sepsis and septic shock: part 2

complex 4

pathophysiology of sepsis

• initiation of immune system

• inflammatory product activated

• vasodilation and blood vessel permeability (decreased SVR)

• impaired oxygen exchange

• triggered coagulation products

• development of organ failure, ARDS, DIC

infection contributing factors

• use of invasive procedures

• indwelling medical devices

• antibiotic resistant microbes

• aging population with more comorbidities

• spread of multidrug resistant organisms

s/s of sepsis

• S- shivering, fever, or very cold

• E- extreme pain or general discomfort (worst ever)

• P- pale or discolored skin

• S- sleepy, difficult to rouse, confused

• I- “i feel like i might die”

• S- SOB

*in older adults, confusion with/without agitation along with tachypnea may be first sign of infection and sepsis

SIRS - systemic inflammatory response syndrome

SIRS criteria consist of:

1. tachycardia > 90bpm

2. tachypnea > 20bpm

3. hyperthermia > 38.3 C (101 F)

4. hypothermia < 36.0 C (96.8 F)

5. leukocytosis (WBC > 12,000/mm3)

6. leukocytosis (WBC < 4,000/mm3)

7. bands >/= 10% bands

8. altered mental status

9. glucose > 140 mg/dL in absence of diabetes

*2 or more SIRS criteria plus infection equals sepsis!

ppl + for SIRS without sepsis

• pt having an asthma exacerbation

• pt experiencing a panic attack

• pt suffering from heat exhaustion and other conditions

sepsis progression

• infection - pneumonia, UTI, wounds, gastrointestinal, cellulitis

• sepsis - temp, HR, RR, WBC, AMS, hyperglycemia (2 SIRS criteria)

• severe sepsis (organ dysfunction) - bilirubin, platelets, hypotension, AKI, resp failure, INR/PTT, lactic acidosis

• septic shock - lactic acidosis, persistent hypotension (presence of either)

• death or recovery

septic shock

classified by persistent

• hypotension and/or lactic acidosis (lactate >/= 4 mmol/L)

• plus signs of organ failure

the role of lactate

• is an indicator of global tissue hypoxia

• increased lactate levels are associated with increased morbidity and mortality

• used to guide resuscitation efforts

medical management for sepsis

• goals:

  • early identification and tx initiation

  • sepsis bundle adherence

  • improved pt outcomes

• actions:

  • correct underlying cause

  • fluid replacement therapy

  • pharmacologic therapy

  • nutritional therapy - initiate 24-48hrs for ICU admission

correct underlying cause

• rapid identification/elimination of infection source

• identify and initiate tx within 1hr

• culture prior to initiating antibiotics

• initiate antibiotics within 1hr of tx

interventions:

• cultures

• IV removal and reinsertion at another site

• catheters removed/changed

• incision/drainage

pharmacological therapy for sepsis

1. antibiotics - broad spectrum vs targeted

2. vasopressors for MAP - norepinephrine, dopamine

3. inotropic agents - contractility of heart

4. IV sedation - energy conservation

5. packed RBC - support O2 delivery

6. volume expanders - albumin

7. corticosteroids - reduce inflammation, inhibits nitrous oxide (vasodilator) by endotoxins

8. PPIs (pantoprazole) - reduce stress ulcers/bleeding

*other meds may include antipyretics, insulin, and low molecular weight heparin for VTE

what is the our first-line vasopressor in septic shock?

norepinephrine (levophed)

sepsis 1-hour bundle

1. obtain lactate level (repeat if increased)

2. obtain blood cultures x2

3. administer antibiotics

4. administer fluids if indicated

5. administer vasopressors if needed

6. constantly reassess