Kindred Healthcare Sepsis Class

1. Uncomplicated Sepsis, Severe Sepsis,
& Septic Shock
Susie Brishaber, RN
August, 2012

2.  All Sepsis categories hold  Tachycardia (HR > 90)
the same general clinical  Warm skin, possibly
manifestations rash
 Hyperthermia (>38  Generalized Weakness
degrees Celsius)  High WBC count
 Hypothermia (<36 (>12,000 µL-1)
degrees Celsius)  Low WBC count
 Difficulty Breathing (<4,0000 µL-1)
(Tachypnea, >20 BPM)  Coagulation Imbalance

3.  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

4.  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

5.  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)

6.  NEUROLOGICAL
◦ Altered LOC
◦ Altered CNS function
◦ Encelopathy
 ENDOCRINE
◦ Hyperglycemia (in absence of Diabetes, >140)
◦ Weight loss
◦ Cachexia (Muscle atrophy)

7.  Skin
◦ Poor tissue perfusion
 Lactic Acid Level (>5 mmol/L)
 Edema (With fluid management)

8.  Activity Intolerance
 Acute Pain
 Anxiety
 Chronic Pain
 Decreased Cardiac Output
 Impaired Gas Exchange

9.  Process of PES
 P = Problem statement/diagnostic label/definition
 E = Etiology/related factors/causes
 S = Defining characteristics/signs and symptoms

10. 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.

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

12.  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)

13.  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.

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

16.  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

17.  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)

18.  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.

19.  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

20.  Apache II Score
 Measure Serum Lactate Levels
 Blood cultures
 Initiate IV Antibiotic Therapy
 Treatment of Hypotension
 Keep oxygen saturation stable/Ventilator

21.  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

22.  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

23.  When patients do not respond to initial fluid
resuscitation, use vasopressor therapy to maintain a
MAP > 65mm Hg
◦ Dopamine
◦ Norepinephrine
◦ Titrate according to protocol

24.  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

25.  http://www.survivingsepsis.org/What_You_Should_Kn
ow/Pages/default.aspx
 http://www.nigms.nih.gov/Education/factsheet_sepsis.h
tm
 http://www.merckmanuals.com/professional/critical_ca
re_medicine/sepsis_and_septic_shock/sepsis_and_septi
c_shock.html
 http://www.merckmanuals.com/home/infections/bacter
emia_sepsis_and_septic_shock/sepsis_and_septic_shoc
k.html

26.  http://www.survivingsepsis.org/SiteCollectionDocumen
ts/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.

27.  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/12/2/1
20.full