2300 sepsis project

2300 Sepsis Project2300 Sepsis Project

Systemic Inflammatory Systemic Inflammatory Response - SIRSResponse - SIRS

A systemic response to a clinical insultTrauma, burns, pancreatitis, infectionConsists of:

• Vasodilation• Increased capillary permeability• Release of “pro-coagulation” tissue factor• Results in inadequate tissue perfusion and

lactic acidosis

Severe SepsisSevere Sepsis Sepsis associated with organ

dysfunction Hypoperfusion or Hypotension Lactic acidosis Oliguria Altered LOC

Septic ShockSeptic ShockSepsis associated with

hypoperfusion and hypotension despite adequate fluid resuscitation

Mortality rate of 45 %

How Sepsis ProgressesHow Sepsis Progresses

Complex clinical picture…Complex clinical picture…Edematous…but volume depletedMicroclots…but bleedingInitially cardiac output…but

hypoperfusionVasodilation…but you’d expect

compensatory vasoconstriction

Common sources of Common sources of infectioninfection

WoundsUTIsPneumonia

Immediate ManagementImmediate ManagementMaintain adequate ventilation

and oxygenationFind and eliminate sourceRestore intravascular volumeBroad spectrum antibiotics within 1 hour

Immediate ManagementImmediate Management

Increase cardiac output•Vasopressors to reverse vasodilation

(increase afterload)•Inotropes to increase contractility

Restore coagulation/anticoagulation balance

Enteral feedings to maintain GI barrier

Adult Septic Shock ProtocolAdult Septic Shock Protocol

Created to streamline the treatment of the patient admitted with Severe Sepsis or SIRS.

Can be initiated in the Emergency Department with a “Code Sepsis”

Goal Directed Therapy

Adult Septic Shock ProtocolAdult Septic Shock ProtocolIf there are 2 or more SIRS criteria plus known of

suspected source of infection

Temp >38.3C (100.9F) or < 36C (96.8F)Heart rate >90Respiratory rate >20 or PaC02 <32mmHgWBC >12,000 or <4,000, or > 10% bands

And if MAP <65

If both are true then it is Septic Shock – Immediate intervention is paramount


Order Set Number MR912500 is the Adult Septic Shock Protocol

Orders are outlined in a flow chart format

Follow the arrows to complete the order set

There are 2 Pages – be sure the physician fills out both pages completely


Section 1 Page 1This 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


Section 2 Page 1This section outlines the various orders

Boxes are optional – Others are standard for all patients


Section 3 Page 1Timing of antibiotics is essential and patients should receive

their first dose within 1 hour of the protocol being initiated.


Section 4 Page 1This 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


Section 1 Page 2This section contains very important information regarding

fluid resuscitation and management of Blood Pressure.


Section 2 Page 2


Section 3 Page 2Additional 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


Some Key Elements Start Antibiotics within an hour

Obtain SCVO2 ASAP

Dobutamine is started for a low SCVO2

Repeat SCVO2 1 hour after interventions and every hour until normal or otherwise ordered by MD

Central and Mixed Central and Mixed Venous SaturationVenous Saturation

Venous O2 Saturation…Venous O2 Saturation…Tells us what percentage of O2 was consumed or extracted from the blood

Tells us about O2 supply and demand

Venous Saturation depends Venous Saturation depends on …on …

Oxygen supply◦Cardiac output◦Hemoglobin◦pO2, SaO2

Oxygen demand◦Metabolic rate (pain, shivering, WOB,

seizures)Oxygen consumption

◦Compensatory mechanism if increasing CO isn’t effective

Saturation of arterial blood is Saturation of arterial blood is 100%100%Normally 25% of available O2 is

extractedSo normal venous saturation is

75%Normal value 65 -77% or 60 –

80%

The patient is HYPOXIC…The patient is HYPOXIC…The tissues need more O2So they extract more O2 from

arterial blood◦Let’s say 40%◦100% minus 40% = 60% returning to

R heart◦So SvO2 is 60%

The patient is SEPTIC …The patient is SEPTIC …The cells are unable to use

available O2Tissues can only extract 15%100% minus 15% = 85%So SvO2 is 85%

SvO2 less than 50% indicates SvO2 less than 50% indicates anaerobic metabolism and anaerobic metabolism and development of development of acidosisacidosis

Where is the best place to get Where is the best place to get venous blood to measure venous blood to measure venous saturation?venous saturation?

Superior vena cava – ScVo2PA catheter tip – pulmonary artery

blood – SvO2

If the SaO2 drops due to If the SaO2 drops due to suctioning suctioning or the development of ARDS, or the development of ARDS, what do you expect to happen what do you expect to happen to the SvO2?to the SvO2?

If the SaO2 drops due to suctioning If the SaO2 drops due to suctioning or the development of ARDS, or the development of ARDS, what do you expect to happen what do you expect to happen to the SvO2?to the SvO2?

You would expect it to drop88% - 25% = 63%

If you gave your patient a fluid If you gave your patient a fluid bolus that they really needed bolus that they really needed (CVP 0, (CVP 0, CI 1.8), what would you expect CI 1.8), what would you expect to happen to the SvO2?to happen to the SvO2?

If you gave your patient a fluid bolus If you gave your patient a fluid bolus that they really needed (CVP 0, CI 1.8), that they really needed (CVP 0, CI 1.8), what would you expect to happen to what would you expect to happen to the SvO2?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

SvO2

extraction

SvO2 75%

(65 – 77)

SvO2 extraction

delivery

demand

delivery

demand

Hypothermia

Sepsis

Anesthesia

Neuromuscular blockade

•Anemia, hypoxia, cardiogenic shock, low BP•Hyperthermia, shivering, pain, anxiety, nursing care

Assess for the cause of Assess for the cause of SvO2SvO2Is O2 supply adequate?Check hemoglobin valueMeasure cardiac outputIs patient agitated, shivering?

Think ACIDOSIS or HYPOPERFUSION!

That’s all for now!That’s all for now!

Now you can take the post test and see what you have learned.

Thanks to all those who worked hard on these powerpoints to make this presentation a success!

2300 sepsis project

Documents

severe sepsis sepsis

septic shock sepsis

sepsis project

code sepsis goal

adult septic shock protocol

systemic response

f heart rate

respiratory rate