Seeing Sepsis: Every Patient is at Risk!

Objectives

• Explain the impact sepsis has on the patient experience

• Discuss the pathophysiology of SIRS, Sepsis, Severe Sepsis, and Septic Shock

• Outline the benefits of the sepsis screening tool.

Faces of Sepsis!

• http://www.sepsisalliance.org/resources/video/

Personal Story

Normal Inflammatory Response

Aerobic Cellular Metabolism

• Kreb’s Cycle– Glycolysis + oxygen = CO2, H2O– AND 38 molecules ATPNormal perfusion= healthy cells

Anaerobic Cellular Metabolism

• Glycolysis + no oxygen = anaerobic metabolism

• H+ (lactate) & only 2 molecules ATP!

• High lactate = inadequate perfusion

PNHS Sepsis Case Study: Mary Jones

Confidentiality: Patient identifiers changed

Sepsis Case Study: Mary Jones

PMH• 42 year old• CKD and HTN

Surgery• Elective s/p laparoscopic robotic assist hysterectomy

POD1• Expected discharge POD1• Delayed due to pain control issues & low UOP

Vital Signs and SIRS Criteria Day 1

Day 1 1 1 1 1Time 0600 0400 1400 1944 2300Temp (>38.3 or <36) 36.7 36.6 36.5 36.8 36.9RR (>20 or PaCO2<32) 16 16 16 18 18HR (>90) 78 78 96 92 92B/P 116/83 122/84 110/70 132/84 128/70Sat 97 +97 95 91 93O2 RA RA RA RA RAUOP 175 90 25 20IVFWBC (<4 or >12)

Sepsis Case Study: Mary Jones

POD 2•Low UOP remains (3500 ml

boluses given/24hr)•Bilateral effusions

Vital Signs and SIRS Criteria Day 2

Sepsis Case Study: Mary Jones

POD 3

• 02 started on nights, O2 Sats 80s• Continued abdominal pain, Oliguria• Transfer to ICU, Levophed Started • To OR emergently

Vital Signs and SIRS Criteria Days 2 & 3

Day 2 2 2 3 3 3 3 3 3Time 0500 1300 2000 0200 0530 0800 0900 1000 1100Temp (>38.3 or <36) 37.1 36.6 37.1 36.8 37.2 37 37.2 36.5

RR (>20 or PaCO2<32)

16 18 18 18 18 20 27

HR (>90) 104 110 110 113 113 125 124 125B/P 132/70 140/70 132/84 140/68 134/72 110/62 137/85 112/67

Sat 94 95 90 90 89 94 96 90O2 RA RA RA 1LNC 2LNC 4LNC 10LFM 10LFM 12LFM

UOP 5 30 15 45 50 /300WBC (<4 or >12) 14.9 14.9 19.9 9.5 9.5 9.5

Lactate

SIRS + Yes Yes Yes Yes Yes Yes Yes Yes Yes

Sepsis Case Study: Mary Jones

POD3• OR: Large Ischemic Bowel, packed open• CRRT, Lactate 6.5, triple antibiotics started

POD 4• WBC 19, Lactate 13.6• Multisystem Organ Failure, multiple pressors, on ventilator

POD 5

• WBC 27, lactate 18.4• DNR• Withdrew care

Sepsis Bundle

Sepsis Summary

• Time is Tissue!• Everyone is at risk• Early recognition leads to early intervention• Stop the continuum• Save patient lives!

ReferencesAngus DC & van der Pool T. (2013) Severe Sepsis and Septic Shock. New England Journal of Medicine.369:840-851. DOI: 10.1056/NEJMra1208623

Dellinger, P., Levy, M., Boin, J., Parker, M., Jaesenke, R., Reinhart, K. et al. (2008). Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock:2008. Intensive Care Medicine. 34 17-60.

Dellinger, P., Levy, M., Rhodes, A., Arrane,A., Gerlach, H., et al. (2013). Surving sepsis campaign: International surveillance for management of severe sepsis and septic shock: 2012. Critical Care Meidcine. 41(2) 580.637.

Hall MJ, Williams SN, DeFrances CJ & Golosinskly A. (2011, June). Inpatient care for septicemia or sepsis: A challenge for patients and hospitals. CDC:National Center for Health Statistics-NCHS Data Brief. 62:1-8.

Angus DC, et al. (2001). Crit ical Care Medicine. 29:1303-1310.

American Heart Association. (2013) Heart and Stroke Statistical Update 2013. http://www.heart.org/HEARTORG/General/Heart-and-Stroke-Association-Statistics_UCM_319064_SubHomePage.jsp. Accessed September 3, 2013.. www.opsimaging.net.

Ruth Kleinpell, Leanne Aitken and Christa A. Schorr (2013). Implications of the New International Sepsis Guidelines for Nursing Care. American Journal of Critical Care. 22(3). 212-222.