SIRS, Sepsis, & Septic Shock

What classifies sepsis?

SIRS criteria + suspected source of infection

What does sepsis do to the body?

When the body’s response to infection injures its own tissues & organs

What leads to septic shock?

When sepsis does not respond to therapy/treatment (persistent hypotension)

What classifies septic shock?

Persistent hypotension despite adequate fluid resuscitation

Inadequate tissue perfusion resulting in tissue hypoxia

What are the key goals when it comes to sepsis?

1. Timely recognition of early infection

2. Early treatment with antibiotics & IV fluids

3. Appropriate escalation to high-acuity or ICU care

What is SIRS criteria?

2 out of 5:

1. HR > 90

2. RR > 20

3. Temp =>38 or <36

4. WBC > 12 or < 4

5. Altered mental status (GCS)

Who would have cold sepsis (temp < 36)

Patients with:

• Auto immune diseases

• Immunosuppressant medication

• Older adults

• Young children

• Organ donors

• Patients with multiple comorbidities

Signs of possible infection

• Cough, sputum, chest pain

• Abdominal pain, distension, vomiting, diarrhea

• Dysuria, frequency, indwelling catheter

• Skin or joint pain, swelling, redness

• Central line present

• Mottle skin, cold extremities

• Invasive devices (IVs, catheters)

Early interventions for sepsis: labs & diagnostics

• CBC

• Urinalysis

• Procalcitonin

• Glucose level

• White blood count

• Blood cultures

• Lactate

• Chest cray

• ECG

What are the 3 first interventions done for early sepsis?

1. Labs & diagnostics

2. Antibiotics

3. IV fluids Appropriate escalation

4. Monitoring

Why is a blood culture done for sepsis?

Looking for organisms in the blood as the patient as a (suspected) systematic infection

• Will also show what spectrum should be given

What is the wait period before administering antibiotics when waiting for a blood culture to be done?

30 minutes

Why is lactate done for sepsis?

Lactate is a chemical released when the body is under stress. It is an indicator for septic progress (high number, worst outcome)

How long will a blood culture take before a more specific antibiotic can be given

24-48 hours (initial antibiotic will be broad-spectrum)

What IV fluids/boluses are given for early stage sepsis?

0.9 sodium chloride, 30mls/kg for the first 3 hours

When giving IV fluids/boluses, what gauge should the IV be?

20 gauge or larger for bolus to get into vascular space quickly

What is a bolus?

A fast infusion (1L boluses)

Why are IV fluids/boluses given?

Increases blood pressure, aids organ perfusion

When monitoring a patient under sepsis, what are you looking for?

• Patient response to treatment

• Vital signs Q6H, then Q4H for 12 hours

• GCS Q6H

• Urine output every hour

If SBP < 90mmHg, what should be done?

• Advocate for a catheter to better monitor end organ perfusion

  • Will see if there is vasoconstriction in the kidneys which organs when the body is stressed

What urine output will show that there is a lack of perfusion?

30mls/hr

When should the MD be called?

• Deterioration of VS

  • RR < 10 or > 30

  • O2 < 90%

  • P < 40 or > 140

• U/O < 25cc/hr

• Sudden changes in LOC

What are some factors that places you at an increased risk for sepsis?

• Age— young & old

• Patients on immunosuppressant drugs

• Organ transplant

• Multiple chronic diseases

• Patients with invasive devices

In septic shock, what defines persistent hypotension?

Hypotension that is not resolved despite IV fluids resuscitation

• SBP < 90mmHg or MAP > 65 mmHg

• Lactate => 2ml/L

Describe the progression of sepsis

1. Infectious organism

2. Systemic inflammation or inflammatory response

3. Circulation defects, tissue hypoxia, organ dysfunction

4. Severe sepsis

5. Multiple organ dysfunction & refractory hypotension

6. Septic shock

What do inotropes do during sepsis?

They increase cardiac output to improve oxygen delivery, given to patients experiencing persistent hypotension

Examples of inotropes

• Norepinephrine

• Dopamine

• Vasopressin

What does vasopressin require when being given for sepsis?

Requires a central line & monitoring of urine output

Aside from the main interventions, what other supportive treatment can be given?

• Catheter to minimize risk of another infection

• Aggressive pulmonary management

• Reducing oxygen demand

• Optimal nutrition

• Providing glycemic control

Why is it important to provide glycemic control?

Hyperglycaemia is a breeding ground for bacterial growth

What are some aggressive pulmonary management interventions?

• Deep breathing

• Coughing exercises

• Early ambulation when strong enough

• Reduce pneumonia

What is MODS

Multiple Organ Dysfunction Syndrome

• Development of progressive & potentially reversible physiologic dysfunction in 2 or more organ systems

When patient is experiencing MODS, what is happening to the organs?

• Lungs: crackles

• Liver: tests results will increase

• GI: hypoactive

• Skin: itchy, easily bruised

• Kidneys: color of urine will be darker

• Brain: decreased LOC

• Heart: decreased/increased HR

What is the treatment for MODS

• Maintaining adequate oxygenation

• Preventing sepsis early

What is the survival rate for sepsis?

61% of survivors live past 5 years