Kellie Murphy, BSN, RN, CCRN

Erin's Story

It is the clinical syndrome that results from a dysregulated inflammatory response to an infection (UpToDate, 2012).

Sepsis is not a specific event in time, but rather a syndrome that occurs on a continuum.

~750,00 cases annually (trend has been on a steady increase since the 70’s)

Thought to be influenced by:

aging population

increase in immune suppressed population

increased drug resistant diseases

~200,000 deaths/year

Patients >65 account for nearly 60% of all cases(Angus, et all, 2001).

Increased incidence during winter months

30-50% mortality, severity dependent

Septic patients have 2x as long hospital stay as patients without

Costs the health care system over $16 billion dollars annually

Critically-ill patients

Severe community-acquired pneumonia

Chronic diseases

Immuno-compromise

Age

Obesity

Intra-abdominal surgery

Urinary tract infection

Invasive lines

All hospitalized patients

SIRS SepsisSeptic Shock

MODS Death

Clinical syndrome that results from a dysregulated inflammatory response, but is due to a non-infectious source.

Examples:

Acute pancreatitis

Trauma

Burns

Surgery

SIRS requires 2 or more of the following derangements:

Temp >38.3: (100.4:F) or <36:C (96.8:F)

HR >90

RR >20 or PaCO2 >32 (normal 35-45)

WBC >12,000 or <4,000 or >10% immature cells (bands)

A systemic inflammatory response to infection, triggers cascade of inflammation, coagulation and impaired fibrolysis.

This out of control inflammatory process results in vasodilitation, increased capillary permeability and clotting.

Same criteria as SIRS, however, occurs within a context of known infection.

Sepsis plus at least one of the following signs of hypoperfusion or end organ damage

Areas of mottled skin

Delayed capillary refill

Urine output of <0.5 mL/kg for at least one hour or renal replacement therapy

Lactate >2 mmol/L

AMS

Abnormal EEG findings

Platelet count <100,000

DIC

Acute lung injury or ARDS

Cardiac dysfunction

Exists if there is severe sepsis & one or both of the following:

Systemic mean blood pressure <60 mmHg despite adequate fluid resuscitation

Maintaining systemic mean blood pressure >60 mmHg requires vasopressors despite adequate fluid resuscitation

Vassopressor use is a significant predictor of mortality

Altered function of one or more organs

Primary and secondary MODSPrimary: direct injury/insult to organs that results from a specific event (i.e. pulmonary contusion, liver laceration)

Secondary: indirect injury/insult to organs as a result of systemic event (i.e. SIRS, sepsis)

Mortality with MODS is very high; proportionate to the number of organs involved

2 organ failure mortality 45-55%

3 organ failure mortality >80%

(Bone, et al., 1992).

Localized site of infection, initiates a localized inflammatory response

White blood cells converge to the site of infectionNeutrophils, macrophages

Localized infection can lead to bloodstream infection (bactermia), this is sepsis

Bacteria release endotoxins

Immune system releases proinflammatorymediators (prostaglandins, cytokines)

Endotoxins

Cytokines are immunomodulators (interleukons& interferons) released by WBCs and cause:

Vasodilitation

Increased capillary permeability

Increased coagulation

Prostaglandins in the inflammatory process cause vasodilitation, inhibit platelet aggregation and effect the hypothalamus with regards to thermoregulation (fever)

Vasodilitation is mechanism used to increase blood flow to affected areas allowing for better transport of WBCs

Without corresponding increase in blood volume, hypotension follows

Increased capillary permeability leads to fluid leak third spacing & further volume loss

Impaired fibrinolysis causes decreased clot breakdownmicrothrombi, then tissue hypoperfusion, necrosis & organ failure

Third-spacing/Capillary leak

Microthrombi

In septic shock, the body’s compensatory mechanisms are overwhelmed by malignant inflammatory response.

Leading to:Reduced coronary blood flow with decreased CO, BP & tissue perfusion

Pro-inflammatory cytokines cause imbalances between clotting & lysis, impairing circulation to tissues/organs, third spacing & worsening hypotension

Brain fails to respond with vasomotor responses to hypotension

Peripheral ischemia occurs due to prolonged shunting & microemboli

Survival at this stage in the cascade is <10%

Hyperthermia/hypothermia

Tachycardia

Tachypnea

Hypotension

Oliguria

Altered mental status

Hypoxemia

Decreased capillary refill and/or mottling of extremities

WBCs elevated or suppressed (>12,000<4,000) or normal with >10% bands

Documented infection

Increased lactate >4 mmol/L

Coagulation disturbancesLow fibrinogen, increased fibrin split products

Thrombocytopenia

Elevated INR or PTT

Elevated CRP (C Reactive Protein)

Hyperglycemia

The key to sepsis treatment is: PREVENTIONHAND WASHING

Proper line management

VAP protocols

Hand washing

Catheter removal

Early mobility

Did I mention hand washing already?

Broad spectrum antibiotics within first 1-3 hours

Corticosteroids, if persistent hypotension despite adequate fluid resuscitation; may indicate adrenal insufficiency

no longer requires cortisol stim test to start therapy

Vasopressors, for hemodynamic support after adequate fluid resuscitation

Xigris (drotrecogin alfa) voluntarily pulled from the market in 10/2011 as studies showed no benefit

Stroke: Time is brain

MI: Time is muscle

Sepsis: Time is tissueWith every hour that intervention is delayed, survival drops by 10%

Early recognition and intervention are key to successful outcomes

Prevention is the key to sepsis

http://www.ed4nurses.com/resources/1/pdf/Sepsis.pdf

http://www.sccm.org/Documents/SSC-Guidelines.pdf

http://journals.lww.com/nursingmadeincrediblyeasy/Fulltext/2009/05000/Recognizing_the_signposts_for_sepsis.10.aspx

HighImpactGraphics. (2011, August 14). Sepsis {Video file}. Retrieved from http://www.youtube.com/watch?v=xm437bHXsrY

LoyolaHealth. (2012, September 24). Code sepsis {Video file}. Retrieved from https://www.youtube.com/watch?v=t3qWMcDK-ME

Angus, B., Linde-Zwinde, W., Lidicker, J., Clemont, G., Carcillo, J., & Pinsky, M. (2001). Epidemiology of severe sepsis in the United States: Analysis of incidence, outcome and associated costs of care. Critical Care Medicine, 29(7), 1303-1310.

Bone, R., Balk, R., Cerra, F., Dellinger, R., Fein, A., Knaus, W., . . . Sibbald, W. (1992). Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee, (pp. 1644-55).

Angus, B., Linde-Zwinde, W., Lidicker, J., Clemont, G., Carcillo, J., & Pinsky, M. (2001). Epidemiology of severe sepsis in the United States: Analysis of incidence, outcome and associated costs of care. Critical Care Medicine, 29(7), 1303-1310.

Bone, R., Balk, R., Cerra, F., Dellinger, R., Fein, A., Knaus, W., . . . Sibbald, W. (1992). Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee, (pp. 1644-55).

Dellacroce, H. (2009). Surviving sepsis: The role of the nurse. RN, July, 16-21.

Dellinger, R.P.; Levy, M.M.; Rhodes, A.; Annane, D.; Gerlach, H.; opal, S.M.; Sevrasky, J.E.; Sprung, C.L.; Douglas, I.S.; Jaeschke, R.; Osborn, T.M.; Nunnally, M.E.; Townsend, S.R.; Reinhart, K.; Kleinpell, R.M.; Angus, D.; Deutschman, C.S.; Machado, F.R.; Rubenfeld, G.D.; Webb, S.A.; Beale, R.J.; Vincent, JL; Moreno, R.; Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup. (2012, January 20). Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock: 2012. Society of Critical Care Medicine's 42nd Congress, (41)2, 580-637. DOI: 10.1097/CCM.0b013e31827e83af

McCormick, M.J. Recognizing the signposts for sepsis. Nursing Made Incredibly Easy!, (7)3, 40-51. doi: 10.1097/01.NME.0000350939.27283.30

Woodruff, D.W. Why you need to know about sepsis syndrome {Webinar notes}. (2011, July 22). Retrieved from http://www.ed4nurses.com/resources/1/pdf/Sepsis.pdf

Wood, S.; Lavieri, M.C.; Durkin, T. (2007). What you need to know about sepsis. Nursing2007, 37(3), 46-51