Sepsis Prevention Strategies: Stopping the Progression of Hospital Acquired Infections

Kristen Luttenberger RN, MSN, CCRN-CMC, PCCN, APNC

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…..insufficient perfusion of cells and vital organs, causing tissue hypoxia which results in cellular, metabolic, and hemodynamic derangements

Re-produced and modified by original author (en:User:Panthro) from Alexander, M.F., Fawcett, J.N., Runciman, P.J. (2004) Nursing Practice. Hospital and Home. The Adult.(2nd edition). Edinburgh: Churchill Livingstone. This version created with Inkscape, and released to the public domain.

Stages of Shock  Initial  Compensatory  Progressive  Refractory

•  Inadequate vascular volume: external or internal losses Hypovolemia

•  Impaired ability of the heart to pump blood and maintain adequate tissue perfusion: contractility, filling, and/or emptying

Cardiogenic

•  Inadequate tissue perfusion caused by decreased systemic vascular resistance (SVR). Massive vasodilatation from: infection (septic), anaphylactic, or neurogenic

Distributive/ Vasogenic

Hemodynamic Alterations in Shock Hypovolemic Cardiogenic Early

Septic Late Septic

Anaphylactic Neurogenic

HR High High High High High N or Low

BP N or Low N or Low N or Low

N or Low

Low N or Low

CO/CI Low Low High Low N or Low N or Low

RAP/ PAOP

Low High Low High

maybe N or L

Low Low

SVR/ SVRI

High High Low High Low Low

SvO2 Low Low High Low Low Low

Class IV >40% loss >2000ml, critical HR (>140) & SBP (<70), obtunded, anuria

Class III 30-40% loss 1500-2000ml, >120 HR, >30 RR, <100 SBP, < UO, LOC

Class II 15-30% loss 750-1500ml, >100 HR, normotensive, restless, <UO

Class 1 <15% loss 750ml, state of compensation, normotensive

ABCs Volume Resuscitation

Stop fluid loss

Inotropes after

volume

Mechanical Support

Cardiac Index (2-2.2)

• Tachycardia • Narrow pulse

pressure • Tachypnea • Cool skin • Oliguria • Diminshed bowel

sounds • Restless/confused

Cardiogenic Shock (CI<2)

•  Same symptoms as previous

• Additional: dysrhythmias

• Hypotension •  Lethargy • Anuria

Treatment

• Fix the pump/cath or sx.

• O2 • Pressors •  Inotrope •  IABP • VAD • Transplant

Impairment of the ability of the heart to maintain adequate tissue perfusion ALL ABOUT-**Preload, Afterload, Contractility, HR, Perfusion**

In a nut shell:   IgE binds to the antigen   Activation mast cells and basophils   Release of mediators (histamine)

which trigger vasodilatation, increase contraction of bronchial smooth muscle, and leakage of fluid from blood vessels

  Massive vasodilation from lactic acidosis & nitrous oxide causing the activation of ATP potassium channels in vascular smooth muscle

Anaphylactic

Symptomology:  Hives/Itching/Flushing  Swelling of face, tongue or

throat  Wheezing/Stridor  Coronary Artery Spasm  Tachycardia  Anxiety  Hypotension

Causes include insect bites, foods, and medications. Reaction occurs within 5-30 minutes with IVs and 2 hours with foods.

http://en.wikipedia.org/wiki/Anaphylaxis

#1 PREVENTION!!!!  Maintain airway ABCs  Volume resuscitation  Remove antigen  Modify or block the effects of biochemical

mediators  Administer sympathomimetic-epi, norepi,

dopamine, glucagons, antihistamines, bronchodilators

 STEROIDS

namuvo.com

uic.edu

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 A serious condition related to systemic inflammation, organ dysfunction, and organ failure. It is a subset of cytokine storm

 Defined by the presence of two or more of the following findings:

 When SIRS is suspected or known to be caused by an infection, this is sepsis.

Finding Value Temperature <36 °C (96.8 °F) or >38 °C (100.4 °F)

Heart Rate >90/min

Respiratory Rate >20/min or PaCO2<32 mmHg

WBC <4x109/L (<4000/mm³), >12x109/L (>12,000/mm³), or 10% bands

Treatment of Sepsis Should Begin ASAP!: (1st 3 hrs) 1) Measure lactate level 2) Obtain blood cultures prior to administration of antibiotics 3) Administer broad spectrum antibiotics 4) Administer 30 mL/kg crystalloid for hypotension or lactate 4mmol/L

Within 6 hours: 5) Apply vasopressors (for hypotension that does not respond to initial

fluid resuscitation) to maintain a mean arterial pressure (MAP)65mmHg 6) In the event of persistent arterial hypotension despite volume

resuscitation (septic shock) or initial lactate 4 mmol/L (36 mg/dL): - Reassess physiologic variables (HR, BP, SaO2, RR, Temp, UO & others)

7) Remeasure lactate if initial lactate was elevated* *Targets are MAP>65 (strong recommendation) *Normalization of lactate (weak recommendation)

Maximize O2 Delivery MAP>65 (HR, SaO2, RR, Temp, Urine) Fluid, Blood if Hgb<7, Vasopressors,

Inotropes

Decrease O2 Consumption MV/PEEP

Sedate (neuromuscular blockade <48hrs) Nutritional Status

Complications of Support Control hyperthermia

#1 PREVENTION #2 EARLY ANTIBIOTICS

Trauma causes a sudden loss of background sympathetic stimulation to the blood vessels thereby vasodilatation occurs. Hypotension occurs secondary to the decrease in peripheral vascular resistance. Bradycardia is caused by unopposed vagal activity and has been found to be exacerbated by hypoxia and endobronchial suction.

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Neurogenic:  ABCs  Spinal Cord Immobilization  Warming Measures  Maintain MAP (Fluids, pressors, Dopa)  Maintain HR (Atropine, PPM)  Prevent venous stasis  Volume Replacement  Monitor for complications of shock  STEROIDS?? topnews.net.nz