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  • Average cost of each case of sepsis approx. $22,000
  • Cytokine: TNF…..central mediator in the inflammatory response. Effects fever, increases insulin resistance, stimulates phagocytosis. Locally, TNF causes traditional signs of inflammation: heat, redness, swelling, pain. High concentrations produce shock-like symptoms. IL6….part of the acute response phase crosses blood/brain barrier and effects fever, as well. Also triggers marrow production of neutrophils.
  • Shunting occurs to preserve perfusion to vital organs-periphery feels cold to touch. Also shunts from the bowel, as digestion is considered a nonvital function. Blood is diverted to heart, lungs & brain. Activated Protein C suppresses inflammatory response-reduces clotting, improves fibrinolysis.
  • Transcript

    • 1. Kellie Murphy, BSN, RN, CCRN
    • 2. Erins StoryIt is the clinical syndrome that results from adysregulated inflammatory response to aninfection (UpToDate, 2012).Sepsis is not a specific event in time, but rathera syndrome that occurs on a continuum.
    • 3. ~750,00 cases annually (trend has been on asteady increase since the 70’s)Thought to be influenced by:aging populationincrease in immune suppressed populationincreased drug resistant diseases~200,000 deaths/yearPatients >65 account for nearly 60% of all cases(Angus, et all, 2001).
    • 4. Increased incidence during wintermonths30-50% mortality, severitydependentSeptic patients have 2x as longhospital stay as patients withoutCosts the health care system over$16 billion dollars annually
    • 5. Critically-ill patientsSevere community-acquired pneumoniaChronic diseasesImmuno-compromiseAgeObesityIntra-abdominal surgeryUrinary tract infectionInvasive linesAll hospitalized patients
    • 6. SIRS SepsisSepticShockMODS Death
    • 7. Clinical syndrome that results from adysregulated inflammatory response, but is dueto a non-infectious source.Examples:Acute pancreatitisTraumaBurnsSurgery
    • 8. SIRS requires 2 or more of the followingderangements:Temp >38.3: (100.4:F) or <36:C (96.8:F)HR >90RR >20 or PaCO2 >32 (normal 35-45)WBC >12,000 or <4,000 or >10% immaturecells (bands)
    • 9. A systemic inflammatory response to infection,triggers cascade of inflammation, coagulationand impaired fibrolysis.This out of control inflammatory process resultsin vasodilitation, increased capillarypermeability and clotting.Same criteria as SIRS, however, occurs within acontext of known infection.
    • 10. Sepsis plus at least one of the following signs ofhypoperfusion or end organ damageAreas of mottled skinDelayed capillary refillUrine output of <0.5 mL/kg for at least one hour orrenal replacement therapyLactate >2 mmol/LAMSAbnormal EEG findingsPlatelet count <100,000DICAcute lung injury or ARDSCardiac dysfunction
    • 11. Exists if there is severe sepsis & one or both ofthe following:Systemic mean blood pressure <60 mmHg despiteadequate fluid resuscitationMaintaining systemic mean blood pressure >60mmHg requires vasopressors despite adequatefluid resuscitationVassopressor use is a significant predictor ofmortality
    • 12. Altered function of one or more organsPrimary and secondary MODSPrimary: direct injury/insult to organs that resultsfrom a specific event (i.e. pulmonarycontusion, liver laceration)Secondary: indirect injury/insult to organs as aresult of systemic event (i.e. SIRS, sepsis)Mortality with MODS is very high; proportionateto the number of organs involved2 organ failure mortality 45-55%3 organ failure mortality >80%
    • 13. (Bone, et al., 1992).
    • 14. Localized site of infection, initiates a localizedinflammatory responseWhite blood cells converge to the site of infectionNeutrophils, macrophagesLocalized infection can lead to bloodstreaminfection (bactermia), this is sepsisBacteria release endotoxinsImmune system releases proinflammatorymediators (prostaglandins, cytokines)Endotoxins
    • 15. Cytokines are immunomodulators (interleukons& interferons) released by WBCs and cause:VasodilitationIncreased capillary permeabilityIncreased coagulationProstaglandins in the inflammatory processcause vasodilitation, inhibit platelet aggregationand effect the hypothalamus with regards tothermoregulation (fever)
    • 16. Vasodilitation is mechanism used to increaseblood flow to affected areas allowing for bettertransport of WBCsWithout corresponding increase in blood volume,hypotension followsIncreased capillary permeability leads to fluidleak  third spacing & further volume lossImpaired fibrinolysis causes decreased clotbreakdown microthrombi, then tissuehypoperfusion, necrosis & organ failure
    • 17. Third-spacing/Capillary leakMicrothrombi
    • 18. In septic shock, the body’s compensatorymechanisms are overwhelmed by malignantinflammatory response.Leading to:Reduced coronary blood flow with decreased CO, BP &tissue perfusionPro-inflammatory cytokines cause imbalances betweenclotting & lysis, impairing circulation totissues/organs, third spacing & worsening hypotensionBrain fails to respond with vasomotor responses tohypotensionPeripheral ischemia occurs due to prolonged shunting &microemboliSurvival at this stage in the cascade is <10%
    • 19. Hyperthermia/hypothermiaTachycardiaTachypneaHypotensionOliguriaAltered mental statusHypoxemiaDecreased capillary refill and/or mottling ofextremities
    • 20. WBCs elevated or suppressed (>12,000<4,000)or normal with >10% bandsDocumented infectionIncreased lactate >4 mmol/LCoagulation disturbancesLow fibrinogen, increased fibrin split productsThrombocytopeniaElevated INR or PTTElevated CRP (C Reactive Protein)Hyperglycemia
    • 21. The key to sepsis treatment is: PREVENTIONHAND WASHINGProper line managementVAP protocolsHand washingCatheter removalEarly mobilityDid I mention hand washing already?
    • 22. Broad spectrum antibiotics within first 1-3 hoursCorticosteroids, if persistent hypotensiondespite adequate fluid resuscitation; mayindicate adrenal insufficiencyno longer requires cortisol stim test to start therapyVasopressors, for hemodynamic support afteradequate fluid resuscitationXigris (drotrecogin alfa) voluntarily pulled fromthe market in 10/2011 as studies showed nobenefit
    • 23. Stroke: Time is brainMI: Time is muscleSepsis: Time is tissueWith every hour that intervention is delayed,survival drops by 10%Early recognition and intervention are key tosuccessful outcomesPrevention is the key to sepsis
    • 24.
    • 25. HighImpactGraphics. (2011, August 14). Sepsis {Video file}. Retrieved from (2012, September 24). Code sepsis {Video file}. Retrieved from, B., Linde-Zwinde, W., Lidicker, J., Clemont, G., Carcillo, J., & Pinsky, M. (2001).Epidemiology of severe sepsis in the United States: Analysis of incidence, outcomeand associated costs of care. Critical Care Medicine, 29(7), 1303-1310.Bone, R., Balk, R., Cerra, F., Dellinger, R., Fein, A., Knaus, W., . . . Sibbald, W. (1992).Definitions for sepsis and organ failure and guidelines for the use of innovativetherapies in sepsis. The ACCP/SCCM Consensus Conference Committee, (pp. 1644-55).
    • 26. Angus, B., Linde-Zwinde, W., Lidicker, J., Clemont, G., Carcillo, J., & Pinsky, M. (2001).Epidemiology of severe sepsis in the United States: Analysis of incidence, outcomeand associated costs of care. Critical Care Medicine, 29(7), 1303-1310.Bone, R., Balk, R., Cerra, F., Dellinger, R., Fein, A., Knaus, W., . . . Sibbald, W. (1992).Definitions for sepsis and organ failure and guidelines for the use of innovativetherapies in sepsis. The ACCP/SCCM Consensus Conference Committee, (pp. 1644-55).Dellacroce, H. (2009). Surviving sepsis: The role of the nurse. RN, July, 16-21.Dellinger, R.P.; Levy, M.M.; Rhodes, A.; Annane, D.; Gerlach, H.; opal, S.M.;Sevrasky, J.E.; Sprung, C.L.; Douglas, I.S.; Jaeschke, R.; Osborn, T.M.; Nunnally, M.E.;Townsend, S.R.; Reinhart, K.; Kleinpell, R.M.; Angus, D.; Deutschman, C.S.;Machado, F.R.; Rubenfeld, G.D.; Webb, S.A.; Beale, R.J.; Vincent, JL; Moreno, R.;Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup.(2012, January 20). Surviving sepsis campaign: International guidelines formanagement of severe sepsis and septic shock: 2012. Society of Critical CareMedicines 42nd Congress, (41)2, 580-637. DOI: 10.1097/CCM.0b013e31827e83af
    • 27. McCormick, M.J. Recognizing the signposts for sepsis. Nursing Made IncrediblyEasy!, (7)3, 40-51. doi: 10.1097/01.NME.0000350939.27283.30Woodruff, D.W. Why you need to know about sepsis syndrome {Webinar notes}.(2011, July 22). Retrieved from, S.; Lavieri, M.C.; Durkin, T. (2007). What you need to know about sepsis.Nursing2007, 37(3), 46-51