Complex-Sepsis and Septic Shock

What happens in sepsis?

Distributive shock leads to a Volume shift problem, which leads to loss of sympathetic vasomotor tone/”maldistribution of blood flow” & leaky capillaries

What is Septic Shock?

Sepsis w/ organ dysfunction

What is the prevalence of sepsis?

Each year in the U.S.:​

• 1.7 million Americans develop sepsis​

• Roughly 350,000 die from sepsis​

• 1 in 2-3 hospital deaths is due to sepsis​

• Sepsis affects: ANYONE!

What population is the most vulnerable to sepsis?

• Old/young

• Pregnant women

• Chronic illnesses

• Immunocompromised

What is the pathophysiology of sepsis?

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​

• Triggered coagulation products​

• Development of organ failure, ARDS, DIC

Sepsis starts with an infection. What are the most common HAIs (hospital acquired infections)?

• CAUTI (Cath assoc. urinary tract infection)

• VAP (vent assoc pneumonia​)

• Central line assoc blood stream infection (CLABSI)​

• CDiff Infection

What would you see with Systemic Inflammatory Response Syndrome (SIRS)?

SIRS criteria consist of: (two or more)​

• Heart rate > 90 bpm​

• Respiratory rate > 20 rpm​

• Temperature > 38.3 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

What are some examples of a pt meeting SIRS criteria but not being septic?

• Pt has had trauma or chemo​

• Burn victim​

• Pt having an asthma attack​

• Experiencing panic attack​

• Suffering from heat exhaustion

What is the nurse’s responsibility when it comes to pts w/ sepsis?

• Recognize early​

• Treat promptly​

  • Follow the Sepsis Bundle*​

  • Fluid Replacement​

  • Pharmacologic​

• Astute ongoing assessment​

  • Monitor your patient for trends and report significant changes.

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

How does Sepsis progress?

• Infection source (pneumonia, UTI, wounds, etc)

• Sepsis (2 SIRS criteria) (temp, HR, RR, etc)

• Severe Sepsis (Multiple Organ Dysfunction) (bilirubin, platelet, Hypotension, etc)

• Septic Shock (lactic acidosis or persistent hypotension)

• Death or Recovery

What are signs of organ Dysfunction in Severe Sepsis?

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

• MAP <65 mmHg (key number-needs to be >65), SBP < 90 mmHg, or SBP decrease >40 from baseline​

• Creatinine > 2 mg/dL, UOP <0.5 mL/kg/hr in 6 hrs 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 (severe)

What is the role of lactate in sepsis?

• Lactate is an indicator of global tissue hypoxia (because it accumulates when cells shift to anaerobic metabolism due to insufficient oxygen for aerobic ATP production).​

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

• Lactate levels are used to guide resuscitation efforts.

What is Septic Shock classified by?

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

What are the priorities for a Sepsis 1-hour bundle?

1. Obtain lactate level

2. Obtain blood cultures x2

3. Administer antibiotics

   1. Must be administered w/in the first hour

4. Administer fluids if indicated

5. Administer Vasopressors if needed

6. Constantly reassess

What other labs are needed to diagnose septic shock?

• Lactate (global tissue hypoxia)

• Procalcitonin (bacterial sepsis)

• C-reactive Protein (CRP) (acute infection/inflammation)

• Coagulation/DIC studies (clotting state)

• Blood cultures (microbe identification)

• Urine analysis/culture (kidney & metabolic status)

• Wound cultures, CSF, sputum, pleural, etc.​ (other)

What are the goals of managing septic shock?

• Early identification & treatment initiation​

• Sepsis bundle adherence ​

• Improved patient outcomes

How would you treat septic shock?

• Correct Underlying Cause ​

• Fluid Replacement Therapy​

• Pharmacologic Therapy​

• Nutritional Therapy

• 1, 3, 6 hr bundles

What interventions would help correct the underlying cause of Sepsis?

• Rapid Identification/elimination of infection source.​

• Identify & initiate treatment within 1 hour. ​

• Culture PRIOR to initiating antibiotics.​

• Initiate antibiotics within 1 hour of treatment.

• Cultures ​

• IV removal & reinsertion at another site​

• Catheters removed/changed​

• Incision/drainage

What fluid resuscitation is needed in sepsis?

30 cc/kg of isotonic crystalloid solution

• Normal Saline

• Lactated Ringers

Use Ideal Body Weight

Continuously monitor: VS, mentation, UO, serum lactate

What additional medications are needed for septic shock?

• Volume expanders (such as albumin)​

  • To increase intravascular volume and improve B/P​

• 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 LMWH for VTE prophylaxis, just to name a few…

What would you do for persistent hypotension?

• B/P is measured every 15 minutes post-fluids​

• Two consecutive low B/P readings indicates persistent hypotension​

• Vasopressors should be started without delay​

• Goal MAP >/= 65 mmHg​

What are some Vasoactive meds for persistent hypotension?

Inotropic Agents: Improves contractility, Increases SV, Increases CO

• Dobutamine (Dobutrex)

• Dopamine (Intropin)

• Epinephrine (Adrenalin)

• Milrinone (Primacor)

Vasodilators: Reduces preload & after load, reduces O2 demand on heart

• Nitroglycerine (Tridil)

• Nitroprusside (Nipride)

Vasopressor agents: Increases BP by vasoconstriction

• Norepinephrine (Levophed)

• Dopamine (Neo-Synephrine)

• Vasopressin (Pitressin)

• Epinephrine (Adrenalin)

What is our first-line vasopressor in septic shock?

Norephinephrine

What nutritional therapy is needed for persistent hypotension?

• Malnourishment impairs infection resistance; worse outcomes​

• Initiate 24-48 h of ICU admission​

• Enteral feedings > parenteral route

What are some other interventions for persistent hypotension?

• IVF then vasopressors if persistent hypotension​

  • Goal MAP >/= 65mm Hg​

• Invasive intravascular monitoring ​

• BP support to achieve urine output​

  • 0.5 mL/kg/h over 6-hour​

• Support respiratory system ​

  • supplemental O2, mechanical ventilation​

• Control BG < 180 mg/dL with IV insulin​

• Prophylaxis for DVT, GI ulcers​

• Advance care planning