ASSESSMENTUncomplicated Sepsis, Severe Sepsis,

& Septic Shock

Susie Brishaber, RNAugust, 2012

AssessmentClinical Manifestations All Sepsis categories hold

the same general clinical manifestations

Hyperthermia (>38 degrees Celsius)

Hypothermia (<36 degrees Celsius)

Difficulty Breathing (Tachypnea, >20 BPM)

Tachycardia (HR > 90) Warm skin, possibly

rash Generalized Weakness High WBC count

(>12,000 µL-1) Low WBC count

(<4,0000 µL-1) Coagulation Imbalance

Severe Sepsis – in addition to general clinical manifestations

Is categorized by having one or more vital organs affected

◦ Lungs

◦ Heart

◦ Kidney

◦ Liver

◦ Central Nervous System

Assessment Clinical Manifestations

Severe Sepsis –

RENAL SYSTEM:

Serum Creatinine level > /= 177 µ mol/L

Oliguria (Output of < 0.5 ml/Kg/ hr., if adequate fluid resuscitation)

CARDIOVASCULAR:

Hypotension (Systolic < 90 mm Hg, Diastolic < 60mm Hg)

Atria or Ventricular Rhythms

MAP < 65

Assessment Clinical Manifestations

LIVER◦ Jaundice◦ Increased levels of Hepatic Enzymes

AST > 48 U/L ALT > 55 U/L PT > 10.8 seconds INR > 1.5 PTT > 60 seconds

IMMUNILOGICAL◦ Nosocomial Infection development◦ Increase Leukocytosis◦ Fever (>100.0)

AssessmentClinical Manifestations

NEUROLOGICAL

◦ Altered LOC

◦ Altered CNS function

◦ Encelopathy

ENDOCRINE

◦ Hyperglycemia (in absence of Diabetes, >140)

◦ Weight loss

◦ Cachexia (Muscle atrophy)

AssessmentClinical Manifestations

Skin

◦Poor tissue perfusion

Lactic Acid Level (>5 mmol/L)

Edema (With fluid management)

Assessment Clinical Manifestations

Activity Intolerance

Acute Pain

Anxiety

Chronic Pain

Decreased Cardiac Output

Impaired Gas Exchange

Nursing Diagnosis

Process of PES

P = Problem statement/diagnostic label/definition

E = Etiology/related factors/causes

S = Defining characteristics/signs and symptoms

Nursing Diagnosis

Etiology/Related Factors/Causes

Sepsis can be caused from many different

infections in different areas of the body. With

each body system, bacteria has a place to

grow if given the chance.

The lungs are the major source of infection in severe sepsis (especially with hospital-acquired infections), with sepsis usually associated with pneumonia.

Lungs

Infection in the abdomen, eg, appendicitis, bowel problems, gallbladder infections. When the outer surface of the abdominal organs (called the peritoneum) is involved in the infection, it is called "peritonitis.“

Diabetic patients are also at increased risk of urinary infections leading to sepsis. Sometimes this is referred to as "urosepsis" which just refers to sepsis related to a urinary tract infection.

(Surviving Sepsis Campaign)

Bowels and Kidney

Bacteria enter the skin through wounds and skin inflammations; they also enter the skin and blood through an opening provided by intravenous ("IV") catheters (small tubes for dripping fluids), which are required for the administration of fluids and/or medicines.

Skin

Surviving Sepsis Campaign◦ Setting Aims◦ Establishing Measures◦ Creating a Protocol◦ Enhancing Reliability◦ Testing Changes

PlanningWhat do we do?

PlanningSepsis Algorithym (Surviving Sepsis Campaign)

The goal is to perform all indicated tasks 100%of the time within the first 6 hours of identification of severe sepsis.

The tasks are: 1. Measure serum lactate 2. Obtain blood cultures prior to antibiotic

administration 3. Administer broad-spectrum antibiotic, within 3 hrs.

of ED admission and within 1 hour of non-ED admission

PlanningSepsis Resuscitation Bundle

4. In the event of hypotension and/or a serum lactate > 4 mmol/L◦ a. Deliver an initial minimum of 20 ml/kg of crystalloid or an

equivalent◦ b. Apply vasopressors for hypotension not responding to initial fluid

resuscitation to maintain mean arterial pressure (MAP) > 65 mm Hg 5. In the event of persistent hypotension despite fluid

resuscitation (septic shock) and/or lactate > 4mmol/L◦ a. Achieve a central venous pressure (CVP) of > 8 mm Hg◦ b. Achieve a central venous oxygen saturation (ScvO2) > 70 % or

mixed venous oxygen saturation (SvO2) > 65 %

(Surviving Sepsis Campaign)

Planning Sepsis Resuscitation Bundle

Efforts to accomplish these goals should begin immediately, but

these items may be completed within 24

hours of presentation for patients with severe sepsis or septic

shock.

1. Administer low-dose steroids for septic shock in accordance

with a standardized ICU policy. If not administered, document why

the patient did not qualify for low-dose steroids based upon the

standardized protocol.

PlanningSepsis Resuscitation Bundle (Surviving Sepsis Campaign)

2. Administer drotrecogin alfa (activated) in

accordance with a standardized ICU policy. If not

administered, document why the patient did not

qualify for drotrecogin alfa (activated).

3. Maintain glucose control > 70, but < 150 mg/dl

4. Maintain a median inspiratory plateau pressure (IPP)*

< 30 cm H2O for mechanically ventilated patients

Sepsis Resuscitation Bundle Cont.

Apache II Score

Measure Serum Lactate Levels

Blood cultures

Initiate IV Antibiotic Therapy

Treatment of Hypotension

Keep oxygen saturation stable/Ventilator

Implementation

Broad Spectrum Antibiotics should be administered within 3 hours of suspected Severe Sepsis or Septic Shock

Blood cultures need to be drawn before antibiotics are started

Implementation

Treat Hypotension

If presenting with hypotension and/or lactate level of

>4 mmol/L give 20mL/kg of crystalloid solution

◦ Lactated Ringer’s

◦ Normal saline

Fluid administration to reach a CVP of >8mm Hg

Implementation

When patients do not respond to initial fluid resuscitation, use vasopressor therapy to maintain a MAP > 65mm Hg◦ Dopamine◦ Norepinephrine

◦ Titrate according to protocol

Implementation

Blood cultures should be re-evaluated in 48 hours to determine specific antibiotic therapy

Continue monitoring patient’s vital signs till hemodynamically stable

Follow protocols for PICC dressing, hand washing, dressing changes, and peri care

Evaluation

http://www.survivingsepsis.org/What_You_Should_Know/Pages/default.aspx

http://www.nigms.nih.gov/Education/factsheet_sepsis.htm

http://www.merckmanuals.com/professional/critical_care_medicine/sepsis_and_septic_shock/sepsis_and_septic_shock.html

http://www.merckmanuals.com/home/infections/bacteremia_sepsis_and_septic_shock/sepsis_and_septic_shock.html

References

http://www.survivingsepsis.org/SiteCollectionDocuments/Pathophysiology%20of%20Sepsis%20Phil(2).pdf

Surviving Sepsis Campaign, 2010 Dellinger, P., Levy, M., Carlet, J., Bion, J., Parker, M.,

Jaeschke, R.,et al (2008). Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock. Critical Care Medicine, 1-33, DOI: 10.1097/01.CCM.0000298158.12101.41.

References

Wesley, E., Kleinpell, R., Goyette, R., (2003). Advances in the understanding of clinical manifestations and therapy of severe sepsis: An update for critical care nurses. American Journal of Critical Care, 12(2),120-133. Retrieved from http://ajcc.aacnjournals.org/content/12/2/120.full

References