Sepsis

Question 1

sepsis

Answer 1

life threatening organ dysfunction caused by dysregulated response to infection occurring when microorganisms invade the body and initiate a systemic inflammatory response

Question 2

causes of increased prevalence of sepsis

Answer 2

bigger awareness of sepsis/septic shock, aging population ( w/ chronic illnesses), antibiotic-resistance, increase of invasive procedures being done, increased use of immunosuppressant and chemotherapy agents

Question 3

factors for increased mortality risk

Answer 3

65 +, hyperglycemia on admission, inability to clot, site of infection (if unknown, GI, or pulmonary), type of infection, and restoration of perfusion

Question 4

“q sofa” screening

Answer 4

GCS less than 15, systolic bp less than 100, and a respiratory rate greater than 22; if you have 2/3 in a pt with a suspected infection, think sepsis

Question 5

septic shock criteria

Answer 5

vasopressor required to maintain MAP of 65, serum lactate level greater than 2, and absence of hypovolemia

Question 6

septic shock

Answer 6

a subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality

Question 7

pathophysiology of sepsis

Answer 7

body’s immune response is triggered in response to pathogen, WBCs release inflammatory mediators and cytokines resulting in vasodilation, capillary leakage (–> third spacing), and blood clotting; there isn’t enough blood to get to organs (hypoperfusion); metabolic acidosis occurs (organs aren’t getting the blood they need and can’t get excrete waste products that are building up and kidneys can’t make enough HCO3 to balance out the blood pH); evolves to septic shock if the patient has received fluid resuscitation but their blood pressure isn’t responding; evolves to MODS when 2 or more organs have failed

Question 8

SIRS

Answer 8

(not in new definition but still used) temperature greater than 38C (100.4) or less than 36C (96.8), HR above 90 bpm, RR over 20 or PaCO2 less than 32, and WBC greater than 12,000 or less than 4,000; need 2 or more to dx

Question 9

SIRS –> Sepsis

Answer 9

2/4 SIRS with a suspected or confirmed source of infection

Question 10

severe sepsis

Answer 10

sepsis + dysfunction of 2 or more organ systems r/t hypoperfusion

Question 11

organ dysfunction/failure criteria

Answer 11

respiratory usually fails first –> tachypnea or low O2 sat; liver failure –> jaundice, elevated liver enzymes or bilirubin greater than or equal to 4; renal –> decreased UOP (should be 0.5ml/kg/hr), Cr greater than 0.5 from baseline; bone marrow –> plt less than 100 or INR greater than 1.5; CNS –> altered LOC/confusion/delirium; CV –> HR above 90, dysrhythmias, SBP below 90 or decreased 40 from baseline, altered CVP/PAWP; lactate greater than 2, stress ulcers r/t decreased GI perfusion

Question 12

sepsis –> septic shock

Answer 12

severe sepsis + refractory hypotension (given fluids but not helping bp rise) and lactic acidosis (lactate greater than 2)

Question 13

septic shock criteria

Answer 13

MAP less than 65 or SBP less than 90/decreased 40 from baseline; no improvement after fluid resuscitation

Question 14

fluid resuscitation

Answer 14

30ml/kg crystalloid solution within first 3 hrs, additional fluids depend on reassessment of hemodynamics; usually NS, might add albumin

Question 15

diagnosis of sepsis

Answer 15

2 sets of aerobic and anaerobic testing from different sources, appropriate microbio cultures, gram-stains

Question 16

antimicrobial therapy

Answer 16

empiric broad-spectrum antibiotics, at least 2 antibiotics within different antimicrobial classes (if septic shock) for 7-10 days, eval procalcitonin levels to know when to de-escalate antibiotic administration

Question 17

vasoactive therapy

Answer 17

use when fluid resuscitation has not achieved MAP of at least 65; norepinephrine is first choice, might add vasopressin/epinephrine to decrease norepinephrine dosage

Question 18

corticosteroid therapy

Answer 18

MAP still not sufficient after the use of fluid resuscitation AND vasoconstrictors; hydrocortisone 200mg/day

Question 19

blood products for sepsis

Answer 19

platelets given if count less than 10,000 and pt is not bleeding, with active bleeding plt count at or above 50,000; PRBC if Hgb less than 7 or s/s of cardiac ischemia/hemorrge

Question 20

mechanical ventilation with sepsis

Answer 20

development of ARDS –> high levels of PEEP to get PaO2 to tolerable level; prone positioning if PaO2/FiO2 ratio less than 150; TV 6ml/kg (predicted body weight); plateau pressure less than or equal to 30; with spontaneous awakening trials and minimal sedation

Question 21

glucose control

Answer 21

IV insulin if 2 consecutive blood sugars above 180; goal to keep below 180; recommend using arterial blood for accurate results

Question 22

renal replacement therapy

Answer 22

continuous –> dialysis, intermittent –> “sled” dialysis at bedside but not for 24 hr+; use if pt hemodynamically unstable r/t fluid balance

Question 23

VTE prophylaxis

Answer 23

lovenox or mechanical prophylaxis

Question 24

stress ulcer prophylaxis

Answer 24

PPI or H2 receptor antagonist

Question 25

nutrition

Answer 25

enteral feedings preferred over parenteral; might give dextrose to supplement

Question 26

setting goals of care

Answer 26

discuss treatment plan, end-of-life planning, palliative care option, address topics early (w/i 72 hours of ICU admittance)

Question 27

Surviving Sepsis Campaign (SSC) 1 hour bundle

Answer 27

measure lactate, repeat if above 2; obtain blood cultures prior to antibiotic admin; administer broad-spectrum antibiotics; initiate rapid fluid resuscitation at 30ml/kg for hypotension or lactate greater than or equal to 4; apply vasopressors to increase bp if fluid resuscitation cannot achieve MAP of 65 or greater

Question 28

potential nursing diagnoses

Answer 28

deficient fluid volume r/t relative loss, decreased cardiac ouput r/t alterations in preload, decreased cardiac output r/t alterations in contractility; impaired gas exchange r/t VQ mismatch or intrapulmonary shunting