AH 2 Chapter 34: Sepsis

The nurse plans care understanding that which is the primary reason clients experience vasodilation in septic shock? 1.There is a release of endotoxins from bacteria. 2There is heart failure with diminished cardiac output. 3There is blood or fluid loss, and the body compensates by dilating the blood vessels. 4There is an obstruction of blood flow, and the body compensates by dilating the blood vessels.

1.There is a release of endotoxins from bacteria. Rationale:A massive infection can lead to sepsis as a result of endotoxins being released, which causes vasodilation, pooling of blood, and capillary permeability. The remaining options do not provide the reason for vasodilation in septic shock.

A client who had a myocardial infarction is at risk for cardiogenic shock. The nurse plans care knowing that the primary cause of cardiogenic shock results from which process? 1A pump failure and reduction in cardiac output 2A physical obstruction that decreases filling or outflow of blood 3Dilated vasculature decreasing the movement of blood to the body 4Loss of vasoconstrictor tone, leading to pooling of blood in vessels

1A pump failure and reduction in cardiac output Rationale:Cardiogenic shock is caused by the heart itself not being able to pump effectively, resulting in decreased cardiac output. Cardiac output reflects blood reaching the tissues and vasculature. The remaining options do not describe the pathophysiology associated with cardiogenic shock.

The Golden Hour What We Need To Get Done

2 Large bore IVs. If unsuccessful with 2 attempts immediately notify provider for US guided IV or central line. Labs: CBC, lactate, PT/PTT, CMP, Type and Screen, Blood Cx from 2 sites. If there is a PICC or CWP draw 1 set of Cx and document site on the bottle. UA, Urine Cx (30+% of sepsis cases are urosepsis) Fluid Resuscitation 30mL/kg bolus starts immediately with pressure bag. Trauma Naked- look for sources including wounds. Accurate Weight using trauma stretcher. IV antibiotics within 1st hour. Chest Xray

How do you fix a leaky hose and low pressure?

30ml/kg } fill the tank If MAP less than 65 after fluid bolus, administer norepniephrine to tighten the hose

Identifying Sirs; criteria

Core temperature: Rectally 38 C= 100.4F 36C= 96.8F Older population show sepsis through hypothermia.

Antibiotic Administration

Early and appropriate antibiotic therapy Obtain blood cultures prior to antibiotics Initial broad spectrum antibiotics to cover any potential infections Use 2 or more antibiotics to prevent selection of resistance. Provides synergy against a single pathogen

Overall Goals of Therapy

Obtain blood cultures Lactate levels on ALL septic patients Fluid resuscitation Normal Saline boluses @ 30ml/kg in first 2 hrs Start vasopressors for refractory hypotension Rapid initiation of Antibiotics Within 1 hour Maintain BP with at least a MAP of 65 Improve patient survival

Sepsis Spectrum

Sepsis: SIRS that is secondary to suspected or diagnosed infection Severe Sepsis: Sepsis + acute organ dysfunction secondary to infection. (acute kidney failure, elevated lactate, AMS, hypotension, etc.) Septic Shock: Severe sepsis induced hypotension that does not respond to fluid resuscitation and is associated with perfusion abnormalities such as lactic acidosis, oliguria, or acute altered mental status. Hemodynamic endpoint of sepsis ***Cardiac output and blood pressure are low in early sepsis and very low in septic shock.

SIRS stages

Stage I In response to injury or infection the local environment produces cytokines. Stage II Small amounts of cytokines are released into the circulation: Recruitment of inflammatory cells. Acute Phase Response Normally kept in check by endogenous anti-inflammatory mediators (IL-10, PGE2, Antibodies, Cytokine receptors antagonists) Stage III Failure to control inflammatory cascade: Loss of capillary integrity Stimulation of nitric oxide production Maldistribution of microvascula Organ injury and dysfunction

SIRS

Systemic Inflammatory Response Syndrome) Clinical syndrome that results from a deregulated inflammatory response or to a noninfectious insult

Lactic Acid Measures

Measures adequate tissue perfusion on a cellular level. Effective indicator of tissue hypoxia/hypoperfusion Values Normal <=2 Suspect SIRS >2 but <4 Severe Sepsis >4 Elevated Lactates at 24 hours has an 89% mortality rate

Sepsis Bundle; 3 hours vs 6 hours

The 3 hour bundle should ideally be completed within 1 hour; maybe 1 hour and a half

Sepsis Signs and Symptoms

Temp > 100.4 <96.8 (rectal temps if abnormal high or low) HR > 90 SBP <90 RR>20 Altered Mental Status Recent or Suspected Infection Lactate >2 (10% of sepsis pts will not have elevated lactate) WBC > 12,000 or <4,000 Lower oxygen saturation decreased-to-absent urine output No single laboratory test confirms the presence of sepsis and septic shock

The nurse caring for a client with sepsis as a result of bacterial pneumonia is monitoring for signs of systemic inflammatory response syndrome (SIRS). Which conditions are indicative of this complication? Select all that apply. 1Fever 2Diabetes insipidus 3Altered mental status 4Development of severe hypotension 5Development of acute respiratory distress syndrome (ARDS)

1Fever 3Altered mental status 4Development of severe hypotension 5Development of acute respiratory distress syndrome (ARDS) Rationale:SIRS is a systemic inflammatory response characterized by generalized inflammation in organs separate from the initial affected area and is caused by severe bacterial infections, trauma, or pancreatitis. A fever will occur related to the infection. The client will have global vasodilation and thus will have decreased blood pressure and perfusion to the other important organs such as the lungs and brain, affecting breathing and mentation. SIRS can also be triggered by many other complications associated with tissue trauma, such as burns.

Due to an extreme staff shortage, the nurse has been sent to the intensive care unit to assist registered nurses in the care of clients. The nurse understands that which factor is most important to consider when treating a client with cardiogenic shock? 1.Use of diuretics to decrease circulating volume 2Use of whole blood to easily restore fluid volume 3Use of intravenous and oral fluids to restore circulating volume 4Restriction of volume expanders because of secondary pulmonary edema

4Restriction of volume expanders because of secondary pulmonary edema Rationale:Because there are several types of shock, it is important to know which shock state the client is in so that it can be managed appropriately. A client in cardiogenic shock may have secondary issues such as pulmonary edema due to the ineffective pumping mechanism of the heart. Fluid restoration is a key ingredient in treating shock states although it must be used conservatively in clients with cardiogenic shock. Therefore, options 2 and 3 are incorrect. Option 1 is incorrect because the problem is with the pumping action of the heart and not increased blood volume.

The nurse plans care for a client with sepsis, understanding that which of the following are characteristic of sepsis? Select all that apply. 1The client can develop coagulopathy. 2The infection can be caused by a parasite. 3Sepsis is the bodily response to an infection. 4The causative organism is always gram-negative bacteria. 5The client may display abnormal vital signs along with abnormal laboratory values.

1The client can develop coagulopathy. 2The infection can be caused by a parasite. 3Sepsis is the bodily response to an infection. 5The client may display abnormal vital signs along with abnormal laboratory values. Rationale:Sepsis is a group of symptoms in response to an infection. The infection can be caused by gram-positive or gram-negative bacteria, or it can be viral, fungal, or parasitic in origin. Sepsis can cause coagulopathy. The client's vital signs, as well as laboratory values, will be abnormal.

What is sepsis?

Acute organ dysfunction secondary to infection. Most common admission diagnosis to the ICU Strikes approximately 750,000 people a year with 225,000 fatalities Mortality range 28-50% Estimated $17 billion is spent per year to treat sepsis in the US.