Sepsis and DIC

Severe Sepsis

- Increasing lactic acid - Organ dysfunction (respiratory failure, renal failure, encephalopathy, coagulation abnormalities, heart failure)

Sepsis- definition

- Presence of bacteria, infectious organisms, or toxins in the bloodstream - Spread throughout the body

Onset

- Sepsis (20% incidence from gram NEGATIVE bacteria) - Neoplasms (malignancy) - OB complications (not common, but not unheard of) - Trauma - Toxins/venoms (rattlesnake)

Principles of Sepsis

1. Infection that is not controlled by body's local aspects 2. Failure of local control 3. SIRS

Failure of local control

1. Physiologic responses fail to prevent spread 2. Extensive tissue and vascular changes 3. Altered oxygenation and perfusion

Progression to DIC

1. Systemic intravascular coagulation 2. Intravascular thrombin and fibrin are used up 3. Clotting factors are exhausted and depleted 4. Spontaneous hemorrhage occurs

Impact of severe sepsis

2.26 per 100 hospital discharges Reported mortality 30-50% 40% of all ICU expenditures $16.7 billion in USA 6X greater cost than a non-sepsis client Average length of stay 19.6 days

Why could aggressive IV fluids also be a negative thing for septic patients?

A lot of the fluid will go straight into the tissues because they have an increased permeability. However, if we don't give fluids, the blood pressure could get down to the 40s, which isn't good either.

Why do you want them to achieve a low tidal volume?

Because large intakes of air at one time can cause lining of the lungs to rip d/t them being inflamed and stiff

Clinical Presentation: Skin

Bleeding (mainly from FRAGILE sources like eyes, nose, IV site, mouth) Petechiae (red spots) Ecchymosis (RED)

DIC categorizations

Bleeding, organ failure, massive bleeding, and non-symptomatic [*type is related to underlying disorder]

Some possible causes of DIC (always occurs as an accompanying factor from some other condition, never by itself)

Infection, solid cancers, hematological malignancies, OB diseases, trauma, aneurysms, and liver diseases

Nursing Implications: glycemic control

Maintain WBC < 180 mg/dl Insulin infusion Nutritional modifications

Nursing Implications: adequate oxygenation

Mechanical ventilation* Low tidal volume 6mL/kg --> smaller breaths but more of them Permissive hypercapnia --> may be in the 50s or 60s and let this happen as long as we are getting enough O2 Consider kinetic therapy --> bed flips upside down to allow for blood and fluid to get to the front of the lungs and get better oxygenation

Diagnostics

PT= 11-14 seconds (long) Platelet count= 150-400 X 10^3 (low) Fibrinogen= 200-400 mg/dl (low) D-dimer= < 250 ng/mL (high?)

Nursing Implications/Treatments for DIC: Blood products

Platelets FFP (helps to replace clotting factors) Cryoprecipitate (ONLY clotting factors, fibrinogen) 1. admin blood products, 2. then transfuse them with clotting factor replacements

What goes along with an increase in coagulation and inflammation?

Proinflammatory mediators, endothelial injury, tissue factor expression, thrombin production

Septic shock (Sepsis continuum)

Refractory hypotension

Septic Shock

Refractory hypotension Reduced red-cell deformability Microvascular thrombosis (micro-clots everywhere that are blocking off blood vessels) Inflammation Dysfunction of vascular endothelium Cell death/loss of barrier integrity (lose ability to keep fluid where it is) Mitochondrial dysfunction

Clinical Presentation: Organ dysfunction

Renal Hepatic Pulmonary Neurologic Adrenal

Sepsis definition (Sepsis continuum)

SIRS with a presumed or confirmed infectious process

Purpura Fulminans

See slide with picture (acute often fatal thrombotic disorder)

Severe sepsis (Sepsis continuum)

Sepsis with organ failure

How do you differentiate sepsis, severe sepsis, and septic shock?

Sepsis: SIRS and infection Severe sepsis: sepsis and organ dysfunction Septic shock: severe sepsis and refractory hypotension

Progression to Secondary Shock

Severe metabolic acidosis Anuria (or really dark and concentrated d/t shunting of kidneys) Hypoglycemia (liver failure) Myocardial failure CNS impairment (not a tolerable organ, doesn't like increased BUN/creatinine, toxins, fever) Disseminated Intravascular Coagulation Death

Nursing Implications/Treatments for DIC: ASSESSMENT

Signs of active, new, worsening bleeding (that won't stop) Ecchymosis Hematomas (collection of blood deep under surface) **look for CHANGES and TRENDS

Mortality in septic shock patients (trend)

The incidence decreases from sepsis --> septic shock, but the mortality increases from sepsis --> septic shock

DIC definition

The systemic activation of blood coagulation, which generates intravascular thrombin and fibrin, resulting in the thrombosis of small-medium sized vessels and ultimately organ dysfunction and severe bleeding. Wikipedia= "pathological process characterized by the widespread activation of the clotting cascade that results in the formation of blood clots in the small blood vessels throughout the body"

What is one thing important to remember about steroid use for septic patients?

They are NOT for inflammation, rather, the adrenal glands fail and stop producing endogenous cortisol, so steroids are given to replace the natural steroids the body isn't producing

Why is a patient with sepsis not a good candidate for a liver transplant?

They are not healthy enough to receive one

What could happen if you flip or give a bath to a septic patient too quickly?

They could go into cardiac arrest, so BE CAREFUL

Why do you want to give a little something orally to a sepsis patient?

To stimulate the gut and ensure it is still functioning slightly

Sepsis Treatment

Transfer to ICU* IV fluids (aggressive) Vasopressors (meds to increase BP) Source ID IV antibiotics (AFTER identifying the source) Support organ function (liver and brain can't be helped much)

Nursing Implications

VS monitoring (continuous pulse ox) Physical assessment Adequate oxygenation Medication administration (very little orally because gut is deprioritized) Glycemic control (up to about 150 to make sure enough glucose is available to the body)

Physiologic changes during sepsis

Vasodilation Leukocyte accumulation Microvascular permeability (need to be in order for WBCs to get to the site of concern, but also allows other things to get into the tissues that shouldn't be there) **Xrays will look worse,

Nursing Implications: hemodynamic support

Vasopressors (MAP > 65mm Hg, vasopressin 0.04 units/minute) --> increase BP Inotropes (Dobutamine) --> increase FOC to get blood to tissues Steroids for non-responders to vasopressors (hydrocortisone 200mg/day)

Homeostasis is Lost in sepsis

[Picture on slides] Main points: INCREASED coagulation and inflammation, DECREASED fibrinolysis

Nursing Implications/Treatments for DIC: Avoid

IM injections (because has a big chance of significant bleeding) Unnecessary trauma (IV stick maybe, don't put direct pressure in nose)

Nursing Implications/Treatments for DIC: Pharmacology

IV fluids O2 Anticoagulants

What goes along with a decrease in fibrinolysis?

Increased PAI-1, TAFI2, and reduced protein C (activated protein C inhibits PAI-1)

Nursing Implications: source ID

Appropriate cultures Antibiotics Radiology imaging Surgery if indicated Prevention against further incidence** along with management of old infections

SIRS criteria

At least two of the following: - T > 38°C (100.4) or < 36°C (96.8) - HR > 90 beats/min - RR > 20/min or PaCO2 < 32 or mechanical ventilation - WBC > 12,000/mm3, <4,000mm, or > 10% bands

Nursing Implications: IV fluids

Crystalloids Possible colloids MUCH greater than 30 ml/kg* CVP 8-12 mmHg

Clinical Presentation: GI

Hematemesis Melena Hematochezia "Red out top, bottom, or black tarry out of bottom"

Clinical Presentation: Genitourinary

Hematuria

Pathophysiology of DIC (like stability picture in slides)

Hemostatic system with hypercoagulation (ORGAN FAILURE) and hyperfibrinolysis (BLEEDING d/t leukemia, OB diseases, or aneurysms)

Clinical Presentation: Neurologic

Delirium Paresthesias **Look for signs of stroke, HA, alt. in mental status

Objectives for DIC content

Discuss principles of DIC ID causes and characteristics of DIC Review means of identifying DIC Discuss nursing implications for the client experiencing DIC

High risk patients

Elderly Chronic illness Post op/trauma Post splenectomy Immune suppressed Malnourished Delayed treatment Increased comorbidities

What do they look like for REAL?

Fever or "shocky" (pale mucous membranes, cool to touch but clammy, eyes dull and sunken) Tachypnea: d/t compensation, around 20-35x/min Tachycardia: compensation Hypotensive Metabolic acidosis High WBC (maybe, anticipate high but don't be shocked if it is low)

Sepsis may be associated with what symptoms of systemic illness?

Fever, chills, malaise, hypotension, mental-status change