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sepsis

ICU CLASS
by

Julie Gamboa

on 22 June 2015

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Transcript of sepsis

Severe Sepsis and Septic Shock
Sepsis Bundles
the first 3 hours
the next 6 hours
Apply

vasopressors

if no response to fluids

For persistent hypotension

measure CVP or ScVO2

Remeasure Lactate

if was initially high
Measure

Lactate

Obtain

Blood cultures

prior to antibiotic

Give broad spectrum

Antibiotic

Give 30ml/kg of
Crystalloids
for hypotension or Lactate > 4
What: Definitions

Why: Pathophysiology

How: Interventions

Objectives
1. Define SIRS, sepsis, septic shock

2. Understand the pathophysiology of septic shock

3. List 3 components of Sepsis Bundle

case study: the cheerleader
*19 year old female on the Big Island had teeth extracted. Noticed black spots on lips
*Emergent trach in
North Hawaii
* VS: HR 117, BP 98/34 on
pressors, RR: 22, Temp: 37.5,
O2 Sat 100% on FiO2 100%
* WBC: 8.6
* Lactic Acid 6.8
* Bands: 35
* Creatinine 3.8
* Transferred to QMC inserted CVC, AL, PAC,
Vascath, placed on kinetic bed, CRRT
case study: Mr Alawai
34year old male assaulted four days prior to admission was treated but returned with complaints of malaise and pustular rash. Pt admits he fell in the Ala Wai canal.

Labs: WBC: 4.9, Creatinine 2.6,,
Lactic Acid 8.5
ABG on 100% NRBM: 7.11/49/50/-14/16/89%
Pt intubated: 6.97/50/246/-20/12/99%

* CVC, AL, PAC, Vascath
* Fluid resuscitation: 18L
* Bair Hugger (warm air)
* Pressor: Norephinephrine, Dopamine
* Abdominal compartment syndrome->
open abdomen to wound vac
* Inotropes: Dobutamine, Primacor
* Kinetic bed therapy,
* CRRT.
Supportive Therapy in Severe Sepsis
* Fluid therapy
*Vasopressors
*Corticosteroid
*Inotropic therapy
*Blood transfusion
* Mechanical Vent
* Renal Replacement
Therapy



* Deep vein thrombosis
* Sedation, analgesia
* Stress Ulcer prophylaxis
* Nutrition
* Glucose Control
* Set goal of care
case study: Mr Alawai
Acute Renal Failure

Necrotic limb

Septic Shock

Multiple Organ Failure
4 days later...

Family Meeting
Code Status changed
Care withdrawn
Pt expired
Julie Gamboa RN, BSN, CCRN
Initial Resuscitation Goals
1. Central venous pressure 8-12 mm Hg
2. Mean Arterial Pressure >/= 65 mm Hg
3. Urine output > 0.5 ml/kg/hr
ScVO2 >70% or SvO2 >65%

Target resuscitation to normalize elevated Lactate levels
find the source
Source Control
Cultures: sputum, urine
Chest xray
CT scan
Consider line removal
Fluid Therapy
- crystalloids are the initial fluid of choice
- No starches
-albumin may be used when a substantial amount of crystalloids are needed
-fluid challenge may be used if there is hemodynamic improvement
Vasopressors (Target MAP>65 mm Hg)
*
Norepinephrine
*Epinephrine may be added or substituted
*Vasopressin 0.03 unit/min not a first line vasopressor
*Dopamine: low risk dysrhythmia and absolute or relative bradycardia
*Phenylnephrine: if norepinephrine causes serious arrhythmias

arterial catheters with pts requiring vasopressor(s)
Inotropic Therapy
Consider when ongoing s/s of hypoperfusion despite adequate fluid resuscitation
*Dobutamine
*Milrinone
Corticosteriods

-use if unable to achieve hemodynamic stability
-No need ACTH stimulation test
-taper off when no longer needed
Blood transfusion
-PRBC for Hgb<7 with goal 7-9g/dL
-consider platelets
-consider FFP if pt is bleeding or an invasive procedure is planned (central line insertion, surgery)
Mechanical Ventilation
-goal tidal volume 6L/kg in ARDS
-target upper limit plateau pressure <30cm H20
-set PEEP to avoid alveolar collapse
-consider prone position for sepsis-induced ARDS with PaO2/FiO2 <100mm Hg
-HOB 30-45 degrees
-regularly evaluate weaning potential
-use fluid strategy with sepsis induced ARDS
-do not use PA catheter for routine monitoring of pts with sepsis induced ARDS
Renal Replacement Therapy
use continuous therapies to facilitate fluid mgmt in hemodynamically unstable patients
Sedation/Analgesia/NMB
-continuous or intermittent sedation should be minimized in patients with sepsis who are vented
-sedation targets should be in place
-avoid neuromuscular blockade if possible
(monitor train of four with continuous infusions)
Deep Vein Thrombosis Prophylaxis
-use LMWH subcutaneously daily
-pneumatic compression device
-use mechanical device if pharmacoprophylaxis is contraindicated
Stress Ulcer Prophylaxis
-use H2 blocker or PPI
-should not be used if without risk factors
Nutrition
-administer oral or enteral feedings as tolerated within first 48hrs
-low dose feeding in the first week (up to 500cal/day
-use IV glucose and enteral feeding vs TPN alone or in combination with enteral feeding in the first 7 days

Glucose Control
-Target goal: 180 mg/dL with a protocolized approach
Consider Limitation of Support
-discuss prognosis and goals of care
-address ASAP within 72hrs
-incorporate end of life care planning and palliative principles where appropriate
tachycardia
hypotension
altered CVP &
PAWP
altered mental status
confusion
psychosis
Tachypnea
PaO2<70mm Hg
SaO2<90%
PaO/FiO2 Ratio <300
oliguria
anuria
increased creatinine
body aches
decreased insulin
production
hyperglycemic
How we monitor patients
*Vital signs: BP, HR, Pulse ox, Temp, RR
*ScVO2
*SVO2
*Stroke Volume, Cardiac Output/Index
*Urine Output
*Lab Values: biomarkers
*StO2
*Clinical Assessment: pulse quality, skin color, skin temp, pt affect

(aka Early Goal Directed Therapy)
SIRS:
temp>100.4 <96.8
HR>90
RR >20
PCO2 <32mmHg
WBC >12 <4
*Find it early:

*(c) L.A.F. at it:

* Support

Summary
assessment skills
culture,
lactate,
abx,
fluids
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