Term
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Definition
-11th leading cause of death in the United States
-6% of all deaths
-Most common cause of death in non-cardiac ICUs
- >1 million cases in 2010 |
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Term
| 3 types of host defenses: |
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Definition
1. Inadequate - overwhelming infection (death)
2. Adequate - infection control = regulation (survival)
3. Excessive - sepsis/organ dysfunction -> out of control immune response and death |
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Term
| 4 stages from infection to severe sepsis |
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Definition
| infection/trauma -> SIRs ->sepsis -> severe sepsis |
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Term
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Definition
| Systemic Inflammatory Response Syndrome - A clinical response arising from a nonspecific insult |
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Term
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Definition
- Temp >= 38 C or <= 36C
- HR >= 90 beat/min
- Resp >= 20/min
- WBC >= 12,000 or <= 4,000 or >10% immature neutrophils |
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Term
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Definition
| SIRS with a presurred or confirmed infection |
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Term
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Definition
Sepsis with >=1 sign of organ failure:
- Cardiovascular
- Renal
- Respiratory
- Hepatic
- Hematologic
- CNS
- Unexplained metabolic acidosis |
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Term
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Definition
| Severe sepsis with hypotension refractory to adequate fluid resuscitation |
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Term
| Multiple Organ Dysfunction Syndrome (MODS) |
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Definition
| Altered organ function in an acutely ill patient such that homeostatic regulation is lost |
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Term
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Definition
-Infections:
Bacteremia
Community acquired pneumonia
Hospital acquired pneumonia
UTI
Meningitis
Wound infection or cellulitis
Peritonitis
MDRO
- Age
-Critically ill
-Invasive lines (CVC, Foley, ET tube/trach)
-Chronic diseases (co-morbidities)
-Immunocompromised
-Malnourished
-Intra-abdominal surgery |
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Term
| Source of infection in all surgical patients most commonly found in the ___? |
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Definition
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Term
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Definition
-Infection (but blood cultures negative 40% of time)
-Ischemia
-Trauma
-Shock
-Surgery, especially abdominal
-Burns
-Aspiration
-Pancreatitis
-Immunodeficiency
-Transfusion reaction |
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Term
| Mortality _____ with the number of SIRS symptoms: |
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Definition
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Term
| What causes sepsis not to progress? |
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Definition
-Homeostatic mechanisms remain effective
-Genetic differences
-Early identification
-Rapid intervention—”Early goal-directed therapy” |
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Term
| Cardiovascular dysfunction: |
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Definition
-Endothelial dysfunction → increased capillary permeability → systemic vasodilation and loss of intravascular volume
-Decreased vascular tone → venous pooling/third spacing → decreased volume of blood returning to heart (preload) → decreased cardiac output
-Hypotension →hypoperfusion of end organs
-Tissue and organ edema→ hypoperfusion of end organs → organ dysfunction |
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Term
| What do you monitor for cardiovascular dysfunction? |
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Definition
Monitor for:
-SBP < 90, especially if refractory to fluids
MAP < 65
-Need for vasopressors to maintain pressure (ICU and ED only)
-Severe sepsis if low BP responds to fluids
-Septic shock if low BP does not respond to fluids (refractory) and needs vasopressors to maintain SBP & MAP |
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Term
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Definition
-Lungs are very vascular and very sensitive to hypoperfusion and edema—usually one of the first signs of trouble
-Pts require more O2 to maintain their saturation r/t increased cellular oxygen demand.
-May need to be intubated & vented for ARDS |
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Term
| What do you monitor for respiratory dysfunction? |
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Definition
Monitor for:
-Increase in O2 by 2L or 28% FiO2 in last 24 hours
-Drop in O2 sat >5% for at least 4 hours that occurred in the last 24 hours |
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Term
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Definition
Not related to a chronic problem (CRF, CKD)
increased demand on the kidneys to conserve fluids and remove toxins AND decreased renal tissue perfusion and intravascular volume deficit → AKI (acute kidney injury) |
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Term
| What do you monitor for renal dysfunction? |
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Definition
Monitor for:
-Acute increase in creatinine >50% from baseline
-UOP < 0.5ml/kg/hr (quick method to calculate: half their weight in kg=minimum uo in ml/hr)
-Patient requiring ACUTE hemodialysis |
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Term
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Definition
-Not related to a chronic problem or anticoagulation meds
-Problems with bleeding AND clotting
Platelet levels can drop below 100 if they have been activated by an inflammatory process and consumed.
-INR may increase beyond the normal limits if the sepsis process has activated a condition known as disseminated intravascular coagulation (DIC).
-May develop petechiae or bleeding from IV sites, or have septic emboli which cause gangrene |
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Term
| What do you monitor for Hematologic Dysfunction? |
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Definition
Monitor for:
-Platelet count < 100,000
-INR increase over the upper normal limit
-Mottling or cyanotic extremities |
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Term
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Definition
-Lactic acidosis r/t cells switching to anaerobic metabolism due to hypoxia & hypoperfusion
-Adrenal exhaustion—give low dose steroids
-Hyperglycemia—maintain tight glycemic control (“don’t feed the bacteria”) |
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Term
| What do you monitor for Metabolic Dysfunction? |
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Definition
Monitor for:
-pH < 7.30
-Lactate Level > 2.4 |
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Term
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Definition
-Not related to CHRONIC problem
-Due to primary infection in liver (exposure to bacteria) or secondary due to “gut-barrier failure” due to increased capillary permeability or edema |
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Term
| What do you monitor for Hepatic Dysfunction? |
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Definition
Monitor for:
-ALT > 72 (reflects liver functioning)
-Total Bilirubin > 2 (total bilirubin will rise with increased stress on the body) |
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Term
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Definition
-Not related to CHRONIC problem (dementia)
-Hypoxia and hypoperfusion cause altered LOC (delirium) |
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Term
| What do you monitor for CNS Dysfunction? |
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Definition
Monitor for:
-Altered LOC from BASELINE
-Reduced Glasgow Coma Scale |
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Term
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Definition
-A series of evidence-based therapies that, when implemented together, achieve better outcomes than when implemented individually.
-This bundle of interventions must be completed 100% of the time within 6 hours for patients with severe sepsis, septic shock and/or lactate >4 mmol/L (36 mg/dL) |
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Term
| Sepsis Resuscitation: within 6 hours of identification: |
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Definition
-Give oxygen to keep oxygen sat > 94%
May need 100% oxygen per non-breather
May need to be intubated and ventilated
-Obtain 2 separate blood cultures BEFORE starting antibiotic, also other cultures
-Initiate antibiotic therapy as soon as BC drawn.
-Fluid resuscitation—may need significant volume. Normal saline first choice
-Monitor for fluid overload…
-Measure lactate level
-Insert urinary catheter to monitor hourly urine output. |
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Term
| Sepsis Management Bundle: within 24 hours |
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Definition
-Efforts to accomplish these goals should begin immediately, but may be completed within 24 hours
-Administer low-dose steroids for septic shock in accordance with a standardized ICU policy.
-Maintain adequate glycemic control.
-Prevent excessive inspiratory pressures on mechanically ventilated patients. |
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Term
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Definition
-Vasopressors—start with norepinephrine
-Corticosterioids
-Low dose
-For septic shock for BP refractory to fluids and pressors
Important note: Xigris is no longer on the market, not proven to be effective. |
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Term
| Problems with Severe Sepsis Management: |
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Definition
-Inconsistency in early diagnosis
-Inadequate volume resuscitation
-Late or inadequate use of antibiotics (7% increase in mortality for each hour antibiotics are delayed)
-Failure to:
support adequate cardiac output
control hyperglycemia
use low tidal volumes and pressures in acute lung injury
treat adrenal inadequacy |
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Term
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Definition
-Infection prevention & control
Assessment, early identification
-Implementing medical interventions and monitoring effectiveness or lack thereof
-Implement POC to prevent standard complications re immobility & hospitalization
ex/ DVT, pressure ulcer, etc
-Patient and family education and support |
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