Goal and Objectives Goal- To decrease mortality from severe sepsis in adults through education and implementation of evidenced-based care bundles Objectives- Recognize the signs and symptoms of sepsis Understand the difference between the types of sepsis; SIRS, sepsis, severe sepsis, and septic shock Learn the sepsis resuscitation care bundle Audience- Nurses
What is sepsis? Sepsis is a condition in which the body is fighting a severe infection that has spread via blood stream. This is characterized by a systemic inflammation response syndrome called, SIRS. The body may develop this inflammatory response to microbes in the blood, urine, lungs, skin, or other tissues. There is a continuum to sepsis that includes infection, sepsis, severe sepsis, septic shock, and multiple organ dysfunction
Systemic Inflammatory Response Syndrome (SIRS) Two or more of: Temperature >38˚C or <36˚C Heart rate >90 (unless taking beta-blocker, calcium channel blocker, or the heart is paced Respiratory rate >20 breaths/min or PaCO2 < 32 mmHg WBC >12,000 or < 4,000
Types of sepsis Sepsis: Two or more SIRS criteria, known or suspected infection Severe sepsis: Sepsis as above Organ dysfunction -hypotension: systolic <90 mmHg, MAP <65 mmHg, or a decrease in 40 mmHg from usual reading -Lactate > 4mmol/L -Altered mental status -Hyperglycemia in the absence of diabetes -Hypoxemia, O2 < 93% -UOP <0.5 ml/kg/hr and/or raised urea or creatinine -Coagulopathy, INR >1.5
Sepsis Continued Septic shock: Severe sepsis Hypotension or raised lactate that does not improve with adequate fluid resuscitation Multiple organ dysfunction: Perfusion is compromised, ischemia and hypoxia of organs Cardiovascular-Heart Failure, Neurological- change in LOC, Pulmonary-ARDS, Renal- Acute Renal Failure, Metabolic-acidosis, Hepatic- Liver Failure, Hematologic-Disseminated Intravascular Clotting
Sepsis Identifying patients with severe sepsis in primary care, emergency departments, wards or admission units is crucial to reducing mortality In the severe sepsis resuscitation bundle, a time limit of six hours is given for all elements to be completed, although elements should be completed as soon as possible.
Sepsis Resuscitation Bundle Measure serum lactate Blood cultures obtained prior to administration of antibiotic From time of presentation, broad spectrum antibiotics must be administered within 3hrs of ED admission, or within 1hr of non-ED admission In the event that hypotension and/or serum lactate >4mmol a) Deliver initial minimum of 20ml/kg of crystalloid or colloid equivalent. b) Apply vasopressors for hypotension not responding to initial fluid resuscitation to maintain a MAP of ≥65mmHg. Consider insertion of urinary catheter (measure UOP) If hypotension persists and serum lactate >4mmol despite fluid resuscitation achieve a) CVP ≥8mmHg and b) (ScvO2) of ≥70%.
Unfortunate Progression of Sepsis Decrease Oxygenation Cont. decrease in oxygenation Lower BP Signs Death Low BP Fluids Vasopressors Treatments Mechanical Ventilation Face Mask O2
Were Objectives Met? Can you recognize inflammation through signs such as redness, heat, swelling, pain and loss of function? Are you aware of changes in vital signs; tachycardia, hypotension, decrease in O2, increase in respirations? What labs should you monitor aggressively? Do you have a better understanding of the need for urgent fluid resuscitation to reverse hypovolemia that has occurred from sepsis? Did this information help you interpret physiological observations to decrease mortality rate in adults with sepsis?
References Carter, C. (2007). Implementing the severe sepsis care bundles outside the ICU by outreach. British Association of Critical Care Nurses, Nursing in Critical Care, 12 (5), 225-230 Peel, M. (2008). Care bundles: resuscitation of patients with severe sepsis. Nursing Standard, 23 (11), 41-46 Simrandeep, S., Pradeep, S., Gurjit, S. (2009). Systemic inflammatory response syndrome outcome in surgical patients. Indian Journal of Surgery, 71, 206–209