical_care_medicine/sepsis_and_septic_shock/sepsis_and_septic_shock.html
http://www.merckmanuals.com/home/infections/bacteremia_sepsis_and_septic_shock/sepsis_and_septic_shock.html
References
http://www.survivingsepsis.org/SiteCollectionDocuments/Pathophysiology%20of%20Sepsis%20Phil(2).pdf
Surviving Sepsis Campaign, 2010 Dellinger, P., Levy, M., Carlet, J., Bion, J., Parker, M.,
Jaeschke, R.,et al (2008). Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock. Critical Care Medicine, 1-33, DOI: 10.1097/01.CCM.0000298158.12101.41.
References
Wesley, E., Kleinpell, R., Goyette, R., (2003). Advances in the understanding of clinical manifestations and therapy of severe sepsis: An update for critical care nurses. American Journal of Critical Care, 12(2),120-133. Retrieved from http://ajcc.aacnjournals.org/content/12/2/120.full
References