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Sepsis/Septic Shock Fleming

Terms in this set (40)

Sepsis
life-threatening organ dysfunction caused by a dysregulated host response to infection
Sepsis occurs when
microorganisms invade the body and initiate a systemic inflammatory response
Maldistribution of blood flow to the tissue is...
distributive shock
Factors that increase the risk of mortality
-advanced age ( >65)
-hyperglycemia on admisson
-hypo-coagulability (inability to clot)
-site of infection (unknown=more mortality)
-noscomial infections mortality rate > community acquired
-restoration of perfusion (MAP >65, Lactate >4)
Diagnosis and Management is difficult because
1.there is no confirmatory diagnostic test
2.diagnosis is based on clinical judgement of suspected infection
Patho of septic shock
there is an 1.overwhelming systemic inflammatory response
2.mediators are activated
3.wide spread endothelial damage
4.repeated activation of the coagulation cascade
5.inhibition of fibrolysis
Results of inappropiate inflammatory response
1.increase capillary permability
2.profound peripheral vasodilaton
3.third spacing of intravascular fluids
4.pro coagulation and micro emboli
5.hypoxic tissue injury
Nursing goals
-early identification
-early appropriate interventions
Systemic Inflammatory Response Syndrome (SIRS)
-systemic response to injury
-normal inflammatory process
SIRS Criteria
Presence of 2 or more:
-Temp between 96.8 F (36 C) but 100.4 F (38 C)
-Pulse >90 bpm (tachycardia)
-RR > 20 bpm (tachypnea)
-PACO2 <32
-WBC between 4,000 and 12,000
Sepsis Criteria
2 or the SIRS criteria
AND suspected or confirmed infection
Severe Sepsis ID
sepsis AND dysfunction of two or more organ systems in response to hypo-perfusion
Organ dysfunction Criteria
-use SOFA/QSOFA TO assess
-tachypnea/SAO2 <90%
-Decrease UOP <0.5ml/kg/hr
-HR >90
-dysrhytmia
-SBP <90 or 40 below baseline
-altered or low CVP/ PAWP
-lactate > 2
Septic shock identification
Presence of severe sepsis
AND refractory hypotension and lactic acidosis (lactic acid >2)
Septic shock Identification ctd
MAP <65
OR
SBP <90 despite fluid resuscitation
MAP
best indicator of perfusion
want to keep above 65
LR most closely resembles
plasma
Fluid bolus should be given
-warmed
-30 ml/kg
-within 1st 3 hours
1.Fluid resuscitation
-first line tx
-within 1st 3 hours
-crystalloid (NS/LR)
2.Diagnois
2 sets of blood cultures
(aerobic and anaerobic)
3.Antibiotic therapy
-broad spectrum
-within 1 hour of culture
-procalcitonin indicates inflammatory response not used exclusively
Source control
-identify/exclude
-rapid intervention
4.Use Vasopressors if..
-unable to maintain MAP of 65 with fluid
-norepinephrine (1st choice)
-add vasopression to decrease nonepi
5.Use corticosteroids if..
hemodynamic instability persists after fluid and vasopressor therapy
-IV hydrocortisone is steroid of choice
Vitamin C,Hydrocortisone,and thiamine
have been used to successfully treat sepsis
Blood products
Platelets
-prophalaytic: <10,000 no bleeding
-active bleeding platelet count >50,000
-PRBC transfusion Hgb <7
Mechanical Ventilation if
pt goes into ARDS
Glucose protocol
IV insulin if 2 consecutive >180 mg/dl
-monitor q 1-2 h
Renal Replacement Therapy
don't use in RRT in pts with sepsis and AKI for increase in cr. and oliguria without other definitive indications for dialysis
CRRT will
manage fluid balane in unstable pt
Acute Kidney Injury (AKI) common in septic shock
Feeding
enteral (feeding tube)
over parenteral (TPN)
Discuss end of life plans
as soon as feasible but within 72 hrs
Surviving Sepsis Bundle
1.Maintain lactace level >2
2.Obtain blood culture prior to antibiotic therapy
3.Adminster broad spectrum antibiotics
4.Fluid resisutation for lactate >4
5.Vasopressors if MAP is less than 65 after fluid
Sepsis
susupected or confirmed infection
AND
2/3 of QSOFA
OR
rise in SOFA score by 2 or more
septic shock
sepsis
AND
vasopressors need to keep MAP >65
AND
lactacte >2
QSOFA
2 of 3 may be an indicator for sepsis
1.SBP < 100 (hypotension)
2.altered mental status
3.RR > 22 (tachypnea)
MODS (multiple organ dysfunction syndrome)
-complication of any form of shock due to inadequate tissue perfusion
-failure of 2 or more organ systems
-end result if complete shock isn't stopped and treated
Most common causes of MODS
sepsis
septic shock
S/s of MODS
◦Tachypnea/hypoxemia
◦Petechiae/bleeding
◦Jaundice
◦Abdominal distension
◦Oliguria which eventually turns into anuria
◦Tachycardia
◦Hypotension
◦Change in level of consciousness
Additional info
•
•All issues stem from hypovelima
•Priority decreased tissue perfusion
•Q sofa initial sofa
•Do they have other criteria
•Early stages of SS
•CO at 1st increases high CO, low SVR
•Parameters to determine if fluid if effective RAP,MAP,skin,UOP 0.5/ml/kg/hr at a minumin
•Goal CVP: 8 or more for fluid volume titration
•MAP > 65
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