What is the leading cause of death in non-coronary ICU
In septic shock, what % of ppl will die from it?
Why is sepsis on the rise?
Aging population, overuse of antibiotics, survival of immunocompromised
Do ppl usually contract sepsis in ICU?
No, at home or med-surge
What is the physiological response to any injury?
Microbial, mechanical, or thermal
Inflammation vs Infection
protective defense mech vs result of the invasion of cells/tissue by living organisms
What is the progression from injury to death by sepsis?
1. Systemic inflammatory response syndrome (SIRS)
2. Sepsis----catch it now or else!...
3. Severe sepsis
4. Septic shock & Multiple organ dysfunction syndrome (MODS)
What causes SIRS?
A systemic inflammatory response a VARIETY of injuries/conditions:
Is SIRS organ or system specific?
No, it can be caused by almost any type of injury
Critieria for SIRS...Must have 2 to Dx
Temp FEBRILE of >38C (100.4F) or HYPOTHERMIC <36C (96.8F)
Pulse: >90 bpm
Resp Rate >20/min or PaCO2 <32 mmHg
WBC >12,000/mm or <4,000 &/or >10% bands
What type of breathing might be seen in SIRS?
What ABG would the hyperventilating SIRS pt manifest?
Do you have to have SIRS to have sepsis or can sepsis stand alone?
someone with sepsis always has SIRS
The clinical signs of SIRS + an infection=
In sepsis, do we need proof of infection to diagnose?
No, infection can be presumed.
Is sepsis present in specific systems or organs?
No , sepsis is systemic, affecting entire body.
What are the hallmark (differentiating) labs of sepsis?
increased serum lactate and increased bands (neutrophils)
Three sepsis 'marker' organs/systems?
Renal, pulmonary and neuro
What 3 'dysfuncional problems assoc w/ Severe Sepsis?
Organ dysfunction, hypotension, and/or hypoperfusion
What are the manifestations of hypoperfusion?
Tachycardia, oliguia and acute alteration in cognition/affect
What part of vitals are we very concerned about in Severe Sepis
MAP <65 or systolic BP <90mm/Hg
How can we help w/crap MAP (<65) in severely septic pt?
What does giving fluids do for a pt w/severe sepsis?
Raises BP, increases vascular volume
What type of shock is septic shock?
distributive, fluids lying stagnant out in peripherals and places
What called when severely septic pt is unresponsive to fluids?
They have moved into septic shock
Is there hypotension in severe sepsis?
Yes, SBP <90 or MAP < 65
Septic Shock: Despite fluid replacements, what is renal output?
Septic Shock: ABG status?
Lactic acidosis, metabolic acidosis
Septic Shock: Neuro status?
Acute alteration in mental...if concious
What happens when fluid replacement given to septic shock?
What does the HCP order after fluids failed to raise BP?
Vasopressors or inotropes
Why would inotropes be given to septic shock?
Support BP after vasopressors tried AND to boost a sluggish heart. Encourage strong contractions which increase C/O
What is MODS: Multiple Organ Dysfunction?
2 or more organ dysfunction in an acutely ill pt where homeostasis cannot be maintained w/out intervention...BAD!
MODS: How is BP/perfusion in MODS?
Shite. SystolicPB <90 or reduction of 40mmHg Systolic off baseline OR MAP <65 in absence of no other cause for hyPOtension
Sepsis RISK factors: Age and nutrition?
The very young and very old are at higher risk <1yr & > 65yr
Malnourished (anorexic/bulimic) ppl have fewer physio resources.
What kind of common ICU invasive tubes can lead to sepsis?
Endotracheal tubes and Central Veinous caths (central lines) PICC lines
What particular vent-assoc illness often leads to sepsis?
Ventilator Associated Pneumonia
What immunodeficiencies can put one at risk for sepsis?
chemotherapy, alcoholism, HIV
How are stroke pt's particularly vulnerable to sepsis?
Aspiration and subsequent pneumonia/pulmonary infection
What chronic illnesses put person at risk 4 sepsis?
Diabetes (surprise! bacteria love sugar) and chronic (or acute) renal failure
Do surgeries and/or invasive procedures put pt at risk 4 sepsis?
What happens if you culture AFTER starting antibiotics?
You will have skewed results.
What is the highest PRIORITY action for a sepsis pt?
What is the FIRST thing to do for a septic pt?
Culture blood and whatever else BEFORE starting antibiotics
What do you culture from a septic patient?
Everything, blood, sputum, urine, any wounds
What will the CBC of a septic pt reveal?
WBC elevated w/shift to left. Elevated immature granulocytes (bands, baby neutros)
Sepsis: Why are platelets decreased in serum?
Platelets are out 'microcoaulating' where they shouldn't be. They had an irregular response to infection/injury and are being used up.
What will serum lactate levels look like? & what kind of cellular metabolism is that indicative of?
Increased as ? How much anaerobic metabolism pt has.
What will elevated serum lactate levels do to bodY?
Eventually create a metabolic acidosis.
Why is pt in anaerobic metabolism?
Cells starved for O2 as microcoagulation cuts them off from vascular perfusion.
What does procalcitonin do for the septic body?
It neutralized H2O2 at a cellular level.
What will be on our coagulation profile?
PT/INR & PTT. D-Dimer and activated protein C.
Sepsis: What will PT/INR & PTT look like?
All elevated, all clotting factors out and now a bleeding risk.
What is activated protein C?
Heck if I know, but it's elevated in sepsis.
Severe Sepsis and normal inflammation response
Severe sepsis is an exaggeration of the responses to the infectious process.
Severe sepsis activates 2 systems and impairs 1...which?
Activates inflammatory process & coagulation. Impairs fibrinolysis.
Where do endotoxins come from?
The by product of invading bacteria
Patho Severe Sepsis: What happens w/clotting cascade?
Excessive, unnecessary clotting in the microcirculation & cellular dysfunction interfere w/blood flow & DECREASE cell O2
Severe sepsis patho: What will that look like in the peripheral extremities?
Mottling, perhaps pale and cool to touch.
Severe Sepsis patho: What happens after underoxygenated cells stunned and die?
The tissue/organs they make up begin to necros/fail.
Where is the endothelium?
The single-layer cells that line the inside 'lumen' of blood vessels.
Is there endothelium in stents?
Not at first, but it grows in there.
What has to be adhered to because of lack of endothelial cells in stents?
coumadin, heparin, enoxaparin, ASA
How do endothelial cells relate to clotting?
They resist it, they are slippery.
How do single-layer endothelial cells resist clotting? 3 ways
1. endothelial protein C receptors
2. generate & secrete antithrombotic substances
3. secret vasodilating substances including NO3
What happens when endothelial cells/lining get injured?
Produce substances that encourage localized clotting
Where do the endothelial clots form and why is that problematic?
They form in the local microvasculature and further damage endothelium.
What happens if endothelial damage is extensive?
Cells are damaged and microvessels are porous and leaky
What happens with leaky vessels & why problematic?
fluid leaks into interstitial spaces causing edema & worsening hypovolemia
What happens when damaged endothelial cells secrete too much NO3 cuz of damage?
Vasoregulation is impaired and vessels stay dilated...
What can be a temporary effect of this unregulated vasodilation? Then what?
Temporary Excellent perfusion, then as vasodilation fails to self-regulate...boom! HYPOperfusion
What is refractory hypotension?
When efforts to raise BP (fluids) fail to achieve desired effect.
As sepsis progresses, what can severe vasodilation, refractory hypotension & impaired microcirculation lead to?
MODS & death
Severe/Septic shock: S/S Labs? WBC, bands, platelets, glucose?
WBC >20,000/mm OR < 4,000/mm: INCREASED due to inflammatory process OR DECREASED!
bands, immature neutros: >10%
Platelets: DECREASED due to over distribution/dysfunctional use
Glucose: INCREASED due to stress response, metabolic demand
Severe/Septic shock: Renal?
Decreased urine output, shows up early! NO perfusion, no pee pee
Severe/septic shock: Vitals?
Temp: febrile (38C, 100.4F or higher) or hypothermic (36C or 96.8F or lower)
Pulse: >90 Bpm: tachycardia (decreased volume, infectious process, cytokines, adrenal trigger)
RR: >20/min or PaCO2 <32
What is hyperglycemia doing to effect S/S in severe sepsis or septic shock?
Helps coagulate in microvasculature, gunks up caps and feeds bacteria
Severe/septic shock: What is assessment of extremities probably going to reveal?
Mottled, cool, pale skin. (Decreased perfusion), petechiae or purpura (dyfunctional clotting), poor cap refill.
Severe/septic shock: Why pt tachypnic?
Trying to blow off excess CO2 metabolic acidosis, hyperventilating, won't work
Severe/septic shock: Neuro status?
Whacked, altered LOC and probably not oriented.
Severe/septic shock: How will pt feel?
Like hell, probably major chills, extreme lethargy, 'out of it'
Septic shock is what kind of shock?
distributive: vessels inappropriately dilated for too long, 3rd spacing due to damaged caps (endothelial injury) leaking fluid into tissue
classic signs of a systemic infection:
Tachypnea, Tachycardia, HIGH WBC count (left shift?), FEVER
Signs of severe sepsis
The severity of the septic reaction should also produce other warning signs, such as:
Hot, flushed skin
Newly altered mental status
Widened pulse pressure (Pulse pressure is the difference between the systolic and the diastolic blood pressure values.)
Elevated blood lactate level