Sepsis for Certified Emergency Nursing (CEN)

Sepsis

Definition/Etiology:

So, we know what sepsis is, right? It’s the presence or suspicion of infection with 2 or more of the SIRS criteria. Septic shock is the progression of sepsis to an emergency state. It is a sepsis-induced distributive shock with hypotension despite adequate fluid resuscitation. It is usually accompanied by lactic acidosis, oliguria, or an acute change in mental status.

Pathophysiology:

• Septic shock results when infectious microorganisms in the bloodstream induce a profound inflammatory response causing hemodynamic decompensation. The pathogenesis involves a complex response of cellular activation that triggers the release of a multitude of proinflammatory mediators. (Cascade of events)

• Let’s talk for a sec about distributive shock. What is happening? Blood fills the vessel and goes where it is supposed to without a problem. This is a vessel in distributive shock. Same amount of fluid present. See how it changes the flow? This is why we try to fill the vasculature with fluids initially. Can we just fill up the space? When that doesn’t work, we bring in the pressors to constrict those vessels and get the fluids where they need to be. (to the Organs)

• Don’t worry, there are a whole bunch of resources online if you want to get more into the patho of septic shock

Clinical Presentation:

The initial presentation is that of Sepsis:

• Fever >100.8F or <96.8F
• Tachycardia (>90 BPM)
• Tachypnea (>20)
• Altered mental status
• Lab values
• WBC >12000
• Serum Glucose >120 – non-diabetic

Severe sepsis –

• The above and:
  • SBP <90 or MAP <65
  • Cr >2.0 or urine output <0.5ml./kg x 2 hours
  • Platelets <100,000
  • Lactate >4.0

If the patient meets shock criteria and is hypotensive with SBP <90 which isn’t fixed with fluids, then ding ding ding…we win septic shock!

Collaborative Management:

Follow the sepsis protocol for your facility to start. It usually involves:

• Blood work including blood cultures x 2 and lactate levels
• O2
• VBG
• Fluid resuscitation
• Antibiotics (after cultures)
• If septic shock identified
• Consider RSI
• Central Line
• Pressors to maintain MAP >65

Try to treat underlying cause

Evaluation | Patient Monitoring | Education:

Is the patient improving? Monitor hemodynamic status. Don’t worry, if all goes according to plan (which of course it never does), these patients will be admitted to the ICU and be out of your department before you can truly see the results of your amazing intervention!

Linchpins: (Key Points)

• Going south – identify worsening progression
• Protocol! – Follow your sepsis guidelines
• Shocking – This is a form of shock, and we need to intervene as such