Sepsis & Oncological Emergencies Study Terms & Definitions

define SIRS, how does it relate to sepsis

- systemic inflammatory response syndrome caused by allergens, injury/trauma, ischemia, post CPR, decreased perfusion, or infection

- in sepsis you will ALWAYS have SIRS, but SIRS does not always mean sepsis

SIRS criteria is used to...

identify early sepsis

what is the criteria for SIRS

- temperature >100.4 or <96.8

- HR >90

- RR >20 or PaCO2 <32

- WBC >12,000 or <4,000 OR >10% bands (immature WBCs)

sepsis workup is indicated if...

2+ of SIRS criteria is met with suspected/confirmed source of infection

diagnosis of sepsis is made based on...

the entire clinical picture (there is no single dx test)

define sepsis

life-threatening syndrome in response to infection characterized by dysregulated pt response alone with new organ dysfunction

describe the management of sepsis

- the sooner the better! (usually w/i 1hr)

- measure lactate → obtain blood cultures → begin IVF → administer broad spectrum ABX → begin vasopressors (if needed)

lactate indicates ___ and is remeasured if...

- indicates anaerobic metabolism = decreased O2

- > 2mmol/L

what is the amount of IVF needed for sepsis tx

30mL/kg

when would vasopressors be used in sepsis

if hypotension persists during or after fluids (map >65mmhg)

when does septic shock occur

persistent hypotension despite adequate fluid resuscitation and inadequate tissue perfusion, or lactate >4 (needs vasopressors!)

what are the 3 majors effects of septic shock

vasodilation, maldistribution of blood flow, myocardial depression

shock is a syndrome characterized by...

decreased tissue perfusion and impaired cellular metabolism

___ metabolism results in increased lactate

anaerobic

what are examples or vasopressors used for septic shock

- norepinephrine (first line) and vasopressin (second line)

- epinephrine, phenylephrine, dopamine

manifestations of septic shock

tachypnea → resp alkalosis (COMPENSATORY) then resp failure → resp acidosis, febrile, warm & flushed (early) → cold & mottled (late), decreased Uop, altered mental status, GI dysfucntion

what labs indicate septic shock

elevated lactic, + blood cultures, high or super low WBC, decreased platelets

the higher the lactate...

the worse off the pt is

what is the purpose of the passive leg raise in septic shock

- to increase fluid return back to heart (around 150-500mL) and see if pt responds 1-2mins after

- if there is a change in CO/CI = increase fluids, no change in CO/CI = vasopressors needed

other nursing considerations of septic shock

monitor temp and tx, control blood sugar, stress ulcer prophylaxis

what are the stages of progressive septic shock

sepsis → increased platelet activation, decreased heart & lung function → tissue hypoxia → tissue necrosis → multi-organ failure

describe MODS

multiple organ dysfunction syndrome: 2 or more organ systems fail in relation to SIRS

what are s/s of MODS

crackles & tachypnea, ARDS, decreased HR, decreased CO, decrease Uop, increased BUN & CR, DIC (bleeding, bruising, petechiae), paralytic ileus, jaundice, decreased albumin = edema, increased blood glucose

describe SOFA

- sequential (sepsis related) organ failure assessment: predicts sepsis related mortality in the ICU (higher the score = worse)

- calculated 24hrs after admission to ICU, and every 48hrs after

describe qSOFA

- quick sequential organ failure assessment: calculates risk of death from sepsis outside of ICU

- criteria: RR >22, AMS, systolic BP <100

what are the 3 and 6 hour sepsis bundles

-3 hr bundle: from time sepsis suspected, lactic, blood cultures, abx, 30ml/kg IVF bolus

- 6 hr bundle: from time sepsis suspected, vasopressors if needed, re-assessment of fluid volume, remeasure lactate

describe an oncological emergency

acute potentially life threatening event either directly or indirectly related to a patient's cancer or it's tx, ALWAYS caused by an underlying condition

define metabolic oncologic emergency and gives examples

- metabolic: ectopic hormone production r/t tumor, cancer, or cancer tx

- ex: SIADH, hypercalcemia, tumor lysis syndrome, septic shock, DIC

describe obstructive oncologic emergency and give examples

- obstructive: tumor blocking blood to an organ or vessel

- ex: superior vena cava syndrome, spinal cord compressiosn syndrome

describe infiltrative oncologic emergency and give example

- infiltrative: cancer or cancer tx invades/damages major organs

- ex: cardiac tamponade

what is the most common oncological emergency? what cancers is this seen in?

- hypercalcemia (>10.5)

- lung, breast, hematologic, multiple myelooma, metastatic, parathyroid

manifestations of hypercalcemia

can be asymptomatic, lethargy, apathy, impaired concentration, muscle weakness, n/v, constipation, anorexia, dehydration, renal calculi, seizures, renal failure, nocturia/polyuria, EKG changes (sinus brady, prolonged PR, shortened QT)

who is at risk for hypercalcemia

bone involved malignancies, mucositis, renal failure, immobility, taking thiazide diuretics in breast and lung cancers

management of hypercalcemia

3000-4000mL/daily to promote kidney excretion, meds to inhibit bone breakdown (biphosphonates), hemodialysis, daily labs, increase mobility, seizure precautions

what are examples of biphosphonate? considerations?

- pamidronate, zoledronic acid

- tales 2-4 days to reach effects so calcitonin injections may be used during this period

what med is used if other interventions do not work to lower calcium

prolia (denosumab)

what is the relationship between albumin and calcium

low albumin = high calcium (b/c any calcium bound to albumin is inactive, therefore if theres decreased albumin, there is more free calcium)

how do you determine accurate calcium level

ionized calcium level

describe tumor lysis syndrome (TLS)

occurs when malignant cells are rapidly killed and intracellular contents are released into the bloodstream during chemotherapy (24-48hrs after) or radiation

what labs are a result of TLS

hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia

who is at risk for TLS

lymphoma, large bulky tumors, pre-existing renal dysfunction

manifestations of TLS; main concern?

- weakness, muscle cramps, diarrhea, nausea, vomiting, cardiac dysrhythmias, seizure, syncope

- main concern in cardiac abnormalities r/t electrolyte imbalance

tx for TLS

hypouricemic agents to decrease uricemia (allopurinol, febuxostat, rasburicase), aggressive IV hydration

considerations of allopurinol, febuxostat, and rasburicase

- allopurinol: used w/ intermediate risk, only prevents future development of uric acid

- febuxostat: more expensive but less interactions

- rasburicase: used w/ high risk, reduces and prevents

management of hyperkalemia and hyperphosphatemia in TLS

- hyperkalemia: sodium polystyrene sulfonate, Iv insulin + dextrose, calcium gluconate, dialysis

- hyperphosphatemia: hydration, phosphate binders (caclium carbnate)

hypocalcemia is only tx if...

it is symptomatic (ex. chovsteks and trousseaus sign)

describe SIADH

syndrome of inappropriate ADH (too much ADH) leading to fluid retention and dilutional hyponatremia

manifestations of SIADH

fatigue, weakness, anorexia, n/v, excessive thirst, lethargy, oliguric, CNS sx, decreased reflexes, diarrhea, cerebral edema, coma death

labs in SIADH

- sodium: <135 (<120 is when we see sx)

- serum osmolality: <280 (LOW)

- urine osmolality: >100 (HIGH)

- urine sodium: >30 (HIGH)

tx of SIADH

fluid restrictions (500-1000mL/day), educate pt that they will be thirsty, hypertonic saline to raise Na+ SLOWLY, seizure precautions, neuro checks, cardiac monitoring

describe superior vena cava syndrome (SVCS)

obstruction or compression of superior vena cava leadng to compromised venous drainage in the head, neck, upper extremities, and thorax

who is at risk for SVCS

malignancies in chest/head/neck, males, central line or pacemakers, previous radiation to chest

manifestations of SVCS

dyspnea, nonproductive cough, upper body swelling, dysphagia chest pain, horner syndrome (constricted pupil in 1 eye), periorbital edema in morning, tightness sensation

late signs of SVCS

hypotension, tachypnea, tachycardia, orbital edema, blurred vision, hemoptysis, syncope, cyanosis

management of SVCS

radiation/chemo of tumor, thrombolysis if clot, stent/surgery, keep HOB elevated, tx pain & anxiety, O2, frequent assessments

what is spinal cord compression (SCC) and who is at risk

- compression of spinal cord r/t malignant disease or collapsed vertebrae, EMERGENCY as neurologic dysfunction can occur

- any cancer in CNS, cancer that can spread to bone (prostate, lung, breast), GI or renal melanomas

manifestations of SCC

back/neck pain often worse when lying flat, vertebral tenderness, loss of bladder/bowel function, sensation and motor impairment

gold standard for SCC dx, why?

MRI bc xray have high false negative rate

what manifestations of a SCC indicate a poor prognosis

urinary or bowel dysfunction, rapid onset, paraplegia prior to tx start

tx for SCC

glucocorticoids, radiation, surgery, biphosphonates, pain, mobility/safety concern

describe febrile neutropenia

ANC <1500 (risk for infection) and one single oral temp >100.4

management of febrile neutropenia

hand washing, monitor ANC, decrease visitors, no live plants

describe DIC and causes

disseminated intravascular coagulation: systemic and simultaneous clotting and hemorrhaging that can be acute (life threatening) or chronic; clotting factors are used up yet there is bleeding

- caused by sepsis, severe head injury, cancer, complicated surgery, etc

signs of thrombosis in DIC

delirium, coma, ischemia, gangrene, oliguria, azotemia, ARDS, paralytic ileus

signs of hemorrhage in DIC

intracranial bleeding, petechiae, ecchymosis, hematuria, dyspnea, hemoptysis, GI bleed, epistaxis, gingival bleeding. bleeding from invasive lines

what lab results indicate DIC

reduced platelets, prolonged PT/PTT, reduced fibrinogen & other clotting factors, elevated D-dimer

tx for DIC

tx underlying cause!