Transcript Sepsis Prevention - Alverno College Faculty

Sepsis Prevention
MSN 621: Advanced Physiology
and Pathophysiology
Tutorial Project
Presented By: Morgan Maves
Instructions
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Objectives…
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Gain an understanding of the basics of infection
and how they pertain to sepsis
Learn to identify the signs and symptoms of
early and late sepsis
Value why sepsis identification and prevention
is important for the health care world and us as
nurses.
Understand what to do when you suspect
sepsis and interventions to apply once sepsis is
diagnosed.
Table of Contents
Basics of Infection
Implications of Sepsis
What is Sepsis
Nursing Interventions
& Guidelines
Stress Response
Aging and Genetics
Signs & Symptoms
Case Studies
The basics of infection…
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An infection is the “colonization of a host organism
by a foreign species” where “the infecting organism
seeks to utilize the host’s resources to multiply,
usually at the expense of the host” (Modric, 2009).
The factors or chain of events that lead to an
infection include several steps which include the
infectious agent, reservoir, susceptible host, portal of
entry, mode of transmission and portal of exit
(Modric, 2009).
Picture from ClipArt
Why even have an Inflammatory
Response?...
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The inflammatory process is self-contained by
feedback mechanisms (Steen, 2009, p. 51).
This self containment leads to inherent checks and
balances which permit the body to remain in
homeostasis (Steen, 2009, p. 51).
Homeostasis is the body’s ability to maintain
equilibrium within itself by adjusting internal factors
(Steen, 2009, p. 51).
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Because of the inflammatory process, individuals
often maintain homeostasis continuously without the
individual even being aware of it (Steen, 2009, p. 51).
So where does the problem arise?
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Although inflammation in and of itself is necessary
and is a beneficial defense mechanism for an
individual, “when an individual starts to display
symptoms of illness and physiological deterioration,
the inflammatory process is no longer localized to
the site of injury and is having a systemic effect. At
this point, a person can be described as having
sepsis or systemic inflammatory response syndrome
(SIRS)” (Steen, 2009, p. 51).
Picture from ClipArt
Stress Response…
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The stress response is a collection of physiological changes
that occur when the body’s demands outweigh its resources.
Through a variety of nerve and hormonal signals, the body’s
adrenal gland releases a surge of hormones including
adrenaline and cortisol.
Adrenaline: increases heart rate, elevates blood pressure and
initially boosts energy supplies.
Cortisol: increases glucose in the bloodstream, enhances
availability of substances to repair tissues, alters immune
system response, curbs nonessential functions
Information from Mayo Clinic, 2010
Question Time…
1. What hormones play a role in the stress response and its
development into sepsis?
Cortisol
Correct! It’s main function is to
increase the amount of glucose in
the bloodstream.
Adrenaline
Great Job! The release of this
would account for the
tachycardia associated with
sepsis.
Estrogen
Try again…This is a female
hormone produced by the
ovaries.
2. The inflammatory process is self contained by ___________.
Down Regulation
Incorrect…This is the
process by which cells
decrease the quantity of a
cellular component.
Feedback
Mechansims
Great Job! Negative and
positive feedback loops help
contain inflammation.
Homeostasis
Try again…This is the body’s
ability to maintain equilibrium.
Stress Response & Sepsis…
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Generally, plasma cortisol levels tend to be higher in septic patients
and are associated with increased mortality.
Studies have shown that increased cortisol levels in septic patients are
unable to control the inflammatory response.
The functionality of the hypothalamic-pituitary-adrenal (HPA) axis is
the greatest determinant of the host’s response to stress. In the case
of sepsis, the HPA axis is in over drive and presents with an increase
in corticotropin and subsequently high plasma cortisol levels. These
increased levels are known as relative adrenal insufficiency (RAI) and
are responsible for the inability to control inflammation.
Above information from: Yi, Y., Ling, L., Bo. Z., Mao-qin, L., Bin, W., Zheng, Y., Qin, G., Hua, S., Hai-bo, Q. (2007).
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It is important to note that there is contradictory opinions in the area of
cortisol levels and septic patients. In an article by Annetta, Maviglia,
Proietti & Antonelli, it is reported that cortisol levels may be high or
low, but are, nonetheless, insufficient to meet the body’s metabolic
needs.
What is sepsis?
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In the most basic sense, sepsis, or septicemia, refers
to the presence of microbial toxins in the blood (Porth
& Matfin, 2009, p.335).
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Sepsis refers to a systemic inflammatory response
that arises from an infective process; This infection
may be caused by bacterial, viral or fungal invasion
that provokes an inflammatory response (Steen, 2009,
p.49).
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Because many of the signs and symptoms that are
associated with sepsis can be caused by other
diseases and diagnoses than sepsis itself, there are
no formal diagnostic criteria for sepsis.
Review…
1) Sepsis refers to the presence of antigens in the
tissue. TRUE or FALSE?
2) The chain of events associated with infection include
infectious agent, reservoir, susceptible host, portal of
entry, mode of transmission and portal of exit.
TRUE or FALSE?
What is sepsis?
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Sepsis can also be defined as, “the
combination of pathologic infections and
physiological changes known collectively as
the systemic inflammatory response
syndrome” (Martin, Mannino, Eaton & Moss, 2003, p. 2).
The inflammation arises as a result of either
tissue ischemia or tissue damage” which
may result from a variety of circumstances
(Steen, 2009, p. 49).
Picture from ClipArt
What is the systemic response to
infection?
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The initiation of the Systemic Inflammatory
Response Syndrome (SIRS) is what causes the
clinical signs and symptoms of sepsis. This
response is produced by the body’s production of
antibodies in such cases as burns, severe trauma,
surgery or myocardial infarctions to name a few.
Although SIRS and sepsis are closely related, unlike
sepsis, SIRS is not always activated in response to
an infection.
Breaking it all down…
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Sepsis is closely linked to SIRS. SIRS is an
inflammatory response that affects the whole body.
It is frequently seen in response to infection and is
closely related to sepsis (Modric, 2009).
Sepsis and SIRS characteristics are similar in most
instances and may include, but are not limited to:
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body temperature less than 36 degrees C or greater than
38 degrees C
heart rate greater than 90 beats per minute
tachypnea (high respiratory rate)
white blood cell count less than 4000 cells/mm3 or greater than
12,000 cells/mm3
Picture from ClipArt
Keep clicking for more information! 
Basic Equation of Sepsis…
Mechanism of
Injury
+
(Infection of tissue)
Body’s
Response
(Inflammation)
Information taken from Steen, C. (2009).
Disease
=
(Sepsis/systemic
inflammatory response
syndrome/signs and
symtpoms of infection)
Review…
1) Sepsis occurs due to an infective process caused by:
A) Bacteria
Try again…
B) Fungal
Try again…
C) Viral
Try again…
D) All of the above
Correct
2) SIRS is a result of the body’s production
of _________.
Antigens
Nope…This
stimulates the
production of
antibodies.
Antibodies
Correct!!!
Hormones
Incorrect…These
are the body’s
chemical
messengers.
Picture from ClipArt
Early Signs & Symptoms
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Fever
Increased heart rate
Tachypnea
Alteration in white blood cell count
(Bone, Balk, Cerra, Dellinger, Fein, Knaus, Schein & Sibbald, 2010, p.1646)
Keep clicking for more information! 
Severe or later signs & symptoms
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Organ dysfunction
Hypoperfusion
Hypotension
Lactic acidosis
Oliguria
Acute alteration of mental status
(Bone,et.al., 2010, p.1646)
Picture from ClipArt
Keep clicking for more information! 
Factors we can’t change…Age and
Genetics
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In the U.S., elderly patients (> or = to 65 years of age) accounted
for 12% of the total population and 64.9% of sepsis cases.
Elderly patients were also more likely to have Gram-negative
infections, especially in association with pneumonia and to also
have co-morbid medical conditions.
With increased age, there was an linearly increase in rates of
case-fatality.
“Elderly sepsis patients died earlier during hospitalization and
elderly survivors were more likely to be discharged to a nonacute health care facility.”
The incidence of sepsis is disproportionately increased in elderly
adults and age is an independent predictor of mortality.
(Information from Martin, Mannino & Moss, 2006, pgs.15-21)
Keep clicking for more information! 
Age Continued…
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Incidence of sepsis “increased > 100 fold with age
(0.2/1,000 in children to 26.2/1,000 in those greater
than 85 years old).”
Mortality related to sepsis also shows a correlation
with age with an increase from 10% in children to
38.4% in those >85 years old.
The number of cases of sepsis is projected to
continue to rise substantially due to the aging U.S.
population.
(Information from: Angus, D.C., Linde-Zwirlbe, W. T., Lidicker, J., Clermont, G., Carcillo, J. &
Pinksky, M. R., 2001).
Keep clicking for more information! 
Aging
Images from ClipArt
Increased Risk of Sepsis
Quick Review…
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Early signs and symptoms of sepsis are? Click on all
that apply…
Altered Mental Stauts
Fever
Increased Heart Rate
Try Again
Correct!!
Correct!!
Tachypnea
Change in WBC count
Correct!!
Try Again
Dizziness
Try Again
Genetics…
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Infection is the basic building block which leads to
Picture from ClipArt
sepsis. “Genetic polymorphisms in the immune
response to infection have been shown to be
associated with clinical outcomes.”
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Studies which involve genetic polymorphisms in
essential genes have provided important insights
into the pathways and logistics involved in the
pathogenesis of sepsis-induced organ dysfunction.
(Information from: Arcaroli, J., Fessler, M. B. & Abraham, E., 2005)
Keep clicking for more information! 
Genetics…
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Genotyping will provide “valuable information on the
interaction of multiple allelic variants and clinical
outcome.”
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With the ability to differentiate which genes/alleles
are more susceptible to infection and subsequently,
sepsis, physicians will be better able to target those
exact points of infection and ultimately lead to
prevention and/or earlier clinical treatment of sepsis.
(Information from: Arcaroli, J., Fessler, M. B. & Abraham, E., 2005)
Keep clicking for more information! 
Genetics…
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The study completed by Wunderink and Waterer
was explicit in the fact that there is a genetic
component to the risk of developing sepsis which
subsequently, results in additional complications.
Confirmation of the findings [in their study] and
associations with other genetic polymorphisms await
large-scale population studies and further validation
of the physiologic significance of the variant alleles
to prove their validity and generativity.
Picture from ClipArt
Pop Quiz
1)
Due to their immature immune systems, newborns
and infants are at greater risk for developing sepsis
than the geriatric population.
TRUE or FALSE
2) With the ability to differentiate which genes/alleles
are more susceptible to infection and subsequently,
sepsis, physicians will be better able to target those
exact points of infection and ultimately lead to
prevention and/or earlier clinical treatment of
sepsis.
TRUE or
FALSE
= Correct
= Incorrect
Picture from ClipArt
So, what’s the big deal?...
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Picture from ClipArt
One study found that individuals who developed
sepsis post-operatively stayed in the hospital 11
days longer and cost $33,000 more than those who
did not develop it (Sequeira, M. & Campbell, K., 2010).
Sepsis is the “second leading cause of death among
patients in noncoronary intensive care units (ICUs)
and the 10th leading cause of death overall in the
United States” (Martin, et. al., 2003, p. 2).
Keep clicking for more information! 
Why do we care?
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The incidence of sepsis has steadily
increased over time and is expected to
continue to rise “as a result of an increasing
ageing population, underactive immune
systems arising from chemotherapy, organ
transplantation, complex co-morbidities such
as heart disease and diabetes, human
immunodeficiency virus and drug-resistant
invading organisms” (Steen, 2009, p. 48).
National Guideline Clearinghouse
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The following guidelines are all from the National
Guideline Clearinghouse and are interventions to be
carried out by the Registered Nurse…
“A postoperative assessment should be carried out
when the patient returns.”
“The first postoperative assessment should
determine: intraoperative history and postoperative
instructions, circulatory volume status, respiratory
status and mental status.”
“Any patient with circulatory disturbance should be
catheterised and the urine output measured hourly.”
Keep clicking for more information! 
Picture from ClipArt
National Guideline Clearinghouse
Continued…
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“Postoperative blood pressure should always be
reviewed with reference to the preoperative and
intraoperative assessments.”
“Further assessment is required for patients with:
heart rate below 50bpm, heart rate above 100 bpm
or blood pressure below 100 mm Hg systolic.”
“Oxygen saturation should be maintained above
92%.”
Picture from ClipArt
Keep clicking for more information! 
Question time…
1) The incidence of sepsis is predicted to continue to rise due to
several risk factors including, but not limited to (select all that
apply):
A) Organ Transplantation
B) Diabetes
C) Drug-resistant Organisms
D) Cancer
2) It’s important when assessing a post-operative patient to compare those
findings to both their pre- and intra-operative assessments.
TRUE
Correct!! Although there are guidelines to follow
in regards to assessments, each person is an
individual and must be compared against their
baseline
or
FALSE
Try again…Although there are parameters a
physician may indicate as being abnormal for any
patient, individualized care must be utilized to
determine a true change in condition.
National Guideline Clearinghouse
Continued…
“Respiratory rate, pulse rate, and conscious
level should be monitored routinely to identify
postoperative respiratory complication.”
 “The patient should be encouraged to sit up.”
 “Hand washing/glove use.”
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National Guideline Clearinghouse, 2007, p.2-6.
Keep clicking for more information! 
Picture from ClipArt
Nursing Interventions…
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Prevention through aseptic technique
whenever indicated
Removal of invasive intravenous and urinary
catheters that are no longer needed
Early mobilization/ambulation
Encouraging use of incentive spirometery
Maintaining adequate hydration and nutrition
Picture from ClipArt
Keep clicking for more information! 
The sepsis six treatment pathway…
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1)
2)
3)
4)
5)
6)
The following treatment pathway is taken from the
2009 Surviving Sepsis Campaign and explained
from Steen’s article:
Oxygen therapy
Fluid resuscitation
Measurement and monitoring of urine output
Blood cultures
Antibiotic therapy
Lactate, hemoglobin and routine blood monitoring
Keep clicking for more information! 
Case Studies…
Case studies are a wonderful way to look at
potentially real life situations and examine
how you would approach them. Let’s look at
two of them and discuss what your actions
would be.
Picture from ClipArt
Case Study #1
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After getting report at the start of your shift you decide to see
your patient in room 10 first. Mr. Johnson is a 77 y.o. male
admitted for altered mental status from the nursing home in
which he has lived for the past 6 years. The night nurse had no
remarkable notes regarding Mr. Johnson in her report. Upon
doing your initial set of vital signs, you find that Mr. Johnson’s
blood pressure is 92/60 which is a significant decrease from his
baseline of 130’s/80’s. He is unable to tell you his name,
where he is or what the date is. Additionally, according to the
documentation, Mr. Johnson has not voided since 0100 and it is
currently 1000. What do you do?
Case Study #1 Points to Consider…
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It is important to remember to do a complete
assessment so that you are able to present as much
clinically appropriate information to the doctor as
possible. Consider the following questions:
1) What components of your assessment do you think the
physician will want specific information on?
2) What orders do you anticipate to receive from the
physician; both nursing and medical interventions?
Case Study #1 Follow-up Answers...
1) Components of your assessment that the physician will be most
interested in:
 Respiratory Rate, Pulse Rate, Oxygen Saturation and/or Blood
Pressure: Should theses be greatly increased or decreased
from the patient’s baseline it could be indicative of
compensatory mechanisms within the body; early signs and
symptoms of sepsis.
 Conscious Level: If a person’s conscious level decreases from
their baseline, this is a cause for concern. In the later stages of
sepsis, blood flow to vital organs begins decreasing and could
lead to altered levels of consciousness. This is a serious
condition and should be addressed immediately.
 Urine Output: Typically, physicians look for patients to have a
minimum of 30cc urine/hour. If the rate falls below this, it may
be an indication that the kidneys are not functioning properly
and/or the body is compensating for a decrease in blood
pressure, increased heart rate, ect. by retaining fluid.
Case Study #1 Follow-up Answers...
2) Depending on the physician and the specific patient situation,
there are some orders that you may expect to receive in this
situation.
 Due to the fact that Mr. Johnson has not voided in several
hours, the physician may ask you to bladder scan the patient
and dependent upon the results, straight cath or insert a foley
catheter.
 With the decrease in urine output and drop in blood pressure,
administering a IV fluid bolus would also be an expected order
at this time.
 Dependent on the patient’s respirations and oxygenation
saturation, administering oxygen via a nasal cannula would
also be appropriate to maintain his saturation level above 92%.
 Frequent re-orientation will also be required to assess whether
or not the interventions being applied are benefiting his level of
consciousness.
Case Study #2
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You receive a 47 y.o. female s/p total abdominal hysterctomy. The
day of and the day following surgery, the patient is unmotivated to
ambulate. The patient begins spiking temperatures every night,
complains of some SOB and both her heart rate and respirations
have increased significantly from their pre-op baseline.
1) What could possibly be occurring with the patient?
A) The patient had a heart attack overnight.
B) The patient has an infection at the surgical site that is causing her to become septic.
C) The patient has atelectasis in her lungs which is affecting her vital signs.
2) What nursing interventions would you implement to prevent any further
complications?
Encourage Ambulation
Teach to Cough & Deep Breathe
Fluid Bolus
Chest X-ray
Case Study #2 Additional Review…
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There are a number of explanations for the patient’s signs and
symptoms. The patient’s unwillingness to ambulate could be resulting
in atelectasis and subsequent fevers, increase in heart rate and
respirations. These same signs and symptoms could be an indication
of infection. Using your clinical assessment and judgment skills are
critical in determining (along with the physician) what is occurring with
this patient. Remember, early recognition of infection is the key to
preventing sepsis.
Nursing interventions would include: continual education with patient
regarding importance of ambulation, use of IS (Incentive spirometer),
encourage PO (oral) intake and frequent vital sign assessment.
Most likely, the doctor will also give you some medical orders such as;
ask you to encourage ambulation, IS and C&DB (cough and deep
breathing), possible order for fluid bolus if intake is inadequate, strict
I&O’s (intake and output) to measure urine output (possible foley
placement if UO (urine output) is minimal) and/or blood cultures.
Keep clicking for more information! 
References
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Angus, D.C., Linde-Zwirlbe, W. T., Lidicker, J., Clermont, G., Carcillo, J. & Pinksky, M. R. (2001).
Epidemiology of severe sepsis in the United States: Analysis of incidence, outcome, and
associated costs of care. Critical Care Medicine 29(7) p. 1303-1310.
Annetta, M., Maviglia, R., Proietti, R. & Antonelli M. (2009). Use of corticosteroids in critically ill
septic patients: A review of mechanisms of adrenal insufficiency in sepsis and treatment.
Curr Drug Targets 10(9), p. 887-894.
Arcaroli, J., Fessler, M. B. & Abraham, E. (2005). Genetic polymorphisms and sepsis. Division of
Pulmonary Sciences and Critical Care Medicine 24(4) p. 300-312.
Bone, R.C., Balk, R.A., Cerra, F.B., Dellinger, R.P., Fein, A.M., Knaus, W.A., Schein, R.M. &
Sibbald, W. J. (2010). Definitions for sepsis and organ failure and guidelines for the use of
innovative therapies in sepsis. CHEST 101(6), p. 1481-1483.
Levy, M. M., Fink, M. P. & Marshall, J. C. (2003). Sepsis syndromes. Retrieved from:
http://emcrit.org/065-132/132-sepsis.htm.
Martin, G.S., Mannino, D. M., Eaton, S., & Moss, M. (2003). The epidemiology of sepsis in the
United States from 1979 through 2000. The New England Journal of Medicine 348(16) p. 120.
Martin, G. S., Mannino, D. M. & Moss, M. (2006). The effect of age on the development and
outcome of adult sepsis. Critical Care Medicine 34(1) p. 15-21.
Mayo Clinic (2010). Stress: Win control over the stress in your life. Retrieved from:
http://www.mayoclinic.com/health/stress/sr00001.
Modric, J. (2009). Infection-Definition, causes, transmission, symptoms and signs. Retrieved from
http://www.healthhype.com/infection-definition-causes-transmission-symptoms-signs.html.
References Continued…
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National Guideline Clearinghouse (2007). Postoperative management in adults.
A practical guide to postoperative care for clinical staff.
National Guideline Clearinghouse (2007). Postoperative management in adults.
A practical guide to postoperative care for clinical staff.
Sequeira, M. & Campbell, K. (2010). New study shows sepsis and pneumonia
caused by hospital-acquired infections kill 48,000 patients; cost 8.1 billion
to treat. Retrieved from:
http://www.rff.org/News/Press_Releases/Pages/New-Study-ShowsSepsis-and-Pneumonia-Caused-by-Hospital-Acquired-Infections-Kill48,000-Patients;Cost-$81-Billion-to-Treat.aspx
Steen, C. (2009). Developments in the management of patients with
sepsis. Nursing Standard 23(48) p. 48-55.
Wheeler, A. P. & Bernard G. R. (1999). Treating patients with severe
sepsis. The New England Journal of Medicine 340(3) p. 1-20.
Wundrink, R. G. & Waterer, G. W. (2003). Genetics of sepsis and pneumonia.
Current Opinion in Critical Care 9(5) p. 384-389.
Yi, Y., Ling, L., Bo. Z., Mao-qin, L., Bin, W., Zheng, Y., Qin, G., Hua, S. & Haibo, Q. (2007). Relationship between adrenal function and prognosis in
patients with sever sepsis. Chinese Medical Journal 120(18), p. 15781582.