Criteria
SIRS (>2): |
T >100.4/<95.0 HR >90 |
RR >20 or PaCO2 <32 |
WBC >12/<4 or Bands >10% |
Sepsis: SIRS + Infection |
Severe Sepsis (>1 org dysf): |
SBP <90/decrease by >40 or MAP <65 |
Cr >2.0 or UO <0.5 mL/kg/hr x2hr |
Platelets <100,000 |
INR >1.5 or PTT >60 |
Lactate >2 |
Septic Shock: Severe Sepsis + Refractory Hypotension |
Persistent tiss hypoperfusion after fluid resusc |
SBP <90/decrease by >40 or MAP <65 |
Lactate >4 |
MODS: >1 End-organ dysfunction |
Phases of Septic Shock
Early / Hyperdynamic Phase |
hypotension, tachycardia, tachypnea, Ꝋ/↑ CO, ↓SVR, bounding pulse |
warm, well perfused extremities but ↓visceral flow |
flushed, moist skin |
Late / Hypodynamic Phase |
hypotension, tachycardia, tachypnea, narrow thready pulse, vasoconstriction, CO declines |
cold, poorly perfused extremities |
pale, dry skin |
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Sepsis Bundles
Within first 3 hours: |
O2 support. IV access x2 (large bore). |
Measure lactate level |
Obtain blood cultures x2 prior to abx adm |
Adm broad spectrum abx (w/in 3 hr of ER adm or w/in 1 hr of adm to hospital unit) |
Adm 30 mL/kg crystalloid for hypotension or lactate >4 |
Within first 6 hours: |
Draw 2nd lactate level if initial lactate >2 |
Measure CVP or ScvO2 for refractory art hypotension or initial lactate >4. Maintain CVP >8 & Scvo2 >70. |
Add vasopressors for persistent hypotension following fluid resusc. Maintain MAP >65. |
Persistent shock- Consider adding Vasopressin 0.04 units/min. |
Within 24 hours from severe sepsis dx: |
Lung protective ventilation- Maintain insp plateau pressures <300 cmH2O for vent pts. Avoid tidal volume >6 mL/kg for ARDS pts. |
Steroids - Adm low dose steroids for septic shock (hydrocortisone) |
Glucose control/Insulin therapy |
Nursing DiagnosesAlt
R/F infection: superinfection |
R/F fluid volume deficit |
Altered tissue perfusion |
Hyperthermia |
Impaired gas exchange |
Fear/anxiety |
Knowledge deficit |
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Medications
Glycemic control - IV regular insulin to maintain blood glucose <180 (goal <150) |
VTE prophylaxis - Adm low-dose UFH/LMWH |
Stress ulcer prophylaxis - PPI or H2 rec antag |
Vasoactive Meds: |
Norepinephrine 2-20 mcg/min; titrate q5min |
Dopamine 5-20 mcg/kg/min |
Dobutamine 2.5-20 mcg/kg/min |
Vasopressin 0.4 units/min |
Vent Meds: |
Propofol 5-10 mcg/kg/min; max 50 mcg |
Midazolam 1-2 mg/h; max 0.3 mg/kg/hr |
Lorazepam 1-2 mg/h; max 10 mg/hr |
Morphine 1-2 mg/h; max 0.3 mg/kg/hr |
Fentanyl 50-100 mcg/hr; max 3 mcg/k/min |
Nursing Care
Client-family education |
Enteral feeding |
Urinary catheter |
Strict aseptic technique |
Consider ECHO, EKG, Troponin levels |
Assess fluid & perfusion status frequently. |
Monitor coagulation studies (PT, PTT, INR, fibrinogen, FDP, platelets). Adm platelets if counts <5. |
Monitor H/H. Assess for signs of bleeding. Adm PRBCs if Hgb <7. |
Monitor VS, hemodynamics, EKG closely. Adm anti-arrhythmic as needed. VS q5m during titration. |
Monitor temp. Fever reduction as needed. Assess & maintain skin integrity. |
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