1. Sepsis
Subtle – Rapid – Deadly

2. Sepsis Statistics 10th leading cause of death in US 750,000 cases/year
250,000 deaths/year
Patients older than 65 years account for 64.9% sepsis cases
Mortality from severe sepsis/septic shock 40-50%
50% survivors suffer post sepsis syndrome
Pneumonia
Early recognition saves lives

3. Victims of Sepsis

4. Sepsis Pathophysiology
Death in sepsis can occur owing to a hyper-inflammatory response, mediated by a 'cytokine storm', which induces cell and organ injury. Deaths that are due to this hyper-inflammatory response usually occur early during sepsis and therapy directed at downmodulating the immune response might improve survival. Alternatively, as the condition continues, patients develop a hypo-inflammatory response in which they are unable to eradicate the primary infection or they develop secondary hospital-acquired infections owing to immunosuppression. Apoptosis is an important mechanism of immunosuppression by causing depletion of immune cells and inducing an anti-inflammatory cytokine response. Therapy that blocks apoptosis or enhances immune function might improve survival.

5. Risk Factors for Sepsis
Age > 65
Bacteremia
Poorly functioning or weakened immune system (cancer, diabetes, other chronic disease, AIDS)
Taking immune-suppressing drugs
Pneumonia
History of drug/alcohol abuse
Any co-morbidities
Hospitalized
Severe injuries
Medical treatment with an invasive device or presence of invasive line/device
Are very young (e.g., premature babies) or very old
Have a weakened ("compromised") immune system, often because of treatments such as chemotherapy for cancer, steroids (e.g., cortisone) for inflammatory conditions, etc.
Have wounds or injuries, such as those from burns, a car crash, or a bullet
Have certain addictive habits, such as alcohol or drugs
Are receiving certain treatments or examinations (e.g., intravenous catheters [a small tube for dripping fluids into the vein], wound drainage, urinary catheters [a small tube inserted into the bladder]
Are more prone to develop sepsis than others because of genetic factors (or their "genes")

6. What should you do? What Do You Notice?
Every patient in the hospital is at risk!
What should you do?
Be vigilant, Suspect sepsis

7. CMS Sepsis Bundle Guidelines Lactate measurement Blood cultures
Antibiotic administration
Fluids
Vasopressors
Reassessment
Repeat lactate level

8. Look for Sepsis in All the Right PlacesED
Screen the following patients
Pneumonia (Respiratory infections)
UTI
Abdominal Infections
Screen the elderly
83% of patients with sepsis are already septic in the ED
Elderly are 13X more likely to develop sepsis and mortality is 40%

9. Suspect Infections Pneumonia Urinary Tract Infection Diarrhea
Meningitis
Cellulitis
Septic Arthritis
Wound Infections
Endocarditis
Catheter Related Infections
Usual suspects

10. 4 Stages of Sepsis Systemic Inflammatory Response (SIRS) Sepsis
Severe Sepsis
Septic Shock

11. 2 or more of the following
Stage 1 SIRS
2 or more of the following
Temperature above (38 C) or below 96.8 (36 C)
Heart rate greater than 90/minute
Respiratory rate greater than 20/minute or PaCO2 less than 32 mmHg
WBC higher than 12,000 or lower than
4,000 or more than 10% bands
Nursing Role: stay alert! monitor the patient, alert the provider, check labs
Maintain a high level of suspicion

12. 2 SIRS criteria + Known or Suspected Infection
Stage 2 Sepsis
2 SIRS criteria + Known or Suspected Infection
Other inclusion factors: receiving antibiotics, recent procedure
Nursing Role: Increase frequency of monitoring (√ bowel sounds, notify provider, watch for signs of deterioration; initiate therapies, lactate)
Therapies: labs/cultures, fluids, antibiotics, frequent monitoring, evaluate response to fluids – watch BP, HR and RR carefully – monitor trends

13. What Should I Monitor? Vital signs Intake & output
Urine output at least 0.5 mL/kg/hr
Level of consciousness
new onset anxiety, restlessness
Heart & lung sounds
Peripheral pulses & capillary refill
Watch lab values (↑ wbc, creatinine, bilirubin; ↓ platelets)

14. Trending Heart rate changes over a period of 36 hours.
Monitoring trends is essential. Watch for increasing HR, increasing RR and decreasing BP. Patients generally do not “crash” instead they slip down the cliff
Heart rate changes over a period of 36 hours.

15. Stage 3 Severe Sepsis/Organ Dysfunction
Sepsis + One Sign of Organ Failure
Other clinical s/s: lactic acidosis, oliguria, thrombocytopenia and altered LOC
Patient requires aggressive treatment
Nursing Role: immediate notification provider (RRT), oxygen

16. Signs of Organ Dysfunction
Tachycardia
Dysrhythmias
RR greater than 24
BP less than 90 systolic (decrease > 40)
MAP less than 65
Urine output less than 0.5 mL/kg
GCS less than 15; new onset altered mental status
O2 sat less than 90% RA (or needs O2 to keep sat ≥ 90%)
Ileus
Labs:
Hypoxemia
Bilirubin > 2 mg/dL
Creatinine > 2mg/dL
Elevated liver enzymes
Decreased albumin
Coagulopathy (Platelets < 100,000; INR > 1.5; aPTT >60 sec)
↓ Protein C levels
Elevated serum lactate >2)

17. Determining Response to Fluid
A focused exam including: *
Vital Signs
Cardiopulmonary Exam
Capillary Refill
Peripheral Pulse Evaluation
Skin Examination
OR Any 2 of the following: *
Central Venous Pressure Measurement
Central Venous Oxygen Measurement
Bedside Cardiovascular Ultrasound
Passive Leg Raise or Fluid Challenge
*Provider documentation required*

18. Severe Sepsis + Hypotension (unresponsive to fluid resuscitation)
Stage 4 Septic Shock
Severe Sepsis + Hypotension (unresponsive to fluid resuscitation)
Requires advanced monitoring and drug therapy
High morbidity and mortality

19. Indicators of Septic Shock
Hypoperfusion persists after fluid administration
Systolic BP < 90
MAP < 65
Decrease in systolic BP from baseline > 40 mmHg
Lactate level > 4 mmol/L

20. Key Therapies to Initiate Early
Lab tests (blood cultures X 2 -- different sites), source infection cultures, lactate)
Oxygen
Antibiotics
Fluids (Normal Saline)
Strict I&O
Frequent assessments
Infection control
Fluids – some patients require as much as 4-8 liters, fluid boluses 500 mL over 30 minutes, watch BP and MAP; fluid overload a problem with patients who have co-morbid cardiac problems

21. Case Study
Elvira Adams

22. 81 year old female (from assisted living) is admitted to the unit with progressive weakness and diarrhea X 3 weeks. Admitting Dx: Dehydration
Worrisome s/s:
temp = 97 does not meet SIRS/Sepsis guidelines
HR = 99 – tachycardia (1 sign of SIRS) + meets criteria for up - triaging to Level 2
RR = 20 – this is a warning sign (SIRS rr > 20)

23. Initial Assessment
Assessment: ABCs intact, alert/oriented X3, skin warm and dry, IV (22 g) infusing slowly in left hand
History: skin rash X 2 weeks, treated with prednisone, type 1 DM, UTI 2 weeks ago treated with antibiotics
VS: 97ºF, 124/58, 99, 20, 97% RA
Does she have any “possible” SIRS s/s?
Does she have any sepsis risk factors?

24. Ms Adams Sepsis Risk Factors S/S SIRS Age > 65
Poorly functioning or weakened immune system (diabetes)
Taking immune-suppressing drugs
Hospitalized
S/S SIRS
Heart Rate > 90/minute
RR 20 (could be a warning sign)
Check her labs for wbc count & bands

25. A few hours later: Vital signs: 101° F, 107/60, 106, 20, SaO2 96%
Labs are resulted. What lab work will you track?
WBC and bands
11:45 AM Labs resulted
WBC: 26.5 (N )
Bands 24% (N 0-8)
SIRS

26. What does this mean? Ms Adams now meets the criteria for SIRS.
Appropriate Nursing Action:
Recheck vital signs (temp, HR, RR)
100.4°F, 95/41, 109, 24, O2 sat 92%
2. Does she also meet the criteria for Sepsis? Assess for any signs of obvious infection
“UTI 2 weeks ago”
u/a results: 1+ protein, trace blood, nitrate +, trace leuk ester, 4 + bacteria
Is she Septic?
Urine results = possible infection
Meets the criteria for Sepsis – 2 SIRS criteria + known or suspected infection (UTI)

27. Ms Adams meets the criteria for Sepsis
Orders to Obtain/Initiate
Oxygen
Additional Labs (Blood cultures, lactate, urine c/s)
Antibiotics
Fluids
2 good lines (18-20 g)
Frequent vital sign monitoring and trending to watch for Severe Sepsis
Watch for increases in HR, RR, decreases in BP, urine output
Change in mental status, signs of organ failure

28. Later that day
Ms Adams rings for the nurse and states: “I don’t feel well.”
She is oriented only to self and is confused & restless.
Vital signs: 86/25, 125, 28, 91% (2 L n/c), 96.6° F
Does she have any signs of organ failure (Severe Sepsis)?
Systolic BP < 90
Change in mental status
RR > 24

29. RRT (Institution Specific) Please update
RRT Policy NUR R-4
5151
Team
ICU Nurse
Hospitalist
Respiratory Practitioner
Nurse assigned to patient
Documentation in the RRT Narrator

30. What RRT Criteria Does She Meet?
Respiratory
O2 sat <90 despite O2
Increased WOB
SBP < 90
Neurological Status
New onset decrease in LOC

31. Ms Adams meets the criteria for Severe Sepsis
Orders to Obtain/Initiate
Alert physician
Evaluate intake and output
Frequent vital signs
Fluid Boluses (500 over 30 min, repeated until SBP > 90)

32. Ms Adams Deteriorates Blood pressures 60-70s systolic Heart rate 120+
Respiratory Rate 24-28
Cool clammy skin
No urine output
Not responding to Dopamine
Change in mental status

33. What has happened? Severe Sepsis Septic Shock
Outcome: Septic Shock with renal failure
10 day hospital stay
Discharged to long term care

34. Lessons Learned Suspect sepsis early
Reassess for SIRS, sepsis after labs reported
Trend the vital signs – increase frequency of assessments
Initiate nursing interventions while waiting
Document complete and measurable assessments

35. Don’t forget the antibiotics Do evaluate for appropriate level of care
4 Ds for Sepsis
Draw labs
Discover the source
Don’t forget the antibiotics
Do evaluate for appropriate level of care

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