Final - Sepsis, Septic Shock, and DIC

  1. Who is at risk for sepsis?
    • Very young
    • Very old
    • immunocompromised
    • wounds or injuries
    • addictive habits
    • receiving certain treatments or exams
    • genetic factors
  2. What is Sepsis?
    dysregulated host response to infection


    It’s how a person reacts to an infection – an abnormal immune response to infection – sepsis is a setup for DIC
  3. What is the pathophysiology of sepsis?
    • vasodilation of vessels --> hypotension
    • capillary leak
    • low cardiac output
    • decreased tissue perfusion --> hypoxia
    • metabolic acidosis!
  4. What measures the O2 in the tissues?
    lactate
  5. What is the hallmark of sepsis? - according to Darlene that leads to all other issues?
    • endothelial damage
    • causes damage to vessel walls and that -->
    • micro-clots form --> tissue factor is released
    • platelets and clotting factors are used up
  6. Microthrombi production that is widespread and platelet and clotting factors are used causing thrombocytopenia - what syndrome is this?
    disseminated intravascular coagulation (DIC)
  7. Multiorgan failure, uncontrolled bleeding, and refractory hypotension?
    Septic Shock
  8. Despite fluid resuscitative manners the patient remains hypotensive
    Refractory hypotension
  9. How do we monitor central venous pressure (CVP) and fluid status in a patient with septic shock?
    Central venous catheter
  10. What is included in the SURVIVING SEPSIS CAMPAIGN?
    • qSOFA: alteration in mental status, SBP ≤100, respiration >22
    • suspected or documented infection and increase of >2 SOFA pts
  11. What are the qSOFA factors to determine sepsis?
    • An alteration in mental status 
    • SBP ≤100 mm Hg
    • A respiration rate >22 breaths/min
    • infection of some sort
  12. What is the clinical criteria for SEPSIS?
    • Suspected or documented infection
    • increase of >2 SOFA points
  13. What is the clinical criteria for SEPTIC SHOCK?
    • Sepsis
    • Persisting hypotension requiring vasopressors to maintain MAP ≥65 mm Hg
    • Blood lactate >2 mmol/L despite adequate volume resuscitation
  14. What is the fluid resuscitation for Sepsis?
    30mg/kg
  15. What are the first signs of Sepsis?
    • increased resprirations
    • increased HR
  16. GWTG (Treatment bundle) for Surviving SEPSIS Campaign?
    • TO BE COMPLETED WITHIN 3 HOURS OF TIME OF PRESENTATION*
    • 1. Measure lactate level
    • 2. Obtain blood cultures prior to administration of antibiotics
    • 3. Administer broad-spectrum antibiotics
    • 4. Administer 30ml/kg crystalloid for hypotension or lactate ≥2mmol/L *

    • TO BE COMPLETED WITHIN 6 HOURS OF TIME OF PRESENTATION:
    • 5. Administer vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65mmHg
    • 6. In the event of persistent hypotension after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was ≥4 mmol/L, re-assess volume status and tissue perfusion and document findings
    • 7. Re-measure lactate if initial lactate elevated
  17. What must be completed within 3 hours for SEPSIS?
    • 1.Measure lactate level 
    • 2.Obtain blood cultures prior to administration of antibiotics
    • 3.Administer broad spectrum antibiotics 
    • 4.Administer 30ml/kg crystalloid for hypotension or lactate ≥2mmol/L *
  18. What must be completed within 6 hours for SEPSIS?
    • 5. Administer vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65mmHg 
    • 6. In the event of persistent hypotension after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was ≥4 mmol/L, re-assess volume status and tissue perfusion and document findings
    • 7. Re-measure lactate if initial lactate elevated
  19. What does a vasopressor do?
    Constricts vessels - to increase the BP to help perfuse tissues

    **make sure enough fluid is on board before giving vasopressors
  20. What meds are given for Sepsis/Septic Shock?
    • Antibiotics
    • Corticosteroids- Hydrocortisone (< 300 mg/day)
    • Vasopressor: Norepinephrine (Levophed)
    • Inotropic Therapy- Dobutamine
  21. Why do we give positive inotropes for sepsis/septic shock?
    to increase cardiac output

    *sepsis has a myocardial depressant factor
  22. When the body changes from aerobic to anaerobic metabolism what happens?
    metabolic acidosis
  23. What is the plan of care for Sepsis/Septic Shock?
    • High Flow O2 & IV- mechanical ventilation
    • Sedation, analgesia & neuromuscular blockade
    • Fluid Therapy
    • Administration of medications
    • Antibiotics
    • Corticosteroids- Hydrocortisone (< 300 mg/day)
    • Vasopressor: Norepinephrine (Levophed)
    • Inotropic Therapy- Dobutamine
    • Glucose control
    • Deep vein thrombosis prophylaxis
    • Stress ulcer prophylaxis
    • Nutrition
  24. What are the primary assessment functions for Shock?
    • A - airway
    • B - breathing
    • C - circulation - bleeding give blood, platelets, plasma. Give fluids
    • D - NEURO status
    • E - cut off clothing, keep warm
  25. What are the secondary assessment functions for shock?
    • F - full set of V/S, labs, diagnostic tests...
    • G - give comfort measures
    • H - history, head to toe assess
    • I - inspect posterior surfaces
  26. What are the cardinal signs of shock?
    • Increased respiratory rate
    • Increase HR
    • Hypotension
    • Oliguria
    • Abn mental status
    • Metabolic acidosis
    • Cool, clammy skin
  27. What happens in the Initial Stage of Shock (Early Shock)?
    • ↑RR
    • ↑HR
    • Slight ↑DBP
  28. What happens in the Nonprogressive (Compensatory Stage) of Shock?
    • Kidneys allow the body to hold on to fluid and the kidneys to hold on to sodium
    • Changes in LOC
    • Increased respiratory rate
    • Increased HR
    • MAP down 10-15
    • Pulse pressure narrowing
  29. What happens in the Progressive (Intermediate Stage) of shock?
    • MAP drops by 20
    • Overall metabolism is anaerobic (acidosis)
    • hypokalemia
    • Drop in urine output
    • Drop in LOC
    • Increased restlessness and confusion
    • Severe thirst
    • Lactate is increased
    • Cool, moist skin
  30. What happens in the Refractory (Irreversible Stage) of shock?
    • Loss of consciousness
    • Nonpalpable pulses
    • Slow shallow respirations
    • Organ failure (MODS)
    • Cold mottled skin
    • Difficulty getting SpO2 or <70
  31. What is Multiple Organ Dysfunction Syndrome (MODS)?
    • Dead cells break open and release harmful chemicals
    • Formation of microthrombi
    • Occurs first in liver, heart, brain, & kidney
    • Release of myocardial depressant factor
  32. What do we need to monitor to identify shock?
    • V/S
    • Skin
    • Cardiac rhythm
    • ABG’s
    • Hemodynamic (Cardiac output, CVP, …)
    • Urine output
  33. What is the gist of DIC (disseminated intravascular coagulation)?
    endothelial damage --> activates massive clotting cascade --> fibrin deposits --> clotting

    AND

    since the clotting factors and plasma are massively used --> BLEEDING
  34. What ACUTE conditions predispose a person to DIC?
    • Infections
    • Trauma
    • Excessive surgery
    • OBGYN complications
    • Toxins
  35. What CHRONIC conditions predispose a person to DIC?
    • Neoplastic DO's
    • Hematologic / Immunologic DO's
    • Vascular DO's
    • Pulmonary
    • Prosthetic devices
  36. What clinical manifestation will a patient with ACUTE DIC display?
    • Bleeding
    • —Renal dysfunction
    • —Hepatic dysfunction
    • —Respiratory dysfunction
    • —Shock
    • —Thromboembolism
    • —Central nervous system involvement
  37. What clinical manifestation will a patient with CHRONIC DIC display?
    • —Asymptomatic?
    • —Venous thrombosis (DVT)
    • —Arterial thrombosis (stroke)
    • —Minor skin &/or mucosal bleeding
  38. What tests are done to determine DIC?
    • Platelet count  (<100,000/microL)
    • —Microscopic blood smear exam
    • ——Serum fibrinogen - low
    • —PTT - high (prolonged)
    • —PT - high  (prolonged)
    • —Fibrin degradation products - high
    • D-Dimer - high
  39. What is the treatment for DIC?
    • treat underlying disease
    • maintain airway, ventilation, Oxygenation
    • correct hypovolemia, hypotension, hypoxia, acidosis
    • stop bleeding --> support coagulation
    • stop clotting --> heparin
    • treat ischemic pain
    • maintain skin integrity
    • psych support/reassurance
    • monitor for complications
Author
cbennett
ID
343205
Card Set
Final - Sepsis, Septic Shock, and DIC
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Final - Sepsis, Septic Shock, and DIC
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