Sepsis

Definition

Septic Shock

Definition

Sepsis

Pathophysiology

Organisms and their toxins or endotoxins in the blood stream enter other body areas

The inflammatory response becomes and enemy

Leads to extensive tissue and vascular changes that impair oxygenation and tissue perfusion

WBCs produce pro-inflammatory cytokines

This results in vasodilation and pooling of blood in some tissues

Microthrombi begin to form within the capillaries and some organs, causing cell hypoxia and reducing organ function

The number of microthrombi increase due to anaerobic conditions resulting in the generation of more toxic metabolites

Early Sepsis 

Manifestations

• Mild hypotension-caused by SIRS
• Urine output that is lower than expected for fluid intake-compensatory response to impaired oxygenation and tissue perfusion
• Increased respiratory-compensatory response to impaired oxygenation and tissue perfusion
• Decreased cardiac output-caused by hypodynamic state
• Low-grade fever-caused by SIRS
• High fever-caused by SIRS
• Elevated WBC count-caused by systemic infection

Severe sepsis

Definition

Progression of sepsis with an amplified inflammatory response

All tissues are involved and all have some degree of hypoxia, some organs experience cell death and dysfunction

Severe sepsis

Pathophysiology

• Microthrombi formation is widespread, using available platelets and clotting factors or (DIC)
• Amplified SIRS and cytokine release increase capillary leakiness, injure cells and increase cell metabolism
• Damage to endothelial cell triggers the formation of small clots
• anaerobic metabolism continues

Severe sepsis

Manifestations

• Increased cardiac output-caused by pooling of blood and the widespread capillary leak stimulate the heart
• Increased rapid heart rate-caused by pooling of blood and the widespread capillary leak stimulate the heart
• Elevated systolic blood pressure-caused by pooling of blood and the widespread capillary leak stimulate the heart
• Lower oxygen saturation-caused by anaerobic metabolism
• Rapid respiratory rate-compensatory mechanism to maintain oxygenation,caused by hypoxia
• Decreased to absent urine output-caused by capillary leak and low circulating volume
• Change in cognition and affect

Septic Shock

Pathophysiology

Severe hypovolemic shock is present with hypodynamic cardiac function

Results of tan inability of the blood to clot because the platelets and clotting factors were consumed

Capillary leak continues as a result of he presence of pro-inflammatory cytokines

Cardiac contractility is poor from cellular ischemia and the presence of myocardia depressant factor

Septic Shock

Definition

Septic Shock

Manifestations

• Greatly decreased cardiac output-caused by capillary leak, cellular ischemia
• Greatly decreased stroke volume-caused by capillary leak, cellular ischemia
• Decreased oxygen saturation-caused by ARDS
• Hypoxia -Caused by ARDS
• Acute respiratory distress syndrome-cause by continues systemic inflammatory response increasing the formation of oxygen free radicals
• Cool, clammy, pallor, cyanosis, molting skin-blood is shunted away from the skin by vasoconstriction
• Petechiae-caused by DIC
• Blood from gums and other mucous membranes-caused by DIC
• Low urine output-caused by capillary leak, hormonal changes and low circulating volume
• Hypoxemia-caused by poor cell oxygenation

• Urine, blood, sputum and any other drainage for culture to identify the causative organisms
• Arterial blood gases-assess oxygenation status, determine acidosis
• WBC count may show a left shift
• Decreased HGB, HCT, PLTC, Fibrinogen levels from DIC in late septic shock
• Increased serum lactate level-caused when hypoxemia causes acidosis
• Decreased serum bicarbonate levels-caused when hypoxemia causes acidosis
• Decreased activated protein C-caused when endothelial cells are injured b endotoxins and cannot activate protein C
• Increased D-dimmer-rise as fibrin in clots is broken down during sepsis
• Increased or decreased Cytokine interleukin-6 and interleukin-10-is an anti-inflammatory cytokine that changes with stages of sepsis

Sepsis

Expected Outcomes

• Arterial blood gases within the normal range
• Maintenance of a urine output of at least 20 ml/hr
• maintenance of mean arterial blood pressure within 10 mm Hg of baseline
• Absence of multiple organ dysfunction syndrome
• States measures to reduce the risk for sepsis

Sepsis/Septic shock Intervention

Sepsis resuscitation bundle

• Measure serum lactate levels
• Obtain blood cultures before administering antibiotics
• Administer broad-spectrum antibiotic therapy within 1 to 3 hours of establishing diagnosis
• For hypotension or a serum lactate level greater than 4 mmol/L is present, institute: 
• Iv delivery of 20 ml/kl of crystalloid fluids
• If hypotension does not respond, start IV vasopressor therapy
• If hypotension persists monitor therapy effectiveness by: central venous pressure at least 8 mm Hg
• Central venous oxygen saturation of at least 70% 

Sepsis/Septic shock Intervention

Sepsis Management bundle

• When septic shock is present, administer low-dose steroids in accordance to protocol
• Administer drotrecogin alfa for patients meeting the criteria
• Administer insulin to maintain blood glucose levels 
• Use mechanical ventilation to maintain inspiratory plateau pressure

Sepsis 

Drug therapy

• Used to enhance cardiac output 
• restore vascular volume
• Combat sepsis
• Combat adrenal insufficiency
• Combat hyperglycemia
• Combat clotting problems 

Activated protein C

Used to manage microvascular abnormalities and prevent bleeding

Action: Stops the inflammatory responses during sepsis, preventing small clot formation

Used when septic shock progresses to hemorrhage

Use of clotting factors, fresh frozen plasma, or packed red blood cells

• Avoid crowds and people who might be ill
• Do not share eating utensils or personal toilet articles
• Bathe daily
• Wash armpits, groin, genitals, and rectal area at least twice a day with an antimicrobial soap
• Clean toothbrush daily (dishwasher or rinsing with liquid bleach)
• Wash hands thoroughly often
• Was dishes between use
• Do not drink water that has been standing for longer than 15 min
• Do not reuse cups and glasses without washing them
• Do not change pet litter boxes
• Take temperature at least once daily
• Refrigerate and prepare food appropriately
• do not eat raw or uncooked meat, fish, poultry, or eggs
• Report sign or symptoms of infection to physician immediately
• Dio not dig in the garden or work with houseplants
• Use antibacterial cleansers to clean house a least twice each week
• Wear rubber or vinyl gloves while cleaning
• Use condom while having sex
• Take all drugs as prescribed

Used to increase tissue perfusion and oxygenation