Download - Nt isepsis
New Treatments for an Ongoing Problem
Steven Marshall, RNIII, CCRNChip Harris, RN, BSN
Moses Cone Surgical ICU – 2300
Sepsis
Material From:Sepsis: New Insights to the Most Lethal Condition in Acute and Critical Care (NTI 2010 Mastery Session)
Incidence, Pathogenesis, and Management of Sepsis. An Overview (AACN Advanced Critical Care Article, Volume 17, Number 4, 2006)
Sepsis: Stopping an Insidious Killer (American Nurse Today Article, January 2007)
Signs of systemic inflammatory response syndrome SIRS include:
a. respiratory acidosisb. painc. hypotensiond. tachypnea
Signs of systemic inflammatory response syndrome SIRS include:
a. respiratory acidosisb. painc. hypotensiond. (tachypnea)
What is the definition of sepsis?
a. infection plus multi organ dysfunctionb. inflammation with high wbcc. infection as the cause of sirsd. presence of positive blood cultures
What is the definition of sepsis?
a. infection plus multi organ dysfunctionb. inflammation with high wbcc. (infection as the cause of sirs)d. presence of positive blood cultures
Which is the treatment of sepsis?
a. hydrocortisone 300mg qd if hypotension resistant to pressorsb. activated protein cc. arachidonic acid inhibitorsd. fluids to keep scvo2 > 70%
Which is the treatment of sepsis?
a. hydrocortisone 300mg qd if hypotension resistant to pressorsb. (activated protein c)c. arachidonic acid inhibitorsd. fluids to keep scvo2 > 70%
What lab test do you want with suspected sepsis?
a. protein cb. procalcitoninc. serum sodiumd. lactate
What lab test do you want with suspected sepsis?
a. protein cb. procalcitoninc. serum sodiumd. (lactate)
A patient is at risk for sepsis when receiving:
a. insulinb. antibioticsc. vasopressorsd. steroids
A patient is at risk for sepsis when receiving:
a. insulinb. (antibiotics)b. (antibiotics)c. vasopressorsd. steroids
What is the first treatment for suspected sepsis?
a. antipyreticsb. activated protein cc. vasopressorsd. fluids
What is the first treatment for suspected sepsis?
a. antipyreticsb. activated protein cc. vasopressorsd. (fluids)
What is the most common organ to fail?
a. pulmonaryb. renalc. cardiovasculard. central nervous system
What is the most common organ to fail?
a. (pulmonary)b. renalc. cardiovasculard. central nervous system
Which of the following is true with activated protein c administration in pt with severe sepsis?
a. patient must have failed all other txb. based on new research xigris is currently not indicatedc. patient must be at high risk of deathd. any patient with sepsis is a candidate for activated protein c
Which of the following is true with activated protein c administration in pt with severe sepsis?
a. patient must have failed all other txb. based on new research xigris is currently not indicatedc. (patient must be at high risk of death)d. any patient with sepsis is a candidate for activated protein c
What is the least valuable tool for rapid response nurse?
a. capnographyb. stethoscopec. point of care lactate, glucose, phd. non invasive stroke volume monitor
What is the least valuable tool for rapid response nurse?
a. capnographyb. (stethoscope)c. point of care lactate, glucose, phd. non invasive stroke volume monitor
How many patients will die of bleeding after receiving protein c?
a.<1/2 of 1%b. 5-10%c. 25%d. 30-40%
How many patients will die of bleeding after receiving protein c?
a.(<1/2 of 1%)b. 5-10%c. 25%d. 30-40%
Why is sepsis so difficult to recognize?
a. very similar to blood stream infectionb. infrequent and overlookedc. presents with subtle signsd. sepsis has no common pattern in how it presents
Why is sepsis so difficult to recognize?
a. very similar to blood stream infectionb. infrequent and overlookedc. (presents with subtle signs)d. sepsis has no common pattern in how it presents
Which of following statement regarding fluid resuscitation in severe sepsis is most correct?
a. both crystalloid and colloid may be usedb. ns is superior to lrc. albumin should not be usedd. hespan has been associated with improved outcome comp to ns
Which of following statement regarding fluid resuscitation in severe sepsis is most correct?
a. (both crystalloid and colloid may be used)b. ns is superior to lrc. albumin should not be usedd. hespan has been associated with improved outcome comp to ns
Which area has the most sepsis cases?
a. icub. hosp floorc. edd. nursing homes
Which area has the most sepsis cases?
a. icub. hosp floorc. (ed)d. nursing homes
Which is the best method to improve outcomes?
a. appropriate use antibioticsb. activated protein cc. prevention of infectiond. use of fluids early in sepsis
Which is the best method to improve outcomes?
a. appropriate use antibioticsb. activated protein cc. (prevention of infection)d. use of fluids early in sepsis
Sepsis is subtle until it is so obvious you can't
miss it
For a diagnosis of SIRS (Systemic Inflammatory Response Syndrome), you need to have 2 of the following criteria:
Tachycardia Tachypnea
Wbc >12 <4 Hypothermic or Hyperthermic
Sepsis is SIRS plus documented or presumed
source of infection
-No need for positive cultures-Only 50% Pneumonias grow
out an organism
Septicemia is infection of the blood stream but is not necessary for sepsis and no
longer a used term
Patients get sick in response to the virus or bacteria
“The patient appears to die from the body's response to
infection rather than from it”Sir William Osler
Common Signs of Acute OrganSystem Dysfunction in Sepsis
Cardiovascular:
TachycardiaDysrhythmiasHypotension
Elevated central venous and pulmonary artery pressures
Common Signs of Acute OrganSystem Dysfunction in Sepsis
Respiratory:
TachypneaHypoxemia
Common Signs of Acute OrganSystem Dysfunction in Sepsis
Renal:
OliguriaAnuria
Elevated creatinine levels
Common Signs of Acute OrganSystem Dysfunction in Sepsis
Hematologic:
JaundiceElevated liver enzymes
Decreased albuminCoagulopathy
Common Signs of Acute OrganSystem Dysfunction in Sepsis
Gastrointestinal:
Ileus (absent bowel sounds)
Common Signs of Acute OrganSystem Dysfunction in Sepsis
Hepatic:
ThrombocytopeniaCoagulopathy
Decreased protein C levelsIncreased D-dimer levels
Common Signs of Acute OrganSystem Dysfunction in Sepsis
Neurologic:
Altered consciousnessConfusionPsychosis
Evidence-based Treatment
Strategies in Severe SepsisLevel A recommendations
Prophylaxis measuresDeep vein thrombosisStress ulcer
Evidence-based Treatment
Strategies in Severe SepsisLevel B recommendations
Initial resuscitation for sepsis-inducedhypoperfusion
Fluid resuscitation to a central venouspressure of 8–12 mm Hg
Early goal directed therapy (to maximizeperfusion status)
Transfusion of packed red blood cells toachieve a hematocrit of 30%
Administration of inotropic infusion(eg, dobutamine)
Evidence-based Treatment
Strategies in Severe SepsisLevel B recommendations
Mechanical ventilationLung protective ventilation for acute lunginjury/acute respiratory distress syndrome
Blood product administrationTo target hemoglobin of 7.0–9.0 g/dL
Drotrecogin alfa (activated)For patients with sepsis-induced multiple organfailure with no absolute contraindication related to bleeding risk
Renal replacementFor acute renal failure
Sedation, analgesia, and neuromuscular blockadeTo provide comfort yet avoid prolonged sedation
Evidence-based Treatment
Strategies in Severe SepsisLevel C recommendations
Enhance perfusion
Fluid therapy
SteroidsFor patients with relative adrenal insufficiency
Evidence-based Treatment
Strategies in Severe SepsisLevel D recommendations
DiagnosisObtain cultures: at least 2 blood cultures, with one drawn percutaneously and one drawnthrough each vascular access device; culturesof other sites such as urine, wounds, andrespiratory secretions should be obtainedbefore antibiotic therapy isinitiated
Glucose controlTo maintain blood glucose 150 mg/dL
Evidence-based Treatment
Strategies in Severe SepsisLevel E recommendations
Antibiotic therapyEmpirical antibiotics
Source controlRemoval of potentially infected device, drainageof abscess, and debridement of infectednecrotic tissue
Enhance perfusionVaspressorsInotropic therapy
Evidence-based Treatment
Strategies in Severe SepsisLevel E recommendations
DiagnosisDiagnostic studies (eg, ultrasound, imagingstudies)
Consideration for limitation of support
Discuss end-of-life care for critically illpatients
Promote family communication to discuss useof life-sustaining therapies
Evidence-based Treatment
Strategies in Severe Sepsis*These recommendations are based on the following
levels ofevidence: level A research evidence supported by at least 2 level I investigations (large, randomized trials with confident results); level B evidence supported by one level I investigation; level C evidence supported by level II investigations only (small, randomized trials with uncertain results); level D evidence supported by at least one level III investigation (nonrandomized study); and level E evidence supported by level IV (nonrandomized, historical controls, and expert opinion) or level V evidence (case series, uncontrolledstudies, and expert opinion).
Saving Lives from SepsisStep By Step
Evaluate a patient who has an infectionor is receiving antibioticsfor these signs and symptoms ofsystemic inflammatory responsesyndrome (SIRS):• Tachycardia• Tachypnea• Fever• High or low white blood cell count
Saving Lives from SepsisStep By Step
If the patient has an infection andsigns and symptoms of SIRS, suspectsepsis.
If the patient has sepsis, begintreatment as soon as possible.Start all appropriate therapieswithin 24 hours.
Saving Lives from SepsisStep By Step
Determine the severity of sepsis:• Obtain lactate levels.• Detemine if the patient is hypotensive.• Obtain central venous oxygen saturation (ScvO2) measurements via a central I.V. line.• Provide fluids, vasopressors, and inotropic agents to raise ScvO2 above 70%.
Saving Lives from SepsisStep By Step
Obtain blood glucose level. If it’smore than 150 mg/dl, start insulintherapy.
If the patient is hypotensive or hasa low serum cortisol level, give 200to 300 mg of hydrocortisone dailyfor 7 days as replacement corticosteroidtherapy.
Saving Lives from SepsisStep By Step
If the patient has a high risk ofdeath, administer activated proteinC.
Saving Lives from SepsisStep By Step
Activated protein C controversiesTherapy with activated protein C is controversial, in part because of its cost. This recombinant DNA protein costs about $7,000 for a 4-day course of therapy. But one study indicates that using activated protein C rapidly and appropriately shaves 4 days off the average intensive care unit length of stay. That translates into a cost savings of about $9,000.
The drug is also controversial because we don’t yet know whom it benefits most. The Food and Drug Administration suggests that it should be given only to patients with a high risk of death and that a high risk of death be determined using an APACHE II score. This method, which estimates the severity of illness, works well at predicting group responses. But many nurses and physicians don’t use APACHE II scores, or they use them incorrectly. In Europe, one indicator of a high risk of death is the failure of at least two organs.
Because no universally accepted criteria exist for defining high risk of death, the best criterion may be the bedside clinician’s assessment. If the bedside clinician believes the patient is at high risk for death, activated protein C therapy should be considered.
Lab tests and Hemodynamic Measurements for Determination of
Sepsis
Hemodynamic response to sepsis:
Hypovolemia – low cvp, low scvo2, tachycardia
Give boluses!
Lab tests and Hemodynamic Measurements for Determination of
Sepsis
Stroke volume monitoring – swan ganz obsolete except for pa pressure monitoring in pulm htn
Stethoscope is vague – use with guidance
Stroke volume is needed to monitor responses
CVP – research does not support much but it is some marker of success
Lab tests and Hemodynamic Measurements for Determination of
Sepsis
Stroke Volume may be increased with fluid when CVPs may not
Limitations of pressure measurement:CVP and PAOP (Wedge) should never be
used in isolation
Lab tests and Hemodynamic Measurements for Determination of
Sepsis
Measures of tissue oxygenation
Lactate/PhNormal lactate 1-2
ph normal 7.35-7.45
If lactate >4 and PH less than 7.30 consider tissue hypoxemia
Lab tests and Hemodynamic Measurements for Determination of
Sepsis
Triple lumen oximetryExpands ability to assess tissue oxygenation
An easier—less expensive—way to measure ScvO2 levelsMeasuring central venous oxygen saturation (ScvO2) levels requires a central I.V.line. Typically, you’ll take frequent blood samples from the right atrium, using the central I.V. line, so fluids can be titrated to return ScvO2 to 70%.
An easier way to obtain frequent measurements is to use a fiberoptic ScvO2 central line catheter. This tool provides continuous ScvO2 readings. Using a fiberoptic catheter has proven to be cost effective: It reduces length of stay by about 4 days, more than offsetting its cost.
Lab tests and Hemodynamic Measurements for Determination of
Sepsis
Measurement of blood flowDoppler basedArterial line basedPulse contour technique
Show stroke volume - normal stroke index 25-35 – if decreased get tachycardia to compensate
Noninvasive doppler measurement of blood flow aortic and pulmonic valve flows
Noninvasive co/sv measurementEsophageal doppler on sedated patients
Microcirculation – sublingual blood flow
The latest in sepsis treatment and studies can
be found at:
www.survivingsepsis.org