A COMPLEX SYSTEMS VIEW OF SEPSIS:

IMPLICATIONS FOR NURSING

LTC Elizabeth A. Mann-Salinas, PhD, RN, CCRN, CCNS 1,2

Joan Engebretson, DrPH, AHN-BC, RN 2

Andriy Batchinsky, MD 1

1US Army Institute of Surgical Research, San Antonio, TX2 University of Texas Health Science Center, Houston

Complex Systems

• Non-linear• Coupling• Sensitivity to initial conditions• Self-similarity• Emergence• Adaptability• Self-Organization• Connectivity• Robustness

Complicated

Light bulb changer

Linear

Complex Non-Linear

Coupling

1 + 1 = 3

Sensitivity to initial conditions

Self-organization

Fractals

Self-similarity

Emergence

NoveltyIrreducibility to component partsUnpredictable

Adaptability

Connectivity

Robustness

Intra-patient variability

Bone et al. /

Sepsis as a Complex System

• Non-linear• Coupling• Sensitivity to initial conditions• Self-similarity• Emergence• Adaptability• Self-Organization• Connectivity• Robustness

Sepsis

IV Immunoglobin

Corticosteroids

Xigris ™

Organ Support

EarlyAppropriate

ABX

Surviving SepsisCampaign

Surgical Intensive Care UnitUSNS Comfort Hospital Ship, Persian Gulf, 2003

Pattern Recognition

• Data display• “Sniffers”• Smart alarms• Computer decision support systems

Traditional Data Display

Novel Data Display

“Sniffer”

Smart AlarmDate : 13-Mar-11 11:10:09Bed : 4N-4702

Reasons:

Less than 0.5 ml/kg per hour for more than 6 hours

UOP for hour 11:00 = 0.0 ml/kg UOP for hour 10:00 = 0.0 ml/kg UOP for hour 09:00 = 0.0 ml/kg UOP for hour 08:00 = 0.0 ml/kg UOP for hour 07:00 = 0.0 ml/kg UOP for hour 06:00 = 0.0 ml/kg

Vital Signs at 13-Mar-11 11:10:09:

Heart Rate = 129 bpm Blood Pressure: Systolic = 98 mmHg Diastolic = 63 mmHg MAP = 73 mmHg Last Serum Creatinine = N/A

Attending Physician Email: david.zonies@amedd.army.mil

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CDSS

WVSM

Burn Resuscitation CDSS

Is sepsis a complex system?

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Thank You!