sepsis l at the end of this tutorial the learner will be able to: define sepsis and related terms...

Sepsis

ll

At the end of this tutorial the learner will be able to:

Define sepsis and related termsDefine sepsis and related termsDiscuss the incidence of sepsis Discuss the incidence of sepsis Discuss the causes and pathophysiology of Discuss the causes and pathophysiology of sepsissepsisIdentify signs and symptoms of sepsisIdentify signs and symptoms of sepsisDiscuss how other disease processes can affect Discuss how other disease processes can affect outcomes in patients with sepsisoutcomes in patients with sepsisDiscuss nursing interventions and the latest Discuss nursing interventions and the latest evidence based practice for the treatment of evidence based practice for the treatment of sepsissepsis

What is Sepsis?

Sepsis is a serious Sepsis is a serious medical condition caused medical condition caused by the body’s response by the body’s response to an infection. to an infection.

Before we can more Before we can more fully define sepsis we fully define sepsis we need to discuss related need to discuss related terms.terms.

Related Terms

InfectionInfection – A microbial phenomenon – A microbial phenomenon characterized by an inflammatory response to characterized by an inflammatory response to the presence of microorganisms the presence of microorganisms

BacteremiaBacteremia – The presence of viable bacteria – The presence of viable bacteria in the bloodin the blood

Related TermsSystemic inflammatory response syndrome (SIRS)Systemic inflammatory response syndrome (SIRS)A systemic or whole body response to an infection A systemic or whole body response to an infection manifested by two (2) or more of the following manifested by two (2) or more of the following conditions:conditions:

• Temperature above 100.4Temperature above 100.4°F or below 96.8°F°F or below 96.8°F• Heart rate above 90 beats per minuteHeart rate above 90 beats per minute• Respiratory rate above 20 per minute or Respiratory rate above 20 per minute or

PaCO2 below 32 mm HgPaCO2 below 32 mm Hg• White blood cell count above 12,000uLWhite blood cell count above 12,000uL -1-1 or or

below 4,000uLbelow 4,000uL-1-1

Definition of Sepsis

Sepsis can now be more accurately defined as aSepsis can now be more accurately defined as a

systemic inflammatory response syndrome (SIRS) systemic inflammatory response syndrome (SIRS) resulting from infectionresulting from infection

Infection + SIRS = SepsisInfection + SIRS = Sepsis

Source: www.sepsis.comSource: www.sepsis.com

More Related Terms

Septic shockSeptic shock – A sepsis induced state of severe – A sepsis induced state of severe hypotension despite aggressive fluid therapy.hypotension despite aggressive fluid therapy.

Multiple Organ Dysfunction Syndrome (MODS) –Multiple Organ Dysfunction Syndrome (MODS) – A A progressive dysfunction in two or more organs of the progressive dysfunction in two or more organs of the body after the onset of sepsis where intervention is body after the onset of sepsis where intervention is needed to sustain life.needed to sustain life.

The Incidence of Sepsis in the United States

• The incidence of sepsis has increased 91.3 percent over the last ten years.The incidence of sepsis has increased 91.3 percent over the last ten years.

• This year, severe sepsis will likely take 215,000 lives.This year, severe sepsis will likely take 215,000 lives.

• Sepsis is the leading cause of death in the non-coronary ICU.Sepsis is the leading cause of death in the non-coronary ICU.

• Severe sepsis takes more lives than breast, colon/rectal, pancreatic, and Severe sepsis takes more lives than breast, colon/rectal, pancreatic, and prostate cancer combined.prostate cancer combined.

• One of every three patients who develop severe sepsis One of every three patients who develop severe sepsis will die within a month.will die within a month.

Causes of Sepsis• Bacterial infections are the Bacterial infections are the

most common cause of most common cause of sepsis, but sepsis can also sepsis, but sepsis can also be caused by fungal, be caused by fungal, parasitic, or viral parasitic, or viral infections. infections.

• The infection can originate The infection can originate from anywhere in the from anywhere in the body. body.

Pathophysiology of Sepsis

• Sepsis can lead to widespread inflammation Sepsis can lead to widespread inflammation and blood clotting. and blood clotting.

• Inflammation may result in redness, heat, Inflammation may result in redness, heat, swelling, pain, and organ failure.swelling, pain, and organ failure.

• Blood clotting during sepsis causes reduced Blood clotting during sepsis causes reduced blood flow to limbs and vital organs, and blood flow to limbs and vital organs, and can lead to organ failure or tissue damage.can lead to organ failure or tissue damage.

Pathophysiology of Sepsis• In simple terms In simple terms sepsissepsis can be viewed as an imbalance of can be viewed as an imbalance of

inflammation, coagulation, and fibrinolysis.inflammation, coagulation, and fibrinolysis.

• In normal patients homeostasis is maintained when these In normal patients homeostasis is maintained when these are balanced.are balanced.


During a normal response to bacteria in the blood During a normal response to bacteria in the blood the immune system releases inflammatory the immune system releases inflammatory mediators to promote recovery of the tissue. mediators to promote recovery of the tissue. These mediators are known as:These mediators are known as:

• Tumor Necrosis Factor (TNF)Tumor Necrosis Factor (TNF)• Interleukins (IL)Interleukins (IL)• CytokinesCytokines• ProstaglandinsProstaglandins• Platelet Activating FactorPlatelet Activating Factor


• The release of the inflammatory mediators starts The release of the inflammatory mediators starts the the Coagulation CascadeCoagulation Cascade leading to the leading to the development of a clot. development of a clot.

• To maintain this clot, inhibitors are releasedTo maintain this clot, inhibitors are released to suppress fibrinolysis or breakdown. This is to suppress fibrinolysis or breakdown. This is

necessary to have time for the body to destroy the necessary to have time for the body to destroy the bacteria before the clot is gone.bacteria before the clot is gone.

Clotting Cascade

To review the To review the Clotting CascadeClotting Cascade or learn more about or learn more about CoagulationCoagulation follow the link below: follow the link below:

Disorders of Coagulation and HaemostasisDisorders of Coagulation and Haemostasis


Once the bacteria or Once the bacteria or antigen is isolated, the antigen is isolated, the pro-inflammatorypro-inflammatory mediators attract mediators attract neutrophils or WBCs neutrophils or WBCs which attack the antigen which attack the antigen and try to engulf it. and try to engulf it.


To prevent the response from damaging To prevent the response from damaging normal tissue, normal tissue, anti-inflammatoryanti-inflammatory mediators mediators are released including transforming growth are released including transforming growth factors and interleukins (IL-4). This balance factors and interleukins (IL-4). This balance of inflammatory and anti-inflammatory of inflammatory and anti-inflammatory mediators restricts the inflammation response mediators restricts the inflammation response to the local site of infection.to the local site of infection.


When the body is unable to maintain the When the body is unable to maintain the appropriate balance, the immune response is appropriate balance, the immune response is no longer local but becomes systemic.no longer local but becomes systemic.

Inflammation and altered clotting quickly Inflammation and altered clotting quickly spread through the body.spread through the body.


The person with the The person with the infection which was infection which was once localized could once localized could become critically ill if become critically ill if this process is not this process is not correctedcorrected..

That’s right! Hurray! That’s right! Hurray!

Sepsis is the leading cause of death in Sepsis is the leading cause of death in ICU settings.ICU settings.

Sepsis can lead to widespread Sepsis can lead to widespread inflammation and blood clotting.inflammation and blood clotting.

Return to Review QuestionsReturn to Review Questions

Sepsis can be viewed as a dysfunction of Sepsis can be viewed as a dysfunction of coagulation, inflammation and fibrinolysis.coagulation, inflammation and fibrinolysis.

There are 3 integrated responses to sepsisThere are 3 integrated responses to sepsis

Activation of InflammationActivation of Inflammation

Activation of CoagulationActivation of Coagulation

Impairment of FibrinolysisImpairment of Fibrinolysis

Activation of Inflammation

Inflammation is the body’s response to infection.Inflammation is the body’s response to infection.

When this occurs white blood cells (WBCs) generate When this occurs white blood cells (WBCs) generate and release cytokines or mediators of inflammation. and release cytokines or mediators of inflammation.

Inflammatory mediators include: Tumor necrosis Inflammatory mediators include: Tumor necrosis factor-a, Interleukin-1(IL-1), Interleukin-6 (IL-6) factor-a, Interleukin-1(IL-1), Interleukin-6 (IL-6) and Platelet activating factor.and Platelet activating factor.


Although these cytokines (TNF, IL-1,IL-6) play a Although these cytokines (TNF, IL-1,IL-6) play a critical role to fight off infection the body tries to critical role to fight off infection the body tries to reestablish balance by releasing anti-inflammatory reestablish balance by releasing anti-inflammatory cytokines as well.cytokines as well.

Anti-inflammatory cytokines include interleukin -4 Anti-inflammatory cytokines include interleukin -4 (IL-4) and interleukin-10 (IL-10)(IL-4) and interleukin-10 (IL-10)


There is basically a tug of There is basically a tug of war going on between the war going on between the pro-inflammatory and anti- pro-inflammatory and anti- inflammatory components of inflammatory components of the body.the body.

In sepsis, continued release In sepsis, continued release of pro-inflammatory of pro-inflammatory cytokines overwhelms the cytokines overwhelms the anti-inflammatory cytokines.anti-inflammatory cytokines.

Pro-inflammatory (IL-1,IL-6,TNF)Pro-inflammatory (IL-1,IL-6,TNF)

Anti-inflammatory Anti-inflammatory (IL-4, IL-10)(IL-4, IL-10)

Activation of Coagulation

Inflammation and coagulation are closely Inflammation and coagulation are closely linked. The cytokines from inflammation linked. The cytokines from inflammation stimulate coagulation pathways. This results stimulate coagulation pathways. This results in the forming of the enzyme thrombin.in the forming of the enzyme thrombin.

This produces clotting in the body.This produces clotting in the body.

Activation of CoagulationThe enhanced clotting The enhanced clotting continues making tiny continues making tiny clots or “microthrombi” clots or “microthrombi” in the vascular system in the vascular system which impairs blood which impairs blood flow and organ flow and organ perfusion.perfusion.

Activation of Fibrinolysis

Fibrinolysis, or the breakdown of clots, is the body’s Fibrinolysis, or the breakdown of clots, is the body’s response to the increased clotting and inflammation. response to the increased clotting and inflammation.

In sepsis this breakdown is inhibited or slowed because of In sepsis this breakdown is inhibited or slowed because of mediators. These mediators are called:mediators. These mediators are called:

• Plasminogen Activator Inhibitor-1 (PAI-1)Plasminogen Activator Inhibitor-1 (PAI-1)• Thrombin Activatable Fibrinolysis Inhibitor (TAFI)Thrombin Activatable Fibrinolysis Inhibitor (TAFI)

Activation of Fibrinolysis

The increase levels of these two inhibitors,The increase levels of these two inhibitors,

Plasminogen Activator Inhibitor-1(PAI-1) and Plasminogen Activator Inhibitor-1(PAI-1) and Thrombin Activatable Fibrinolysis Inhibitor Thrombin Activatable Fibrinolysis Inhibitor (TAFI), suppress fibrinolysis even more (TAFI), suppress fibrinolysis even more creating a state of “coagulopathy”.creating a state of “coagulopathy”.

The Inflammatory, Coagulation, and

Fibrolytic Response to Infection

Damaged Endothelium

The imbalance The imbalance

of Inflammation, of Inflammation, Coagulation, and Coagulation, and Fibrinolysis and the Fibrinolysis and the effects on effects on endothelium can endothelium can lead to organ failure lead to organ failure even death if left even death if left undetected or undetected or untreated. untreated.

I am sorry that is wrong. I am sorry that is wrong.

Inflammation is caused by the release of Inflammation is caused by the release of cytokines Tumor Necrosis Factor-a, cytokines Tumor Necrosis Factor-a, Interleukin-1(IL-1), Interleukin-6 (IL-6) and Interleukin-1(IL-1), Interleukin-6 (IL-6) and Platelet activating factor.Platelet activating factor.

You are right!

Return to Review QuestionsReturn to Review Questions

Sepsis – What Does it Look Like?

Signs and symptoms of Signs and symptoms of sepsis can vary. Patients sepsis can vary. Patients with sepsis can with sepsis can progressively become progressively become worse. For this reason worse. For this reason early detection or early detection or identification of sepsis identification of sepsis and treatment of and treatment of infections is important.infections is important.

Signs and Symptoms of Sepsis

• Heart rate >90bpmHeart rate >90bpm• Increased respiratory Increased respiratory

raterate• Decreased blood Decreased blood

pressurepressure• High/Low WBC countHigh/Low WBC count• Fever or low body Fever or low body

temperaturetemperature• Altered mental statusAltered mental status• ShakingShaking• ChillsChills• NauseaNausea

Review Signs and Symptoms of Sepsis

Mr. M. Oose is exhibiting the Mr. M. Oose is exhibiting the following signs and symptoms:following signs and symptoms:

• Temperature – 96.2 Temperature – 96.2 °F°F

• Pulse -140 beats per minutePulse -140 beats per minute

• Respirations – 40 breaths per minuteRespirations – 40 breaths per minute

• Blood Pressure – 90/40 mmHgBlood Pressure – 90/40 mmHg

• Labs include a WBC count of Labs include a WBC count of 3,000uL-13,000uL-1

The clinical signs and symptoms of The clinical signs and symptoms of Sepsis are:Sepsis are:

• Heart rate >90Heart rate >90• Increased respiratory rateIncreased respiratory rate• Decreased blood pressureDecreased blood pressure• High/Low WBC countHigh/Low WBC count• Fever or low body temperatureFever or low body temperature• Altered mental statusAltered mental status• ShakingShaking• ChillsChills• NauseaNausea

Source: Core Curriculum for Critical Care Source: Core Curriculum for Critical Care Nursing, 2006Nursing, 2006

Review Signs and Symptoms of MODS

Upon further assessment Mr. M. Upon further assessment Mr. M. Oose is exhibiting the following Oose is exhibiting the following signs and symptoms:signs and symptoms:

• Urine output of 100cc for the last 8 Urine output of 100cc for the last 8 hourshours

• Pulse oximetry of 88% on room airPulse oximetry of 88% on room air

• PallorPallor

Multiple Organ Dysfunction Multiple Organ Dysfunction (MODS) is a progressive (MODS) is a progressive dysfunction in two or more organs dysfunction in two or more organs of the body after the onset of sepsis of the body after the onset of sepsis where intervention is needed to where intervention is needed to sustain lifesustain life


Mr. G. Erbil is exhibiting the Mr. G. Erbil is exhibiting the following signs and symptoms:following signs and symptoms:

• Temperature 95.7 Temperature 95.7 °°FF

• Heart rate 145 beats per minute Heart rate 145 beats per minute

• Respiratory rate 45 breaths per Respiratory rate 45 breaths per minute Blood pressure 70/30mmHgminute Blood pressure 70/30mmHg

• A WBC count of 2,000uL-1A WBC count of 2,000uL-1



Review of Case Study 3He is showing signs of severe sepsis. He is showing signs of severe sepsis.

Temperature 95.7Temperature 95.7°°F – F – Low temperatureLow temperature

Heart rate 145 beats per minute –Heart rate 145 beats per minute –Heart rate over 90Heart rate over 90

Respiratory rate 45 breaths per minute – Respiratory rate 45 breaths per minute – Increased Respiratory rateIncreased Respiratory rate

Blood pressure 70/30mmHg – Blood pressure 70/30mmHg – Decreased BPDecreased BP

Further assessment of him shows a WBC Further assessment of him shows a WBC count of 2,000uL-1 – count of 2,000uL-1 – Low WBC countLow WBC count

Other Factors Affect Outcomes in Patients with Sepsis

Genetics and Sepsis - Is there a Genetics and Sepsis - Is there a relationship?relationship?

All stressed out? All stressed out? Sepsis and the stress response.Sepsis and the stress response.

Metabolism and SepsisMetabolism and Sepsis

Lipid Metabolism and Sepsis Lipid Metabolism and Sepsis Are some patients at risk for Are some patients at risk for sepsis?sepsis?

Genetics and Sepsis – Is There A Relationship?

When the natural When the natural immune system is immune system is altered genetically it altered genetically it interrupts the body’s interrupts the body’s way of protecting way of protecting itself from infection.itself from infection.


Research is showing that Research is showing that there is a genetic component there is a genetic component to an individual’s response to to an individual’s response to infection. In other words, infection. In other words, some people may be some people may be genetically predisposed to genetically predisposed to sepsis.sepsis.


In addition, scientific studies In addition, scientific studies suggest a strong genetic suggest a strong genetic influence on the outcomes of influence on the outcomes of sepsis and indicate that sepsis and indicate that genetics can play a major genetics can play a major part in overall mortality rates part in overall mortality rates for sepsis.for sepsis.


The body’s normal defense The body’s normal defense includes inflammatory and includes inflammatory and anti-flammatory proteins or anti-flammatory proteins or CytokinesCytokines which make which make attempts at keeping attempts at keeping infections away.infections away.

These cytokines include:These cytokines include:•Tumor Necrosis FactorsTumor Necrosis Factors• InterleukinsInterleukins

Source: Chest, 2003Source: Chest, 2003

Genetics and Sepsis – Is There A Relationship?• Genetic alterations in Genetic alterations in

Tumor Necrosis Factors Tumor Necrosis Factors (TNF) are associated with (TNF) are associated with adverse outcomes in a adverse outcomes in a variety of infectious variety of infectious diseases. diseases. • TNF- a is associated TNF- a is associated

with macrophageswith macrophages• TNF- b is associated TNF- b is associated

with lymphocyteswith lymphocytes

Genetics and Sepsis – Is There A Relationship?• Other genetic alterations Other genetic alterations

linked with sepsis include linked with sepsis include those associated with those associated with Interleukin Cytokines (IL):Interleukin Cytokines (IL):• IL-1 and IL-6 are IL-1 and IL-6 are

associated with the pro-associated with the pro-inflammatory responseinflammatory response

• IL-10 is associated with the IL-10 is associated with the anti-inflammatory anti-inflammatory

responseresponse

Genetics and Sepsis – Is There A Relationship? YES!

One’s innate immunity can play a key One’s innate immunity can play a key role in the prevention of sepsis. Genetic role in the prevention of sepsis. Genetic or DNA alterations in cytokines can or DNA alterations in cytokines can affect mortality rates of infection. affect mortality rates of infection.

Genetic testing has also been used to Genetic testing has also been used to take the guesswork out of predicting take the guesswork out of predicting how a person will respond to how a person will respond to medications. In the future, this could medications. In the future, this could affect how we treat patients with sepsis. affect how we treat patients with sepsis.

Source: Chest, 2003; AJN, 2004Source: Chest, 2003; AJN, 2004

Pharmacogenetics

Pharmacogenetics is the Pharmacogenetics is the study of DNA or gene study of DNA or gene differences associated differences associated with an individuals with an individuals responses to drugs.responses to drugs.

Pharmacogenetics

Most research in Most research in pharmacogenetics has focused pharmacogenetics has focused on DNA that produces proteins on DNA that produces proteins involved with drug involved with drug metabolism.metabolism. A mutation in a gene that A mutation in a gene that controls enzymes that controls enzymes that metabolizes drugs can affect metabolizes drugs can affect how people react to antibiotics how people react to antibiotics used in the treatment of sepsis.used in the treatment of sepsis.

AJN, 2004AJN, 2004

Pharmacogenetics

In the future, treatments In the future, treatments for sepsis could involve for sepsis could involve genetic testing to identify genetic testing to identify how someone will how someone will metabolize a drug and metabolize a drug and whether the drug will be whether the drug will be effective in treating the effective in treating the infection.infection.

Sepsis and the “Stress Response”The metabolic response to stress is The metabolic response to stress is initiated by stimulation of the central initiated by stimulation of the central nervous system. nervous system.

This is called the This is called the “Stress Response”.“Stress Response”.

Some factors that trigger the “Stress Some factors that trigger the “Stress Response” include:Response” include:• HypoglycemiaHypoglycemia• Alterations in intravascular Alterations in intravascular

volumevolume• AcidosisAcidosis• HypoxiaHypoxia• PainPain

Source: Critical Care Clinics, 2000Source: Critical Care Clinics, 2000

Sepsis and the “Stress Response”

This response is controlled by This response is controlled by Corticotropin Releasing Hormone (CRH) Corticotropin Releasing Hormone (CRH) and the chemicals Epinephrine and and the chemicals Epinephrine and Norepinephrine.Norepinephrine.

CRH promotes release of pituitary CRH promotes release of pituitary Adreno-Corticotropic Hormone or ACTH.Adreno-Corticotropic Hormone or ACTH.The result is release of Glucocortioids The result is release of Glucocortioids (hormones that affect metabolism). (hormones that affect metabolism).

Epinephrine and Norepinephrine speed up Epinephrine and Norepinephrine speed up the heart and creates “fight or flight” in the heart and creates “fight or flight” in the body.the body.


During stress or illness such as sepsis chemicals During stress or illness such as sepsis chemicals are released and levels of CRH and ACTH are are released and levels of CRH and ACTH are elevated.elevated.

This affects the body’s metabolism including This affects the body’s metabolism including stimulation of triglyceride production, stimulation of triglyceride production, catabolism of muscle, and prevention of fat catabolism of muscle, and prevention of fat breakdown. breakdown.

It affects the kidneys by releasing hormones that It affects the kidneys by releasing hormones that make them hold on to fluid.make them hold on to fluid.

It increases the work of the heart by increasing It increases the work of the heart by increasing the rate and force of contraction, and increases the rate and force of contraction, and increases lung activity.lung activity.

Sources: Critical Care Clinics, 2000Sources: Critical Care Clinics, 2000Core Curriculum for Critical Care Nursing, 2006Core Curriculum for Critical Care Nursing, 2006


Patients who present with signs Patients who present with signs and symptoms of sepsis are going and symptoms of sepsis are going through this “stress” process.through this “stress” process.

Although mechanisms are unclear, Although mechanisms are unclear, theories suggest it may be theories suggest it may be exacerbated or made worse by exacerbated or made worse by inflammatory cytokines. The same inflammatory cytokines. The same cytokines released in sepsis. (TNF, cytokines released in sepsis. (TNF, IL-1, IL-6)IL-1, IL-6)

Metabolism and Sepsis

Persons with sepsis have Persons with sepsis have increased demands on increased demands on the body. the body.

They need more energy They need more energy to sustain homeostasis to sustain homeostasis because their body’s are because their body’s are “Stressed”.“Stressed”.


When homeostasis is When homeostasis is not balanced as in a not balanced as in a state of sepsis, the state of sepsis, the organs and tissues of organs and tissues of the body do not get the body do not get the oxygen or energy the oxygen or energy they need to meet the they need to meet the increased demands.increased demands.


In septic shock the energy in cells is decreased due In septic shock the energy in cells is decreased due to the increased requirements of oxygen involved in to the increased requirements of oxygen involved in the inflammatory, coagulation, and stress processes. the inflammatory, coagulation, and stress processes. This causes hypoxia in the tissues.This causes hypoxia in the tissues.

This lack of oxygen to the cells causes glycolysis or This lack of oxygen to the cells causes glycolysis or breakdown of sugars in order for the cells to have breakdown of sugars in order for the cells to have more energy. It also causes the production of lactic more energy. It also causes the production of lactic acid or acid or Anaerobic Metabolism..


Energy levels in the cells Energy levels in the cells are usually maintained are usually maintained during the initial phases during the initial phases of sepsis but in late of sepsis but in late sepsis when demands are sepsis when demands are high and stores of energy high and stores of energy are low, effects on the are low, effects on the body cause further body cause further problems.problems.


Metabolism changes in sepsis include:Metabolism changes in sepsis include:

Hypermetabolism – The body’s oxygen consumption can be up to 25% Hypermetabolism – The body’s oxygen consumption can be up to 25% above baseline.above baseline.

Altered protein metabolism – The body uses protein primarily within Altered protein metabolism – The body uses protein primarily within skeletal muscles to maintain energy levels.skeletal muscles to maintain energy levels. Altered glucose metabolism – Blood glucose levels increase because of Altered glucose metabolism – Blood glucose levels increase because of stress hormones, insulin resistance occurs, and glycogen stores from the stress hormones, insulin resistance occurs, and glycogen stores from the liver are used.liver are used.

Altered fat metabolism – Lipids stored in fat tissues are broken down and Altered fat metabolism – Lipids stored in fat tissues are broken down and used for energy.used for energy.

Metabolic Effects and Sepsis

The metabolic The metabolic demands of sepsis demands of sepsis only add to the only add to the imbalance causing imbalance causing increased acuity increased acuity levels and decreasing levels and decreasing patient survival rates.patient survival rates.

Lipid Metabolism and Sepsis – Are some patients at risk for sepsis?

Sepsis is associated with a significant Sepsis is associated with a significant increase in lipid metabolism. increase in lipid metabolism. Plasma fatty acids are greatly increased Plasma fatty acids are greatly increased during sepsis and they break down into during sepsis and they break down into triglycerides so hypertriglyceridemia is triglycerides so hypertriglyceridemia is commonly seen in severe sepsis.commonly seen in severe sepsis.

Lipid Metabolism and Sepsis – Are some patients at risk for sepsis?

High-density lipoproteins (High-density lipoproteins (HDLs or good HDLs or good cholesterolcholesterol) are decreased during sepsis and ) are decreased during sepsis and studies have shown that the magnitude of studies have shown that the magnitude of this decrease correlates with the severity of this decrease correlates with the severity of sepsis.sepsis.

This adds to the theory that HDLs can be This adds to the theory that HDLs can be protective against the inflammatory injury protective against the inflammatory injury that can occur to organs during sepsis. that can occur to organs during sepsis.

SummaryWhat’s Bugging Your Patient?

Mortality or deaths related to Mortality or deaths related to severe sepsis remain severe sepsis remain unacceptably high, 30-50%. unacceptably high, 30-50%.

There are approximately There are approximately 750,000 new sepsis cases per 750,000 new sepsis cases per year with almost 1/3 of those year with almost 1/3 of those patients dying.patients dying.

SummaryWhat’s Bugging Your Patient?

Understanding of the Understanding of the pathophysiology pathophysiology of sepsis will increase of sepsis will increase your appreciation of your appreciation of the interventions the interventions designed to decrease designed to decrease mortality rates of mortality rates of sepsis.sepsis.

Latest Treatments for Sepsis and the Role of Nursing

Early identification of the signs Early identification of the signs and symptoms of sepsis is and symptoms of sepsis is crucial to patient outcomes.crucial to patient outcomes.

Once SIRS or sepsis has been Once SIRS or sepsis has been identified, interventions that identified, interventions that are evidenced based should are evidenced based should implemented.implemented.

Nursing Interventions

• Administer antimicrobial agents on timeAdminister antimicrobial agents on time• Monitor antibiotic levelsMonitor antibiotic levels• Monitor for reactions to antibiotics (allergy, resistance)Monitor for reactions to antibiotics (allergy, resistance)• Monitor and adhere to unit specific infection control protocols Monitor and adhere to unit specific infection control protocols

recommended by the Centers for Disease Control or CDCrecommended by the Centers for Disease Control or CDC• Provide at least twice a day teeth brushing with oral cleansing every Provide at least twice a day teeth brushing with oral cleansing every

two hours, and if patients are on a ventilator, suction above the two hours, and if patients are on a ventilator, suction above the endotracheal tubeendotracheal tube

• Assist with treatments that limit infection, i.e. debridements, drainageAssist with treatments that limit infection, i.e. debridements, drainage• Stabilize fractures to limit tissue damageStabilize fractures to limit tissue damage• Maintain strong rapport with family, providing frequent updates and Maintain strong rapport with family, providing frequent updates and

education.education.


• Monitor hemodynamic parameters for changeMonitor hemodynamic parameters for change• Monitor urine outputMonitor urine output• Be prepared to administer fluid resuscitationBe prepared to administer fluid resuscitation• Be prepared to administer vasoactive medicationsBe prepared to administer vasoactive medications• Be prepared to assist with central line insertionsBe prepared to assist with central line insertions• Monitor for signs of visceral or intestinal perfusionMonitor for signs of visceral or intestinal perfusion• Avoid putting patient in Trendelenburg or head down position for lengths of Avoid putting patient in Trendelenburg or head down position for lengths of

timetime• Maximize oxygen use and demandMaximize oxygen use and demand

• Control body temperatureControl body temperature• Limit patient activityLimit patient activity

• Continual assessments for decreasing physical statusContinual assessments for decreasing physical status• Provide enteral feedings as orderedProvide enteral feedings as ordered• Assist in maintaining therapeutic glucose levelsAssist in maintaining therapeutic glucose levels


Involvement in the interdisciplinary team effort to reduce the Involvement in the interdisciplinary team effort to reduce the incidence and mortality rates of sepsis which includes incidence and mortality rates of sepsis which includes implementation of a “Sepsis Bundles”.implementation of a “Sepsis Bundles”.

A “bundle” is a group of interventions when used together A “bundle” is a group of interventions when used together result in better outcomes. (IHI.org) result in better outcomes. (IHI.org)

Sepsis Resuscitation BundleSepsis Resuscitation Bundle

• Monitor serum lactate levelsMonitor serum lactate levels

• Blood cultures prior to antibiotic Blood cultures prior to antibiotic administrationadministration

• Broad spectrum antibiotic Broad spectrum antibiotic administration within 3 hours for ED administration within 3 hours for ED admission and one hour non ED admission and one hour non ED admissionadmission

• Fluids for hypotension and elevate Fluids for hypotension and elevate lactate levels lactate levels

• Central line placement if persistent Central line placement if persistent hypotensionhypotension

Sepsis Bundles

Sepsis Management BundleSepsis Management Bundle

• Low dose steroid administration for Low dose steroid administration for septic shockseptic shock

• Recombinant Activated Protein C if Recombinant Activated Protein C if availableavailable

• Maintain glucose <150mg/dlMaintain glucose <150mg/dl

• Maintain airway pressures <30cm for Maintain airway pressures <30cm for patients on ventilatorspatients on ventilators

Sepsis Bundles

Conclusion

Sepsis is the leading cause of death Sepsis is the leading cause of death in intensive care units with over in intensive care units with over 2000 new cases occurring daily in 2000 new cases occurring daily in the United States.the United States.

Research is ongoing regarding Research is ongoing regarding pathophysiology as well as pathophysiology as well as treatments. But understanding treatments. But understanding relationships of the body’s relationships of the body’s responses to infection helps to responses to infection helps to understand why treatment as well understand why treatment as well as prevention is crucial to saving as prevention is crucial to saving lives.lives.

That’s Right! Way to go!That’s Right! Way to go!

Case Study 1

Mrs. C. Hicken is an 80 year old Mrs. C. Hicken is an 80 year old woman admitted to the medical unit. woman admitted to the medical unit. She states that she has a sore throat, She states that she has a sore throat, persistent cough, and chest pain persistent cough, and chest pain when she takes deep breaths. She when she takes deep breaths. She tells you she has felt this way for tells you she has felt this way for several days prior to coming to the several days prior to coming to the hospital.hospital.

Vital Signs are as follows: Vital Signs are as follows: Temperature - 101.2 Temperature - 101.2 °F°FPulse -110 beats per minutePulse -110 beats per minuteRespirations – 40 breaths per minuteRespirations – 40 breaths per minuteBlood Pressure – 110/60mmHgBlood Pressure – 110/60mmHg

Review of Case Study 1

What clinical symptoms related to sepsis What clinical symptoms related to sepsis does she show? does she show? Click here to review clinical signs and symptoms Click here to review clinical signs and symptoms

Is this considered Systemic Inflammatory Is this considered Systemic Inflammatory Response Syndrome? (SIRS)Response Syndrome? (SIRS)Click here to review clinical signs and symptoms Click here to review clinical signs and symptoms


Mrs. C. Hicken is exhibiting the Mrs. C. Hicken is exhibiting the following signs and symptoms:following signs and symptoms:

• Vital Signs are as follows: Vital Signs are as follows: • Temperature - 101.2 °FTemperature - 101.2 °F• Pulse -110 beats per minutePulse -110 beats per minute• Respirations – 40 breaths per minuteRespirations – 40 breaths per minute• Blood Pressure – 110/60mmHgBlood Pressure – 110/60mmHg



Source: Core Curriculum for Critical Care Source: Core Curriculum for Critical Care Nursing, 2006Nursing, 2006

Return to the Case StudyReturn to the Case Study

Review Signs and Symptoms of SIRS

Mrs. C. Hicken is exhibiting the Mrs. C. Hicken is exhibiting the following signs and symptoms:following signs and symptoms:

• Vital Signs are as follows: Vital Signs are as follows: • Temperature - 101.2 °FTemperature - 101.2 °F• Pulse -110 beats per minutePulse -110 beats per minute• Respirations – 40 breaths per minuteRespirations – 40 breaths per minute• Blood Pressure – 110/60mmHgBlood Pressure – 110/60mmHg

Return to the Case StudyReturn to the Case Study

The clinical signs and symptoms of The clinical signs and symptoms of SIRS are the manifestation of two SIRS are the manifestation of two (2) or more of the following (2) or more of the following conditions:conditions:

• Temperature above 100.4Temperature above 100.4°F or °F or below 96.8°Fbelow 96.8°F

• Heart rate above 90 beats per minuteHeart rate above 90 beats per minute• Respiratory rate above 20 per Respiratory rate above 20 per

minute or PaCO2 below 32 mm Hgminute or PaCO2 below 32 mm Hg• White blood cell count above White blood cell count above

12,000uL-1 or below 4,000uL-112,000uL-1 or below 4,000uL-1

Source: Critical Care Medicine, 2003Source: Critical Care Medicine, 2003


Mrs. C. Hicken is showing three (3) Mrs. C. Hicken is showing three (3) of the conditions that make up of the conditions that make up SIRS SIRS or Systemic Inflammatory Response or Systemic Inflammatory Response Syndrome.Syndrome.

FeverFever above 100.4 above 100.4°F or below 96.8°F°F or below 96.8°F

Heart rate above 90Heart rate above 90 beats per minute beats per minute

Respiratory rate above 20Respiratory rate above 20 per minute per minute or PaCO2 below 32 mm Hgor PaCO2 below 32 mm Hg

White blood cell count above White blood cell count above 12,000uL12,000uL-1-1 or below 4,000uL or below 4,000uL-1-1

Case Study 2Mr. M. Oose is a 47 year old male admitted Mr. M. Oose is a 47 year old male admitted with an infected elbow. On his second day in with an infected elbow. On his second day in the hospital you find him in his room confused the hospital you find him in his room confused and agitated. and agitated.

Vital signs are as follows: Vital signs are as follows: Temperature – 96.2 Temperature – 96.2 °F°FPulse -140 beats per minutePulse -140 beats per minuteRespirations – 40 breaths per minuteRespirations – 40 breaths per minuteBlood Pressure – 90/40 mmHgBlood Pressure – 90/40 mmHgLabs include a WBC count of 3,000uL-1Labs include a WBC count of 3,000uL-1Further assessment of him includes:Further assessment of him includes:

• Urine output of 100cc for the last 8 Urine output of 100cc for the last 8 hourshours

• Pulse oximetry of 88% on room airPulse oximetry of 88% on room air• PallorPallor


What clinical signs and symptoms related What clinical signs and symptoms related to sepsis does he show?to sepsis does he show?Click here to review clinical signs and symptomsClick here to review clinical signs and symptoms

Is he showing signs and symptoms of multiple Is he showing signs and symptoms of multiple organ dysfunction syndrome (MODS)?organ dysfunction syndrome (MODS)?Click here to review clinical signs and symptomsClick here to review clinical signs and symptoms


Mr. M. Oose is displaying four (4) of the Mr. M. Oose is displaying four (4) of the signs and symptoms of clinical sepsis. signs and symptoms of clinical sepsis. They are:They are:

Temperature – 96.2 Temperature – 96.2 °F – °F – Low Low temperaturetemperature

Pulse -140 beats per minute – Pulse -140 beats per minute – Heart rate Heart rate over 90 beats per minuteover 90 beats per minute

Respirations – 40 breaths per minute – Respirations – 40 breaths per minute – Increased respiratory rateIncreased respiratory rate

Labs include a WBC count of 3,000uL-1 Labs include a WBC count of 3,000uL-1 - - Low WBC countLow WBC count

Review of Case Study 2 Further assessment of him includes:Further assessment of him includes:

•Urine output of 100cc for the last 8 Urine output of 100cc for the last 8 hours hours•ConfusionConfusion•Pulse oximetry of 88 on room airPulse oximetry of 88 on room air•PallorPallor

Low urine output indicates possible Low urine output indicates possible altered blood flow to the kidneys. altered blood flow to the kidneys. Confusion, a low pulse oximeter and Confusion, a low pulse oximeter and pallor indicate poor perfusion to the pallor indicate poor perfusion to the tissues. tissues.

Mr. M. Oose is demonstrating multiple Mr. M. Oose is demonstrating multiple organ involvement or MODS.organ involvement or MODS.

Case Study 3Mr. G. Erbil is an 80 year old male Mr. G. Erbil is an 80 year old male who entered the emergency room who entered the emergency room with abdominal pain. His wife says with abdominal pain. His wife says he has had the “flu” for days and now he has had the “flu” for days and now he is “very sick”.he is “very sick”.

Vital signs are:Vital signs are:Temperature 95.7 Temperature 95.7 °°FFHeart rate 145 beats per minute Heart rate 145 beats per minute Respiratory rate 45 breaths per minute Respiratory rate 45 breaths per minute Blood pressure 70/30mmHg Blood pressure 70/30mmHg

Further assessment of him shows a Further assessment of him shows a WBC count of 2,000uL-1WBC count of 2,000uL-1


What clinical signs and symptoms related to What clinical signs and symptoms related to sepsis does he show?sepsis does he show?Click here to review clinical signs and symptoms Click here to review clinical signs and symptoms

After the review of Case Study 3 you will see After the review of Case Study 3 you will see there are other factors that affect how people there are other factors that affect how people respond to sepsis.respond to sepsis.

ReviewAnswer True or False to the following questions

Click on the correct answer.

1. True or or False. Studies have shown that genetics may . Studies have shown that genetics may play a role in how people respond to infection or play a role in how people respond to infection or sepsis.sepsis.

2. True or or False. Metabolism in patients with sepsis is . Metabolism in patients with sepsis is altered, which can make the patients condition altered, which can make the patients condition worse.worse.

3. True or False. Patients with sepsis are also having a or False. Patients with sepsis are also having a “stress response”, releasing chemicals that increase “stress response”, releasing chemicals that increase heart rate and decrease urine output.heart rate and decrease urine output.

Metabolism Metabolism isis altered in sepsis altered in sepsis which makes matters worse for which makes matters worse for patients.patients.

That’s Right! Way to go!That’s Right! Way to go!

Septic patients Septic patients areare having a stress having a stress response to infection.response to infection.

Let’s Stop for a ReviewAnswer True or False to the following questions


1.1. True or False - Sepsis is the leading cause of True or False - Sepsis is the leading cause of death in the ICU setting.death in the ICU setting.

2.2. True or False - Sepsis can lead to widespread True or False - Sepsis can lead to widespread inflammation and blood clotting.inflammation and blood clotting.

3.3. True or False - Sepsis can be viewed as a True or False - Sepsis can be viewed as a dysfunction of coagulation, inflammation and dysfunction of coagulation, inflammation and fibrinolysis.fibrinolysis.

Let’s Stop for a ReviewAnswer True or False to the following questions


1.1. True or False – Inflammation is caused by True or False – Inflammation is caused by the release of cytokines Tumor Necrosis the release of cytokines Tumor Necrosis Factor-a, Interleukin-1(IL-1), Interleukin-Factor-a, Interleukin-1(IL-1), Interleukin-6 (IL-6) and Platelet activating factor.6 (IL-6) and Platelet activating factor.

2.2. True or False – Endothelium plays a key True or False – Endothelium plays a key role in the progression of sepsis.role in the progression of sepsis.

Return to metabolism and sepsisReturn to metabolism and sepsis

sepsis l at the end of this tutorial the learner will be able to: define sepsis and related terms...

Documents

severe sepsis

treatment of sepsis

onset of sepsis

sepsis lat

common cause of sepsis

body response

normal response

inflammatory mediators