Process of PES P = Problem statement/diagnostic label/definition E = Etiology/related factors/causes S = Defining characteristics/signs and symptoms
Etiology/Related Factors/Causes Sepsis can be caused from many different infections in differentareas 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.
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)
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.
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
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)
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.
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
Apache II Score Measure Serum Lactate Levels Blood cultures Initiate IV Antibiotic Therapy Treatment of Hypotension Keep oxygen saturation stable/Ventilator
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
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
When patients do not respond to initial fluid resuscitation, use vasopressor therapy to maintain a MAP > 65mm Hg ◦ Dopamine ◦ Norepinephrine ◦ Titrate according to protocol
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
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.
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