N201 Sepsis

• Infections seen in the surgical setting

  • Urinary tract
  • Pneumonia
  • Abdominal
  • Joint
  • Fistula
  • Bacteremia
  • Surgical wound
• Systemic inflammatory response syndrome (SIRS)

  An exaggerated stress response to a noxious stressor such as trauma, surgery, and infection
• SIRS criteria


  • HR greater than 90bpm
  • RR greater than 20rpm
  • Temperature greater or equal to 38 or less than 36
  • Altered mental state
  • WBC greater than 12.0 or less than 4.0 x 10/L
• Sepsis


  Life threatening organ dysfunction caused by a dysregulated host response to infection
• Sepsis manifestations


  • Skin: cold, clammy, cyanosis
  • CVS: tachycardia, HTN, edema
  • Renal: oliguria: increase BUN and CR
  • Neurological: confusion, disorientation, behavioural changes
  • Respiratory: tachypnea, dyspnea, hypoxemia, pulmonary edema
  • Gastrointestinal: ileus, N&V
• Nursing assessments for sepsis

  • VS Q1H-2H: watch for hypotension, tachycardia, tachypnea, hypoxia
  • Chest assessment Q1-2H
  • Neuro status
  • Peripheral perfusion
  • Urine output Q1H (100ml per hour could be ideal for a person with septic)
  • Blood work and microbiology results
• How we diagnose sepsis

  1. Step 1: nursing assessment

  2. Step 2: MD initiates "early sepsis investigation and treatment" orders

  3. MD to review diagnostic results and ongoing assessment data

  4. Calculate organ dysfunction using SOFA tool

  5. Step 4: if positive for infection and SOFA score of 2 or more -> diagnosis of sepsis confirmed
• Doctors' orders for nursing care


  • Frequent assessment and VS
  • Ensure cultures collected
  • Ensure B/W, especially lactate collected
  • Administer Abx (antibiotic) per orders (after cultures)
  • Oxygenation and RT referral PRN
  • Establish and maintain large-bore IV access
  • Fluid therapy – crystalloid then colloid
  • Ongoing communication with PCC and MRP
  • Call ICU outreach team if pt. status deteriorates
• Sepsis diagnostic bloodwork and micro

  • Blood glucose – elevates in response to stress
  • C-reactive protein – elevates due to overwhelming inflammation
  • Procalcitonin – sepsis biomarker of inflammation from bacterial infection
  • Lactate – elevates d/t anaerobic metabolism
  • Hypoxemia & Alkalosis – o2 decreases, co2 decreases
  • BUN would increase
  • Creatinine would increase
  • eGFR would decrease
• SOFA


  Can be used as a quick screening tool when time, resources, and available assessment data don't allow for a full SOFA calculation
• Sequential Organ Failure Assessment (SOFA)

  • Sepsis-relates
  • Organ
  • Failure
  • Assessment
• SOFA criteria


  • Alerted mental status
  • Fast respiratory rate
  • Low Blood Pressure
• If a client scores 2 or more on SOFA (criteria suggests a greater risk of poor outcome)
• Septic shock


  A subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with greater risk of morality than with sepsis alone
• Septic shock criteria


  • Need vasopressors to maintain MAP of 65mmhg
  • Lactate >2mmol/L in the absence of hypovolemia
• Mortality of septic shock is 40%
• Patient presentation when starting to go into septic shock

  • Altered mental status
  • Hypotension
  • Oliguria or anuria
• If treated well, patient will express better condition
• If not treated well, patient will go into septic shock and multiple organ dysfunction syndrome
• S&S to remember when caring for pts with confirmed infection or high risk of infection

  • Hypotension
  • Tachycardia
  • Tachypnea, hypoxia
  • Decreased LOC and/or restlessness/ confusion
  • Hypo or hyperthermia (warm and flushed early on and cool/clammy later)
• Infections almost always cause inflammation, but not all inflammation is caused by infections
• Not all infections progress to sepsis or septic shock
• If a patient is neutropenic, they may not respond to infection with inflammation
• Those who are immune compromised, elderly or have multiple co-morbidities are more prone to infection
• Most common bacteria causing infections

  • e-coli
  • streptococci
  • staphylococci
• Systemic Inflammatory Response Syndrome (SIRS)

  An exaggerated stress response to a noxious stressor such as trauma, surgery & infection
• SIRS Criteria


  • Heart rate greater than 90 bpm
  • Respiratory rate greater than 20 rpm
  • Temperature greater or equal to 38.0°C or less than 36.0°C
  • Altered mental state
  • WBC greater than 12.0 or less than 4.0 x 10 /L
• Sepsis


  When the exaggerated inflammatory response causes organ dysfunction
• Sepsis Pathophysiology


  1. Nursing Assessments

  2. Neurological

  3. Cardiovascular

  4. Respiratory

  5. Gastrointestinal

  6. Renal

  7. Skin
• Nursing Assessment Priorities


  • VS q1-2H to watch for hypotension, tachycardia, tachypnea, hypoxia
  • Chest assessment q1-2h to watch for subtle changes, pleural effusion and difficulty ventilating
  • Neuro status - increasingly drowsy? Confused? Restless?
  • Peripheral perfusion - cool, mottled lower limbs/knees is a sign of septic shock, perfuse edema
  • Urine output q1h via urometer to assess kidney function and fluid volume status
  • Bloodwork and microbiology results
• Septic Shock


  A subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone
• Septic Shock Criteria


  • Need Vasopressors to maintain a MAP of 65mmhg
  • Lactate > 2mmol/L in the absence of hypovolemia
• Mortality of septic shock is 40%
• From infection to Septic Shock

  1. Infection

  2. Inflammation

  3. SIRS

  4. Sepsis

  5. Septic Shock