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2300 Sepsis Project2300 Sepsis Project
Systemic Inflammatory Systemic Inflammatory Response - SIRSResponse - SIRS
A systemic response to a clinical insultTrauma, burns, pancreatitis, infectionConsists of:
• Vasodilation• Increased capillary permeability• Release of “pro-coagulation” tissue factor• Results in inadequate tissue perfusion and
lactic acidosis
Severe SepsisSevere Sepsis Sepsis associated with organ
dysfunction Hypoperfusion or Hypotension Lactic acidosis Oliguria Altered LOC
Septic ShockSeptic ShockSepsis associated with
hypoperfusion and hypotension despite adequate fluid resuscitation
Mortality rate of 45 %
How Sepsis ProgressesHow Sepsis Progresses
Complex clinical picture…Complex clinical picture…Edematous…but volume depletedMicroclots…but bleedingInitially cardiac output…but
hypoperfusionVasodilation…but you’d expect
compensatory vasoconstriction
Common sources of Common sources of infectioninfection
WoundsUTIsPneumonia
Immediate ManagementImmediate ManagementMaintain adequate ventilation
and oxygenationFind and eliminate sourceRestore intravascular volumeBroad spectrum antibiotics within 1 hour
Immediate ManagementImmediate Management
Increase cardiac output•Vasopressors to reverse vasodilation
(increase afterload)•Inotropes to increase contractility
Restore coagulation/anticoagulation balance
Enteral feedings to maintain GI barrier
Adult Septic Shock ProtocolAdult Septic Shock Protocol
Created to streamline the treatment of the patient admitted with Severe Sepsis or SIRS.
Can be initiated in the Emergency Department with a “Code Sepsis”
Goal Directed Therapy
Adult Septic Shock ProtocolAdult Septic Shock ProtocolIf there are 2 or more SIRS criteria plus known of
suspected source of infection
Temp >38.3C (100.9F) or < 36C (96.8F)Heart rate >90Respiratory rate >20 or PaC02 <32mmHgWBC >12,000 or <4,000, or > 10% bands
And if MAP <65
If both are true then it is Septic Shock – Immediate intervention is paramount
Adult Septic Shock ProtocolAdult Septic Shock Protocol
Order Set Number MR912500 is the Adult Septic Shock Protocol
Orders are outlined in a flow chart format
Follow the arrows to complete the order set
There are 2 Pages – be sure the physician fills out both pages completely
Adult Septic Shock ProtocolAdult Septic Shock Protocol
Section 1 Page 1This section outlines the criteria for SIRS and Septic Shock –
also include the patients height, weight, and what time the protocol was started in this section
Adult Septic Shock ProtocolAdult Septic Shock Protocol
Section 2 Page 1This section outlines the various orders
Boxes are optional – Others are standard for all patients
Adult Septic Shock ProtocolAdult Septic Shock Protocol
Section 3 Page 1Timing of antibiotics is essential and patients should receive
their first dose within 1 hour of the protocol being initiated.
Adult Septic Shock ProtocolAdult Septic Shock Protocol
Section 4 Page 1This section gives an overview of what the hemodynamic
goals of therapy are for the patient. PCWP and CI are only available on patients with Swan Ganz catheters. All patients on the Septic Shock protocol should have CVP
Adult Septic Shock ProtocolAdult Septic Shock Protocol
Section 1 Page 2This section contains very important information regarding
fluid resuscitation and management of Blood Pressure.
Adult Septic Shock ProtocolAdult Septic Shock Protocol
Section 2 Page 2
Adult Septic Shock ProtocolAdult Septic Shock Protocol
Section 3 Page 2Additional orders. Remember if the patient is intubated to
place them on the sedation protocol and if diabetic or high glucose on admission the hyperglycemia protocol
Adult Septic Shock ProtocolAdult Septic Shock Protocol
Some Key Elements Start Antibiotics within an hour
Obtain SCVO2 ASAP
Dobutamine is started for a low SCVO2
Repeat SCVO2 1 hour after interventions and every hour until normal or otherwise ordered by MD
Central and Mixed Central and Mixed Venous SaturationVenous Saturation
Venous O2 Saturation…Venous O2 Saturation…Tells us what percentage of O2 was consumed or extracted from the blood
Tells us about O2 supply and demand
Venous Saturation depends Venous Saturation depends on …on …
Oxygen supply◦Cardiac output◦Hemoglobin◦pO2, SaO2
Oxygen demand◦Metabolic rate (pain, shivering, WOB,
seizures)Oxygen consumption
◦Compensatory mechanism if increasing CO isn’t effective
Saturation of arterial blood is Saturation of arterial blood is 100%100%Normally 25% of available O2 is
extractedSo normal venous saturation is
75%Normal value 65 -77% or 60 –
80%
The patient is HYPOXIC…The patient is HYPOXIC…The tissues need more O2So they extract more O2 from
arterial blood◦Let’s say 40%◦100% minus 40% = 60% returning to
R heart◦So SvO2 is 60%
The patient is SEPTIC …The patient is SEPTIC …The cells are unable to use
available O2Tissues can only extract 15%100% minus 15% = 85%So SvO2 is 85%
SvO2 less than 50% indicates SvO2 less than 50% indicates anaerobic metabolism and anaerobic metabolism and development of development of acidosisacidosis
Where is the best place to get Where is the best place to get venous blood to measure venous blood to measure venous saturation?venous saturation?
Superior vena cava – ScVo2PA catheter tip – pulmonary artery
blood – SvO2
If the SaO2 drops due to If the SaO2 drops due to suctioning suctioning or the development of ARDS, or the development of ARDS, what do you expect to happen what do you expect to happen to the SvO2?to the SvO2?
If the SaO2 drops due to suctioning If the SaO2 drops due to suctioning or the development of ARDS, or the development of ARDS, what do you expect to happen what do you expect to happen to the SvO2?to the SvO2?
You would expect it to drop88% - 25% = 63%
If you gave your patient a fluid If you gave your patient a fluid bolus that they really needed bolus that they really needed (CVP 0, (CVP 0, CI 1.8), what would you expect CI 1.8), what would you expect to happen to the SvO2?to happen to the SvO2?
If you gave your patient a fluid bolus If you gave your patient a fluid bolus that they really needed (CVP 0, CI 1.8), that they really needed (CVP 0, CI 1.8), what would you expect to happen to what would you expect to happen to the SvO2?the SvO2?
Expect it to increase (if it’s low) or remain normal because the increase in CO means the tissues don’t need to extract more O2 than normal
SvO2
extraction
SvO2 75%
(65 – 77)
SvO2 extraction
delivery
demand
delivery
demand
Hypothermia
Sepsis
Anesthesia
Neuromuscular blockade
•Anemia, hypoxia, cardiogenic shock, low BP•Hyperthermia, shivering, pain, anxiety, nursing care
Assess for the cause of Assess for the cause of SvO2SvO2Is O2 supply adequate?Check hemoglobin valueMeasure cardiac outputIs patient agitated, shivering?
Think ACIDOSIS or HYPOPERFUSION!
That’s all for now!That’s all for now!
Now you can take the post test and see what you have learned.
Thanks to all those who worked hard on these powerpoints to make this presentation a success!