Sepsis & Septic Shock

Sepsis: Prevalence and Vulnerable Populations

Each year in the U.S.:

• 1.7 million Americans develop sepsis

• Roughly 350,000 die from sepsis

• 1 in 3 patients who die in the hospital has sepsis

The most vulnerable people are:

• Older adults

• Infants

• Pregnant women

• Those with chronic conditions

• Immunocompromised patients

A form of distributive shock that is caused by a cascade of events:

• Initiation of immune system

• Inflammatory products activated

• Vasodilation and blood vessel permeability (decreased SVR)

• Impaired oxygen exchange

• Trigged coagulation products

• Developments of organ failure, ARDS, DIC

Sepsis is …

What are the most common HAIs?

• Catheter Associated Urinary Tract Infection (CAUTI)

• Central Line Associated Blood Stream Infection (CLABSI)

• Ventilator Associated Pneumonia (VAP)

• Surgical Site Infection (SSI)

• Clostridium Difficile Infection (CDI)

Sepsis: Patient Assessment

• Septic patients can present in different ways.

• A thorough assessment is key.

• Make sure to pay attention to labs!

Systemic Inflammatory Response Syndrome (SIRS)

SIRS criteria consists of:

• Heart rate > 90 bpm

• Respiratory rate > 20 rpm

• Temperature > 38.8 C (100.9 F) or < 36.0 C (96.8 F)

• WBC > 12,000/mm3 or < 4,000/mm3 or > 10% bands

• Altered Mental Status

• Glucose > 140 mg/dL in absence of diabetes

**2 or more and you’re positive for SIRS, but not everyone who is positive for SIRS is septic.

SIRS: What are bands?

They are immature WBCs.

Ex: someone’s WBCs went from 5,000 to 9,000—which is WNL, but if their bands are 17%, that means that their body had to ramp up production of WBCs because they have an acute infection.

source of infection; 2

A patient needs to already have a ______ __ _________ along with _ or more of the SIRS Criteria to be considered to have sepsis.

Not everyone who is positive for SIRS is septic. What are some examples?

• A patient having an asthma exacerbation.

• A patient experiencing a panic attack.

• A patient suffering from heat exhaustion.

bacteremia

The biggest source of sepsis is __________.

Sepsis: Nursing Responsibilities

• Recognize early

• Treat promptly:

  • Follow the Sepsis Bundle**

  • Fluid Replacement

  • Pharmacologic

• Astute ongoing assessment

The Surviving Sepsis Campaign (SSC)

Was launched in 2002 as a collaborative initiative of the European Society of Intensive Care Medium (ESICM), the International Sepsis Forum (ISF), and the Society of Critical Care Medicine (SCCM). It is updated every 4 years.

~Sepsis Bundle

Sepsis Nursing Responsibilities Soap Box

• Monitor your patient for trends and report significant changes!

  • Do not just wait for a parameter to cross a predetermined threshold.

Nursing is about anticipation and preemptive action; addressing potential problems before they become actual problems.

• If a patient’s SBP was 130, but now is 95, that’s concerning. If their potassium was 3.8, but now it’s 5.0, that’s concerning. If a patient’s WBC was 5.2, but now it’s 10.2, that’s concerning.

Sepsis Progression

• Infection

• Sepsis (Compensatory)

• Severe Sepsis (Progressive)

• Septic Shock (Irreversible)

• Death or Recovery

Sepsis: Infection Stage

Initial Insult

Infectious Source

• Pneumonia

• UTI Wounds

• Gastrointestinal

• Cellulitis

Sepsis: Sepsis Stage

Compensatory Stage

2 SIRS Criteria

• Temperature

• Heart rate

• Respiratory rate

• WBC

• AMS

• Hyperglycemia

Sepsis: Severe Sepsis Stage

Progressive Stage

Organ Dysfunction

• Bilirubin

• Platelets

• Hypotension

• AKI

• Respiratory failure

• INR/PTT

• Lactic acidosis

Sepsis: Septic Shock Stage

Irreversible Stage

Presence of either:

• Lactic acidosis

• Persistent hypotension

*DIC most likely present

Severe Sepsis: Signs of Organ Dysfunction

• Respiratory P/F ratio < 250 w/o pneumonia, or < 200 w/ pneumonia

• MAP < 65 mmHg, SBP < 90 mmHg, or SBP decrease > 40 from baseline

• Creatinine > 2 mg/Dl

• UOP < 0.5 mL/kg/hr in 6 hours or < 400 mL in 24 hours.

• Bilirubin > 2 mg/dL

• Platelets <100,000/mm3

• INR > 1.5 or aPTT > 60 secs

• Lactate > 2 mmol/L

The Role of Lactate

• Lactate is an indicator of global tissue hypoxia.

• Increased lactate levels are associated with increased morbidity and mortality.

• Lactate levels are used to guide resuscitation efforts.

persistent hypotension; lactic acidosis

Septic shock is classified by __________ ___________ and/or ______ ________ (lactate > 4 mmol/L)

Sepsis 1-Hour Bundle

Our Priorities:

1. Obtain lactate level

2. Obtain blood cultures x2 (from two different sites, aerobic + anaerobic—so technically 4)

3. Administer fluids

4. Administer broad spectrum antibiotics

5. Administer vasopressors if needed

6. Constantly reassess

Sepsis: Broad Spectrum Antibiotics

• Multiple antibiotics can be used; check for compatibility.

• Delay in antibiotic administration is linked to increased mortality.

Administer IM, PO, or IO

If you can’t get IV access on your patient for broad spectrum antibiotics…

Broad Spectrum Antibiotics Compatibility

Incompatible medications can do many things when mixed:

• Antagonizing (nullifying) effects

• Precipitation (crystallization)

• Consistency changes

• Gas production, all of which are harmful to our patients!

Always check for compatibility within your documentation software. When in doubt, call the pharmacist!

Sepsis: Fluid Resuscitation

30 cc/kg of isotonic crystalloid solution

• Normal Saline

• Lactated Ringers

Calculation should be made using Ideal Body Weight (IBW)

FALSE! A history of heart failure does not exempt a patient from receiving a fluid bolus! Careful monitoring is required!

T/F: A history of heart failure exempts a patient from receiving a fluid bolus because it’s too dangerous.

Sepsis: Persistent Hypotension and Vasopressors

IF:

• BP is measured every 15 minutes post-fluids, so…

• Two consecutive low BP readings indicates persistent hypotension…

THEN:

• Vasopressors should be started without delay!

Norepinephrine (Levophed)

What is our first-line vasopressor in septic shock?

Persistent Hypotension and Vasopressors: Norepinephrine Dose + Receptor

Dose: 0.1-0.5 mcg/kg/min, titrate to effect

Receptor: a1 & b1

33.75 mL/hr

You are caring for a patient diagnosed with septic shock and who requires pharmacological blood pressure support. He weighs 198 lbs.

Order: Start norepinephrine IV drip at 0.1 mcg/kg/min and titrate to keep the patient’s MAP >65 mmHg.

Supply: Pharmacy provides you with the medication shown to the right.

What initial setting will you program your IV pump to deliver this medication at in mL/hr.?

Sepsis: Additional Medications

• Volume Expanders (such as albumin)

  • To increase intravascular volume and improve BP (if fluids don’t work)

• Corticosteroids (such as hydrocortisone)

  • Reduce inflammatory response, inhibit creation of nitrous oxide (vasodilator) by endotoxins

• PPIs (such as pantoprazole)

  • To protect the gut from stress ulcers/bleeding

• Other medications may include antipyretics for fever, insulin for hyperglycemia, and a LMWH for VTE prophylaxis.