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2300 sepsis project


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2300 sepsis project

  1. 1. 2300 Sepsis Project
  2. 2. Systemic Inflammatory Response - SIRS <ul><li>A systemic response to a clinical insult </li></ul><ul><li>Trauma, burns, pancreatitis, infection </li></ul><ul><li>Consists of: </li></ul><ul><ul><li>Vasodilation </li></ul></ul><ul><ul><li>Increased capillary permeability </li></ul></ul><ul><ul><li>Release of “pro-coagulation” tissue factor </li></ul></ul><ul><ul><li>Results in inadequate tissue perfusion and lactic acidosis </li></ul></ul>
  3. 3. Severe Sepsis <ul><li>Sepsis associated with organ dysfunction </li></ul><ul><li>Hypoperfusion or Hypotension </li></ul><ul><li>Lactic acidosis </li></ul><ul><li>Oliguria </li></ul><ul><li>Altered LOC </li></ul>
  4. 4. Septic Shock <ul><li>Sepsis associated with hypoperfusion and hypotension despite adequate fluid resuscitation </li></ul><ul><li>Mortality rate of </li></ul><ul><li>45 % </li></ul>
  5. 5. How Sepsis Progresses
  6. 6. Complex clinical picture… <ul><li>Edematous…but volume depleted </li></ul><ul><li>Microclots…but bleeding </li></ul><ul><li>Initially cardiac output…but hypoperfusion </li></ul><ul><li>Vasodilation…but you’d expect compensatory vasoconstriction </li></ul>
  7. 7. Common sources of infection Wounds UTIs Pneumonia
  8. 8. Immediate Management <ul><li>Maintain adequate ventilation and oxygenation </li></ul><ul><li>Find and eliminate source </li></ul><ul><li>Restore intravascular volume </li></ul><ul><li>Broad spectrum antibiotics </li></ul><ul><li>within 1 hour </li></ul>
  9. 9. Immediate Management <ul><li>Increase cardiac output </li></ul><ul><ul><li>Vasopressors to reverse vasodilation (increase afterload) </li></ul></ul><ul><ul><li>Inotropes to increase contractility </li></ul></ul><ul><li>Restore coagulation/anticoagulation balance </li></ul><ul><li>Enteral feedings to maintain GI barrier </li></ul>
  10. 10. Adult Septic Shock Protocol <ul><li>Created to streamline the treatment of the patient admitted with Severe Sepsis or SIRS. </li></ul><ul><li>Can be initiated in the Emergency Department with a “Code Sepsis” </li></ul><ul><li>Goal Directed Therapy </li></ul>
  11. 11. Adult Septic Shock Protocol <ul><li>If there are 2 or more SIRS criteria plus known of suspected source of infection </li></ul><ul><li>Temp >38.3C (100.9F) or < 36C (96.8F) </li></ul><ul><li>Heart rate >90 </li></ul><ul><li>Respiratory rate >20 or PaC02 <32mmHg </li></ul><ul><li>WBC >12,000 or <4,000, or > 10% bands </li></ul><ul><li>And if MAP <65 </li></ul><ul><li>If both are true then it is Septic Shock – Immediate intervention is paramount </li></ul>
  12. 12. Adult Septic Shock Protocol <ul><li>Order Set Number MR912500 is the Adult Septic Shock Protocol </li></ul><ul><li>Orders are outlined in a flow chart format </li></ul><ul><li>Follow the arrows to complete the order set </li></ul><ul><li>There are 2 Pages – be sure the physician fills out both pages completely </li></ul>
  13. 13. Adult Septic Shock Protocol <ul><li>Section 1 Page 1 </li></ul><ul><li>This section outlines the criteria for SIRS and Septic Shock – also include the patients height, weight, and what time the protocol was started in this section </li></ul>
  14. 14. Adult Septic Shock Protocol <ul><li>Section 2 Page 1 </li></ul><ul><li>This section outlines the various orders </li></ul><ul><li>Boxes are optional – Others are standard for all patients </li></ul>
  15. 15. Adult Septic Shock Protocol <ul><li>Section 3 Page 1 </li></ul><ul><li>Timing of antibiotics is essential and patients should receive their first dose within 1 hour of the protocol being initiated. </li></ul>
  16. 16. Adult Septic Shock Protocol <ul><li>Section 4 Page 1 </li></ul><ul><li>This section gives an overview of what the hemodynamic goals of therapy are for the patient. PCWP and CI are only available on patients with Swan Ganz catheters. All patients on the Septic Shock protocol should have CVP </li></ul>
  17. 17. Adult Septic Shock Protocol <ul><li>Section 1 Page 2 </li></ul><ul><li>This section contains very important information regarding fluid resuscitation and management of Blood Pressure. </li></ul>
  18. 18. Adult Septic Shock Protocol <ul><li>Section 2 Page 2 </li></ul>
  19. 19. Adult Septic Shock Protocol <ul><li>Section 3 Page 2 </li></ul><ul><li>Additional orders. Remember if the patient is intubated to place them on the sedation protocol and if diabetic or high glucose on admission the hyperglycemia protocol </li></ul>
  20. 20. Adult Septic Shock Protocol <ul><li>Some Key Elements </li></ul><ul><li>Start Antibiotics within an hour </li></ul><ul><li>Obtain SCVO 2 ASAP </li></ul><ul><li>Dobutamine is started for a low SCVO 2 </li></ul><ul><li>Repeat SCVO 2 1 hour after interventions and every hour until normal or otherwise ordered by MD </li></ul>
  21. 21. Central and Mixed Venous Saturation
  22. 22. Venous O2 Saturation… <ul><li>Tells us what percentage of O2 was consumed or extracted from the blood </li></ul><ul><li>Tells us about O2 supply and demand </li></ul>
  23. 23. Venous Saturation depends on … <ul><li>Oxygen supply </li></ul><ul><ul><li>Cardiac output </li></ul></ul><ul><ul><li>Hemoglobin </li></ul></ul><ul><ul><li>pO2, SaO2 </li></ul></ul><ul><li>Oxygen demand </li></ul><ul><ul><li>Metabolic rate (pain, shivering, WOB, seizures) </li></ul></ul><ul><li>Oxygen consumption </li></ul><ul><ul><li>Compensatory mechanism if increasing CO isn’t effective </li></ul></ul>
  24. 24. Saturation of arterial blood is 100% <ul><li>Normally 25% of available O2 is extracted </li></ul><ul><li>So normal venous saturation is 75% </li></ul><ul><li>Normal value 65 -77% or 60 – 80% </li></ul>
  25. 25. The patient is HYPOXIC… <ul><li>The tissues need more O2 </li></ul><ul><li>So they extract more O2 from arterial blood </li></ul><ul><ul><li>Let’s say 40% </li></ul></ul><ul><ul><li>100% minus 40% = 60% returning to R heart </li></ul></ul><ul><ul><li>So SvO2 is 60% </li></ul></ul>
  26. 26. The patient is SEPTIC … <ul><li>The cells are unable to use available O2 </li></ul><ul><li>Tissues can only extract 15% </li></ul><ul><li>100% minus 15% = 85% </li></ul><ul><li>So SvO2 is 85% </li></ul>
  27. 27. SvO2 less than 50% indicates anaerobic metabolism and development of acidosis
  28. 28. Where is the best place to get venous blood to measure venous saturation? <ul><li>Superior vena cava – ScVo2 </li></ul><ul><li>PA catheter tip – pulmonary artery blood – SvO2 </li></ul>
  29. 29. If the SaO2 drops due to suctioning or the development of ARDS, what do you expect to happen to the SvO2?
  30. 30. If the SaO2 drops due to suctioning or the development of ARDS, what do you expect to happen to the SvO2? You would expect it to drop 88% - 25% = 63%
  31. 31. If you gave your patient a fluid bolus that they really needed (CVP 0, CI 1.8), what would you expect to happen to the SvO2?
  32. 32. If you gave your patient a fluid bolus that they really needed (CVP 0, CI 1.8), what would you expect to happen to the SvO2? Expect it to increase (if it’s low) or remain normal because the increase in CO means the tissues don’t need to extract more O2 than normal
  33. 33. SvO2 extraction SvO2 75% (65 – 77) SvO2 extraction delivery demand delivery demand Hypothermia Sepsis Anesthesia Neuromuscular blockade <ul><li>Anemia, hypoxia, cardiogenic shock, low BP </li></ul><ul><li>Hyperthermia, shivering, pain, anxiety, nursing care </li></ul>
  34. 34. Assess for the cause of SvO2 <ul><li>Is O2 supply adequate? </li></ul><ul><li>Check hemoglobin value </li></ul><ul><li>Measure cardiac output </li></ul><ul><li>Is patient agitated, shivering? </li></ul><ul><li>Think </li></ul><ul><li>ACIDOSIS or HYPOPERFUSION! </li></ul>
  35. 35. That’s all for now! <ul><li>Now you can take the post test and see what you have learned. </li></ul><ul><li>Thanks to all those who worked hard on these powerpoints to make this presentation a success! </li></ul>