SEPSIS.pptx

sepsis

1. L.D.Wickramanayaka (RN) WD 06 SJGH

2. What is sepsis ? Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. Sepsis is the body’s extreme response to an infection. It is a life-threatening medical emergency . Sepsis happens when an infection you already have triggers a chain reaction throughout your body . Most cases of sepsis start before a patient goes to the hospital. Without timely treatment, sepsis can rapidly lead to tissue damage, organ failure, and death .

3. Epidemiology A recent scientific publication estimated that in 2017 there were 48.9 million cases and 11 million sepsis-related deaths worldwide, which accounted for almost 20% of all global deaths. In 2017, almost half of all global sepsis cases occurred among children , with an estimated 20 million cases and 2.9 million global deaths in children under 5 years of age. approximately 85% of sepsis cases and sepsis-related deaths worldwide occurred in low- and middle-income countries. Health care-associated infections are one of the most frequent types of adverse event to occur during care delivery and affect hundreds of millions of patients worldwide every year.

4. Pathophysiology INFECTION : Sepsis begins with an infection caused by pathogens. this can be systemic or localized. IMMUNE RESPONSE : The immune system detects the infection and initiates an inflammatory response to fight the invading pathogens. INFLAMMATORY CASCADE : The immune response triggers a cascade of inflammatory events, including the release of cytokines.

5. Pathophysiology VASODILATION : Inflammatory cytokines cause blood vessels to dilate. INCREASED CAPILLARY PERMEABILITY : The inflammatory response can cause capillaries to become leaky, TISSUE EDEMA : The leaky capillaries result in tissue edema.

6. Pathophysiology MICROCIRCULATORY DYSFUNCTION : In severe cases, the inflammatory response can lead to dysfunction in the circulation, impairing the flow of blood and oxygen to vital organs. METABOLIC SHIFT : As tissues become hypoxic (lack oxygen), they switch to anaerobic metabolism, producing lactic acid. SYSTEMIC EFFECTS : The systemic inflammatory response can have widespread effects on organs and systems throughout the body. This can result in multi-organ dysfunction.

7. Stages of the disease SEPSIS : When the immune response to infection becomes dysregulated and leads to widespread inflammation and organ dysfunction , it is referred to as sepsis. (organ dysfunction can be identified as acute change in total SOFA score> 2 points) SEPTIC SHOCK : Septic shock is the most severe stage, characterized by extremely low blood pressure (hypotension unresponsive to fluid replacement) and inadequate oxygen delivery to tissues . It is a medical emergency. Mortality rate often exceed 50%. Clinically defined as sepsis with persisting hypotension requiring vasopressors to maintain Mean Arterial pressure equal or more than 65mmHg and with serum lactate more than 2mmol/L

8. Common causes Bacterial infections cause most cases of sepsis. Sepsis can also be a result of other infections, including viral infections, such as COVID-19 or influenza, or fungal infections. diarrheal diseases (9.2 to 15 million annual cases) lower respiratory infections (1.8–2.8 million annually) non-communicable diseases are on the rise ; one-third of sepsis cases and nearly half of all sepsis-related deaths were due to an underlying injury or chronic disease. Maternal disorders (most common non-communicable disease complicated by sepsis)

9. Common causes Among children most common causes of sepsis-related deaths in children were neonatal disorders. lower respiratory infections diarrheal diseases Group B streptococcus is the leading cause of both neonatal and maternal sepsis. though E. coli is an emerging threat.

10. Causative Agents Gram-Positive Bacteria They currently account for nearly 50% of all sepsis cases , Ex:- Staphylococcus species, particularly Staphylococcus aureus, are frequently isolated. Notably, 14% of cultures identify methicillin-resistant S. aureus (MRSA). Gram-Negative Bacteria In the context of ICU infections, gram-negative bacteria cause 62% of cases . Ex- Pseudomonas species and Escherichia coli are prominent gram-negative pathogens linked to sepsis. Anaerobic Bacteria contribute to a smaller percentage of sepsis cases (around 4%). These bacteria are most frequently associated with intra-abdominal infections, representing 50%-70% of such cases. Ex:- Bacteroides fragilis, along with Peptostreptococcus and Clostridium species, are common anaerobic culprits. B. fragilis infections are linked to a 20% increase in mortality and a 16-day longer hospital stay. Fungi account for about 17% of sepsis cases. Candida albicans is the leading fungus responsible for 13% of fungal-related sepsis infections

11. Risk factors Anyone affected by an infection, severe injury, or serious non-communicable disease can progress to sepsis but vulnerable populations are at higher risk including: older persons (65yrs or older) pregnant or recently pregnant women, neonates, hospitalized patients, patients in intensive care units, people with weakened immune systems (e.g. HIV, cancer) people with chronic medical conditions (e.g. kidney disease, cirrhosis). People who survived sepsis.

12. Clinical signs and symptoms fever or low temperature and shivering Tachycardia (with low pulse volume) Tachypnea (shortness of breathing) Hypotension Confusion (altered mental status)

13. Clinical signs and symptoms clammy and sweaty skin with changed color. extreme body pain or discomfort. low urine output. Increased Lactate levels. Worsening organ functions. Suspected or confirmed infection.

14. Symptoms in children include fast breathing convulsions pale skin lethargy difficulty waking up feeling cold to the touch.

15. Diagnostic criteria Sepsis is diagnosed through clinical signs and symptoms with assessment findings . Consider all clinical information, including assessments and lab results. Lactate Levels: Elevated lactate (>2 mmol/L) signifies tissue hypoxia and potential sepsis. Serial lactate measurements are essential. Systemic inflammatory response syndrome (SIRS) is an exaggerated defense response of the body to a noxious stressor (infection, trauma, surgery, acute inflammation, ischemia or reperfusion or malignancy,) Earlier SIRS with a suspected source of infection is termed sepsis. Confirmation of infection with positive cultures is therefore not mandatory.

16. Diagnostic criteria Sequential Organ Failure Assessment (SOFA) SOFA score assesses organ dysfunction. An increase by 2 or more points indicates sepsis. qSOFA helps identify high-risk patients outside the ICU. Criteria: Altered mental status, elevated respiratory rate, low blood pressure.

17. SOFA (Sequential Organ Failure Assessment) It is a scoring system used by medical professionals to assess the severity of a patient's organ dysfunction or failure . The SOFA score evaluates the functioning of several vital organs, including the respiratory system , cardiovascular system , liver , coagulation system , central nervous system , and renal system . SOFA scores are typically calculated at regular intervals during a patient's hospital stay to track changes in organ function and guide clinical management. Patients with a high SOFA score often have significant organ dysfunction and may require intensive interventions. Such as mechanical ventilation for respiratory failure, vasopressor support for cardiovascular instability, dialysis for renal failure, and transfusions for coagulation abnormalities .

18. Modified Early Warning Score (MEWS) Early Warning System: MEWS ( Modified Early Warning Score ) is an early warning system used in healthcare to monitor and detect early signs of patient deterioration . Multiple Vital Signs: It assesses several vital signs like heart rate, respiratory rate, blood pressure, temperature, consciousness level, and oxygen saturation (if available) to create a comprehensive picture of a patient's health. Timely Intervention: MEWS helps healthcare providers identify patients at risk of worsening conditions, including sepsis, allowing for timely interventions and potentially improving patient outcomes

19. National Early Warning Score (NEWS)

20. Sepsis guideline (2021) suggestions For hospitals and health systems, we recommend using a performance improvement program for sepsis , including sepsis screening for acutely ill, high‑risk patients and standard operating procedures for treatment We recommend against using qSOFA compared to SIRS, NEWS, or MEWS as a single screening tool for sepsis or septic shock

21. Investigations Blood Cultures : Blood samples are collected from different sites to identify the specific bacteria, fungi, or other pathogens causing the infection. Full Blood Count (FBC) : This test provides information about the number and type of blood cells. Lactate Levels : Elevated lactate levels in the blood may indicate tissue hypoxia, which is common in sepsis.

22. Investigations Arterial Blood Gas (ABG) or Venous Blood Gas (VBG) : ABG or VBG analysis helps evaluate the patient's acid-base balance, oxygenation status, and respiratory function. Coagulation Profile : Assessing coagulation parameters can help detect abnormalities associated with sepsis-induced coagulopathy. Renal Function Tests : Serum creatinine and blood urea nitrogen (BUN) levels are monitored to assess kidney function. Acute kidney injury is common in sepsis, and these tests help determine its severity.

23. Investigations Liver Function Tests : Liver enzymes, such as alanine aminotransferase (ALT) and aspartate aminotransferase (AST), are assessed to evaluate liver function. Abnormalities may indicate sepsis-induced liver dysfunction. Electrolyte Levels : Measurement of electrolytes like sodium, potassium, and chloride helps identify any imbalances that may occur during sepsis. Chest X-ray or CT Scan : Imaging studies may be ordered to identify the source of infection, such as pneumonia, urinary tract infection, or an intra-abdominal abscess.

24. Investigations Urinalysis and Urine Culture : These tests can help diagnose urinary tract infections (UTIs), which are a common source of sepsis, and determine the causative pathogen. Cerebrospinal Fluid Analysis (if indicated): In cases of suspected central nervous system involvement, a lumbar puncture may be performed to analyze cerebrospinal fluid for signs of infection. Other Cultures : Depending on the clinical presentation, additional cultures such as sputum cultures, wound cultures, or other relevant specimens may be collected to identify the source of infection

25. Elevated Lactic Acid Levels In sepsis, the body's response to infection can lead to widespread inflammation and increased metabolic demands . As a result, oxygen delivery to tissues may become compromised due to factors such as low blood pressure (hypotension) and microvascular dysfunction. This can lead to tissue hypoxia (oxygen deprivation), which, in turn, causes cells to switch from aerobic metabolism (utilizing oxygen for energy) to anaerobic metabolism (producing energy without oxygen). During anaerobic metabolism , lactic acid accumulates in the tissues and is released into the bloodstream, leading to elevated blood lactate levels.

26. Arterial Blood Gas (ABG) changes During sepsis, both Arterial Blood Gas (ABG) and Venous Blood Gas (VBG) values can be affected. Arterial Blood Gas (ABG) Changes: the pH can become acidic due to the accumulation of lactic acid and other metabolic byproducts. This results in a decrease in pH (acidemia). PaO2 levels may decrease during sepsis. Hypoxemia can occur due to impaired lung function or altered oxygen utilization in the tissues. PaCO2 (Partial Pressure of Carbon Dioxide): PaCO2 may be normal or decreased initially but can increase later in sepsis , indicating impaired lung function and potential respiratory distress. In some cases, patients with sepsis may develop septic shock, leading to respiratory failure and increased PaCO2. HCO3- Bicarbonate levels may initially be normal or elevated as a compensatory response to metabolic acidosis. However, as sepsis progresses, bicarbonate levels may decrease due to the accumulation of lactic acid and the inability of the kidneys to fully compensate.

27. Management and treatments

28. Hour-1 bundle: initial resuscitation for sepsis and septic shock 1) Measure lactate level. * 2) Obtain blood cultures before administering antibiotics. 3) Administer broad-spectrum antibiotics . 4) Begin rapid administration of 30mL/kg crystalloid for hypotension or lactate ≥4 mmol/L. 5) Apply vasopressors if hypotensive during or after fluid resuscitation to maintain a mean arterial pressure ≥ 65 mm Hg. *Remeasure lactate if initial lactate elevated (> 2 mmol/L).

29. International Guideline (2021) suggestions 1). Sepsis and septic shock are medical emergencies, and we recommend that treatment and resuscitation begin immediately. 2). For adults with sepsis or septic shock who require ICU admission, we suggest admitting the patients to the ICU within 6 h. 3). For adults with sepsis or septic shock, we recommend prompt removal of intravascular access devices that are a possible source of sepsis or septic shock after other vascular access has been established.

30. International Guideline suggestions 4). For adults with sepsis or septic shock, we recommend initiating insulin therapy at a glucose level of ≥ 180 mg/dL (10 mmol/L) 5). Following initiation of an insulin therapy, a typical target blood glucose range is 144–180 mg/dL (8–10 mmol/L) 6) For adults with possible septic shock or a high likelihood for sepsis, we recommend administering antimicrobials immediately, ideally within 1 h of recognition

31. Fluid resuscitation 8).For patients with sepsis induced hypoperfusion or septic shock we suggest that at least 30 mL/kg of intravenous (IV) crystalloid fluid should be given within the first 3 h of resuscitation (according to clinical setting ) 9) For adults with sepsis or septic shock, we recommend using crystalloids as first‑line fluid for resuscitation 10) Fluid resuscitation should be given only if patients present with signs of hypoperfusion.

32. Vasopressor therapy 11).For adults with septic shock on vasopressors, we recommend an initial target mean arterial pressure (MAP) of 65 mmHg over higher MAP targets 12).For adults with septic shock, we recommend using norepinephrine as the first‑line agent over other vasopressors. 13).For adults with septic shock on norepinephrine with inadequate MAP levels, we suggest adding vasopressin instead of escalating the dose of norepinephrine

33. prevention

34. Nursing management

35. Nursing assessment Initial Evaluation: Begin with a thorough assessment upon admission or presentation. Vital Signs Monitoring: Continuously monitor temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation. Symptom Recognition: Be alert for early symptoms like fever, altered mental status, and malaise. Infection Source Identification: Determine the source of infection to guide diagnosis and treatment. Detailed History: Gather medical history, including recent infections, chronic illnesses, surgeries, and immunosuppression. Physical Examination: Assess skin color, lung sounds, abdominal tenderness, and localized infection signs.

36. Nursing assessment Assessment Tools: Use standardized criteria and scores for sepsis risk assessment. Laboratory and Diagnostic Tests: Order relevant tests, including blood counts, cultures, lactate levels, and imaging studies. Mental Status Assessment: Evaluate consciousness, orientation, and signs of confusion. Fluid Balance Assessment: Monitor intake and output for fluid balance. Skin Assessment: Check for infection and perfusion issues. Neurological Assessment: Examine for neurological deficits indicating organ dysfunction.

37. Nursing Diagnosis Risk for Infection Goal: Prevent Infection Interventions: Regularly assess for signs and symptoms of infections. Ensure hand hygiene compliance. Educate on infection prevention. Administer prophylactic antibiotics as medical order. Maintain sterile techniques while doing procedures.

38. Nursing Diagnosis: Risk for Complication related to Ongoing Sepsis or Infection Goal: Prevention of Complications Interventions: Continuously monitor vital signs and clinical status. Administer prescribed antibiotics promptly. Provide intravenous fluids as ordered to maintain hemodynamic stability. Assess and manage pain and discomfort. Monitor for signs of organ dysfunction or septic shock. Collaborate with the healthcare team to adjust treatment as needed.

39. Nursing Diagnosis: Impaired Gas Exchange Goal: Optimize Oxygenation Interventions: Administer oxygen as needed. Monitor respiratory status. Position for lung expansion. Teach deep breathing exercises. Administer respiratory medications. Manage mechanical ventilation.

40. Nursing Diagnosis: Decreased Cardiac Output Goal: To maintain the cardiac output Interventions: Administer IV fluids and blood products. Monitor NIBP or central venous pressure. Give vasopressors as ordered. Monitor ECG and cardiac status. Maintain a calm environment. Address underlying causes.

41. Nursing Diagnosis: Ineffective Tissue Perfusion Goal: Ensure Tissue Perfusion Interventions: Monitor perfusion parameters.(CRFT) Administer vasoactive medications. Assess skin condition.(turgor, discoloration) Monitor hydration. Educate on hydration.

42. Nursing Diagnosis: Risk for Impaired Skin Integrity. Goal: Prevent Skin Breakdown Interventions: Assess skin regularly. Reposition every 2 hours. Use pressure-relief devices. Keep skin clean and dry. Promote mobility. Address risk factors.

43. Nursing Diagnosis: Altered nutrition less than body requirement Goal: Improve the patient's nutritional status and support recovery. Interventions: Assess Patient: Comprehensive assessment: age, weight, medical history, sepsis factors. Consult Dietitian: Develop personalized nutrition plan with patient's input. Monitor Intake & Output: Track food, fluids, urine, and drainage. Nutrition Support: Enteral or parenteral if oral intake insufficient. Frequent Small Meals: Promote digestion and prevent overload. Assist Feeding: Ensure comfort and support as needed. Dysphagia Check: Assess for swallowing difficulties and take precautions. Patient Education: Stress nutrition's role in recovery and guide adherence.

44. Questions and discussion

45. References https://www.uspharmacist.com/article/empiric-antimicrobial-management-of-sepsis (Pharmacological management of sepsis) SSC Adult Patients | SCCM (surviving sepsis campaign) What is Sepsis? | Sepsis | CDC (CDC) Sepsis (who.int) (WHO- SEPSIS) The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) | Critical Care Medicine | JAMA | JAMA Network (sepsis definition) Executive Summary: Surviving Sepsis Campaign: International... : Critical Care Medicine (lww.com) (recommendations)

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