Advanced Acute Nursing -Sirs, Sepsis, Mods

Front 1

What is the definition of Infection?

Back 1

Microbial phenomenon characterized by an inflammatory response to the presence of microorganisms or the invasion of normally sterile host tissue by those organisms.

Front 2

What is the definition of SIRS?

Back 2

A systemic inflammatory response to an insult or injury with more then one manifestation.

Front 3

What are the manifestations of SIRS?

Back 3

1. Temperature >/= to 100.4F or </= to 96.8F
2. Heart Rate >/= to 90bpm
3. Tachypnea, as manifested by RR >/= 20 or hyperventilation indicated by a PaCO2 </= to 32mmHg
4.Alteration of WBC >/= 12,000 cells/mm3, </= to 4,000 mm3, or the presence of >10% immature neutrophils.

Front 4

What is the definition of Sepsis?

Back 4

SIRS resulting from infection (bacterial, viral, fungal, or parasitic)

Front 5

What is the definition of Severe Sepsis?

Back 5

Sepsis associated with signs of at least one acute organ dysfunction, hypoperfusion, or hypotension.

Front 6

What is the definition of Septic Shock?

Back 6

Sepsis induced hypotension persisting despite adequate fluid resuscitation.

Front 7

What is the definition of MODS?

Back 7

Multiple Organ Dysfunction Syndrome. Presence of altered organ function in two or more organs in an acutely ill patient such that homeostasis cannot be maintained without intervention.

Front 8

List some of the signs and symptoms of SIRS?

Back 8

-Chills
-Hypotension
-Decreased skin perfusion
-Decreased urine output
-Significant edema or positive fluid balance (>20 mg/kg over 24 hours)
-Decreased capillary refill
-Hyperglycemia (>120) in the absence of diabetes
-Unexpected change in mental status.

Front 9

What are the Neuro signs and symptoms that would suggest the onset of acute organ dysfunction?

Back 9

-Altered consciousness
-Confusion
-Psychosis

Front 10

What are the Liver sings and symptoms that would suggest the onset of acute organ dysfunction?

Back 10

-Jaundice
-Increased Enzymes
-Decreased Albumin
-Increased PT

Front 11

What are the Renal signs and symptoms that you would recognize as the onset of acute organ dysfunction?

Back 11

-Oliguria
-Anuria
-Increased Creatinine

Front 12

What are the Respiratory signs and symptoms that you would recognize as the onset of acute organ dysfunction?

Back 12

-Tachypnea
-PaCO2 < 70mmHg
-SaO2 < 90%
-PaCO2/FiO2 </= 300

Front 13

What are the Cardiac signs and symptoms that you would recognize as the onset of acute organ dysfunction?

Back 13

-Tachycardia
-Hypotension
-Altered CVP
-Altered PCWP

Front 14

What are the Hematology signs and symptoms that would suggest the onset of acute organ dysfunction?

Back 14

-Decreased Platelets
-Increased Pt/aPTT
-Decreased Protein C
-Increased D-dimer

Front 15

What is the medical and nursing management of SIRS?

Back 15

A. Initiate resuscitation for sepsis-induced hypoperfusion
B. Obtain appropriate diagnostics
C. Initiate antibiotic therapy (before diagnostic studies)
D. Control the source of infection.
E. Enhance perfusion
F. Consider the us of low-dose steroids
G. Consider the use of drotecogin alfa (recombinant human activated protein C {Xigris})
G. Administer blood products if hemoglobin is below 7
H. Initiate mechanical ventilation if needed.
I. Provide sedation and analgesia
J. Tight glycemic control.
K. Keep the kidneys functioning
L. Initiate preventive measures
M. Communicate with the patient family

Front 16

What are the components of: A. Initiate the resuscitation for sepsis-induced hypoperfusion?

Back 16

-Fluid resuscitation (using NS or LR) to a CVP of 8-12
-Transfusion of PRBCs to achieve a hematocrit of >/= 30%
-Administration of inotropic infusion (such as dobutamine which may or may not be effective)

Front 17

What are the components of: B. Obtain appropriate diagnostics?

Back 17

1) Before starting antibiotic therapy obtain at least 2 blood cultures (one percutaneous and one vascular)
2. Obtain cultures form other sites: urine, wounds, and respiratory secretions (then antibiotics)
3. Diagnostic Studies: Ultrasound, CT, MRI, ECHO

Front 18

What are the components of C.Initiate antibiotic therapy?

Back 18

Empirical Antibiotics

Front 19

What are the components of D. Control the source of infection?

Back 19

-Removal of potentially infected devise
-Drainage of abscesses
-Debridment of infected necrotic tissue

Front 20

In what percent of patients is the infection source NOT identified?

Back 20

20-30%

Front 21

What are the components of E. Enhance perfusion?

Back 21

-Fluid therapy (NS or LR)
-Vasopressors (Norepinephrine/ Levophed)
-Inotropic therapy (Dopamine)

Front 22

What are the components of F. Consider the use of low dose steroids/when should they be given?

Back 22

-They should ONLY be given to ADULT septic shock patients AFTER it has been confirmed that their BP is poorly responsive to fluid resuscitation and vasopressor therapy.
-Administer 100mg hydrocortisone in 100 ml NS continuous IV infusion at a rate of 10-12 ml/hr.

Front 23

What are the components of G. Consider the use of drotecogin alfa (recombinant human activated protein C {Xigris}) for patients with SEVERE sepsis?

Back 23

-Inhibits thrombin generation preventing further clot formation
-This decreased the inflammatory response
-Decreases invading neutrophils
-Reduces inflammatory damage to the endothelium

Front 24

What are the side effects/considerations of drotecogin alfa (recombinant human activated protein C {Xigrix})?

Back 24

-Risk of bleeding (3.5% with Xigirs vs. 2% with Placebo)
-Costly (6800 for 96 hour infusion)
-Efficacy (depending of severity of sepsis absolute reduction in mortality ranges in 6%-29%

Front 25

When would you administer blood products?

Back 25

When the hemoglobin is below 7

Front 26

What is the target hemoglobin level?

Back 26

7-9

Front 27

What are the components of H. Initiate mechanical ventilation if needed?

Back 27

-Lung protective ventilation (ARDS/ALI)
-Absolute risk reduction of decreased mortality of 9%
-elevate HOB

Front 28

What are the components of J. Tight glycemic control?

Back 28

-Maintain blood glucose at 80-100mg/dl and mortality rates are significantly reduced by 3.4%
-Blood glucose levels at 110-150 are associated with worse outcomes.

Front 29

How do you K. Keep the kidneys functioning?

Back 29

Initiate continuous renal replacement therapy

Front 30

What do you do to L. Initiate preventive measures?

Back 30

-Give SubQ heparin
-Use Flowtron/compression stockings
-Use histamine-2 receptores blockers to prevent stress ulcers (tagament, pepcid, zantac)
-Continuous lateral rotation therapy
-Good oral care

Front 31

What should you M. communicate with the patient and family?

Back 31

Discussion regarding end-of-life

Front 32

What is the predicted mortality within 1 year of surviving severe sepsis?

Back 32

26%

Front 33

What is the patho that leads to MODS

Back 33

1) Bacteria invade the body
2) Bacteria is recognized by WBCs (monocytes and neurtophils)
3) Monocytes release substances responsible for inflammation (cytokins and prostialgandins) to fight the infection.
4) Tissue factor initiates the clotting cascade causing thrombin to convert fibrinogen to fibrin leading to the development of a fibrin clot
5) Blood clots form as the body attempts to seal bacteria into specific areas so that the bacteria can be targeted and destroyed more effectively
6) Since the bacteria are found throughout the body clots begin to form in all the tiny blood vessels leading to impaired blood circulation
7) Normal mechanisms to break down clots are impaired (lack of protein C) so clots that form remain in the vessels
8) All these clots lead to the activation of the inflammatory cascade that damages the endothelial lining of the blood vessels and cell membranes
9) Fluid leaks from the vascular space into the interstitial spaces
10) Leads to reduced circulation fluid volume
11) Blood pressure drops
12) Which causes decreased tissue perfusion
13) Which leads to MODS