Sepsis
Sepsis
Sepsis
sepsis
Sepsis is the number one Today is the fourth admission in a month
cause of death in the ICU, the for Mr. Hammill, 70, who has a recent med-
2.5 ical history of coronary artery bypass graft
surgery and atrial fibrillation and also a
ANCC 10th leading cause of death
history of coronary artery disease, chronic
CONTACT HOURS
worldwide, and the 11th leading
cause of death in the United obstructive pulmonary disease, diabetes,
gastroesophageal reflux disease, anemia,
and anxiety. Well known to you as an inter-
States. Older patients with
chronic illnesses are at high active and communicative man, you find
risk for developing this condi- that during this admission he’s irritable and
less talkative. You also note that he has gen-
eralized edema, coarse rhonchi in the ante-
tion. We discuss what you need
to know about sepsis and your rior lobes, and crackles in the bases of both
role in caring for a patient who lungs, and he’s coughing up tan-colored
sputum. This morning, he’s confused upon
awakening, and throughout the course of
has it.
the day you need to reorient him to his sur-
roundings.
By Margaret J. McCormick, RN, MS
Coagulation cascade
Activated
protein C Plasminogen
activator
inhibitor-1
Factor VIIIa
Inactivation
Inactivation
Prevents
Proinflammatory activation
Factor Va
cytokines:
Inactivation
Interleukin-6
Interleukin-1
Thrombin Thrombin-activatable
fibrinolysis inhibitor
Tumor necrosis
factor-alpha
Fibrin
Neutrophil Fibrin clot
and dysfunction.
• partial pressure of carbon dioxide level of less than 32 mm Hg
• WBC count greater than 12,000 cells/mm3, less than 4,000 cells/mm3,
or greater than 10% immature WBC (bands)
Pinning down the culprit
Sepsis can occur in people of all ages, but it’s
• hyperglycemia and abnormal clotting and bleeding.
• pneumonia
SIRS: a syndrome resulting from a severe clinical insult that initiates an
• diarrhea or distension
MODS: the presence of altered function of one or more organs in an
• meningitis
acutely ill patient requiring intervention and support of the organs to
• cellulitis
achieve physiologic functioning required for homeostasis.
mm Hg
• Oliguria
trophils or bands.
• Jaundice
septic shock.
cardia are seen during the first 12 to 24
Complication station hours, followed by a dramatic increase in
Complications associated with sepsis in- the work of breathing. The three phases of
clude acute respiratory distress syndrome ARDS are the acute exudative phase, which
(ARDS), acute renal failure, GI complica- is characterized by profound hypoxemia and
tions, DIC, and multiple organ dysfunction associated with inflammation and diffuse
syndrome (MODS). Let’s take a closer look. alveolar damage; the fibroproliferative
ARDS is defined as the abrupt onset of phase, which is associated with decreased
respiratory distress accompanied by three compliance and increased dead space; and
components: severe hypoxemia, bilateral the resolution phase, which may take 6 to 12
pulmonary infiltrates seen on X-ray, and the months or longer to resolve.
absence of heart failure or fluid overload. Acute renal failure may develop as a
Hypoxemia may be present before the onset result of endotoxins, which are powerful
of other clinical signs. Tachypnea and tachy- vasoconstrictors that can cause intravascular
Colloids
Albumin 5% Used for volume expansion May exacerbate renal insufficiency
Antibiotics
Cefotamine Used for Gram-negative coverage against Adjust dose in severe renal failure
Escherichia coli and Proteus, Klebsiella,
and Pseudomonas species
Ceftriaxone Used because of increased prevalence of Adjust in renal impairment; use caution if the patient
penicillinase-producing microorganisms is allergic to penicillin
Cefuroxime Used for Gram-positive coverage against Monitor renal function; administer a half dose if
E. coli, Klebsiella peneumoniae, Proteus creatinine clearance is 10 to 30 mL/minute
mirabilis, and Haemophilus influenzae
Ticarcillin Used as an antipseudomonal penicillin Monitor renal function and adjust dosage in patients
and beta-lactamase inhibitor with severe colitis
Clindamycin Used against anaerobes (may have some Monitor PT, digoxin, and theophylline levels
activity against streptococcus and
methicillin-sensitive S. aureus)
Metronidazole or Used against Gram-positive and aerobic Metronidazole can potentiate warfarin; ciprofloxacin
ciprofloxacin Gram-negative organisms in GI infections and may increase digoxin and theophylline levels
infectious diarrhea
Vasopressors
Dopamine Used to treat hypotension in fluid Hemodynamic effects are dose related; monitor
resuscitated patients; stimulates adrenergic urine output, cardiac output, pulmonary wedge pres-
and dopaminergic receptors sure, and BP.
Norepinephrine Used to treat hypotension following fluid Use in caution in patients with occlusive vascular
volume replacement; stimulates beta1- disease; correct blood volume depletion before
adrenergic and alpha-adrenergic receptors administration; extravasation may result in severe
and increases cardiac contractility tissue necrosis
Vasopressin Increases vasomotor tone in patients with Dosage is one-tenth of what’s used to treat an upper
septic shock; also increases water reabsorption GI bleed from esophageal varices; monitor BP and
at the distal renal epithelium and promotes urine output
smooth muscle contraction throughout the
vascular bed of the renal tubular epithelium
he becomes acutely hypotensive. He’s resus- Porth CM. Pathophysiology: Concepts of Altered Health
States. 7th ed. Philadelphia, PA: Lippincott Williams &
citated and placed on mechanical ventila- Wilkins; 2006:387-401.
On the Web
These online resources may be helpful to your patients and their families: The more
• eMedicine Health: Sepsis (blood infection): http://www.emedicinehealth.com/sepsis_blood_
infection/article_em.htm
CE, the
• Mayo Clinic: Sepsis: http://www.mayoclinic.com/health/sepsis/DS01004 merrier!
• Medline Plus: Sepsis: http://www.nlm.nih.gov/medlineplus/sepsis.html
• Sepsis.com: http://sepsis.com/index.jsp
• Surviving Sepsis Campaign: http://www.survivingsepsis.org.
INSTRUCTIONS
Recognizing the signposts for sepsis
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