Summary: Why do our ICU patients get sepsis? They are likely on antibiotic therapy, making our patients susceptible to resistant organsims. Plus, our patients are already sick and possibly immunocompromised. Just being in the hospital is a risk as patients deal with the threat of hospital acquired pneumonia, urosepsis from foley catheters and skin infection from wounds/skin tears and IV sites. The Three Stages of Sepsis 1. Uncomplicated- not requiring hospitalization e.g. viral infection 2. Severe- requires hospitalization and involves one or more organs (heart, lungs, kidneys, liver) 3. Septic shock- drop in blood pressure that does not improve with fluid administration, one or more organ involvement and has a 50% mortality rate Pathophysiology of Sepsis The infectious organism secretes an endotoxin that jump starts the inflammatory response and causes massive vasodilation. The patient's organs and tissues are not able to get the oxygen and nutrients they need so organs start to fail. What are the Signs and Symptoms in a Patient with Sepsis? Fever, increased respiratory rate, warm skin, tachycardia, weakness, elevated white blood cell count, positive cultures, and/or elevated serum lactate. The patient may or may not have all of these signs and symptoms. Treatment for a patient with Sepsis Fluid resuscitation with 0.9% Normal Saline (NS) or Lactated Ringers (LR). If unsuccessful at improving blood pressure, vasopressor therapy will be ordered. The first choice pressors in sepsis management are Levophed and Dopamine. Second line is Epinephrine. Our goal is to titrate to a MAP of 65. The MAP goal may need to be higher or lower depending on the patient- some patients tolerate a lower blood pressure and some patients need a higher pressure. Septic patients will also get antibiotic therapy. If the patient comes through the ER, the ER will draw cultures (before antibiotics are started!) and give a broad spectrum antibiotic within 3 hours. If the patient is admitted to the ICU, the ICU will draw cultures and hang antibiotics within 1 hour. Timing is important, sepsis is a life threatening diagnosis. The antibiotic regime will likely be managed by Infectious Disease. In 48-72 hours, they will review the results of the culture and adjust the antibiotics to best attack the organsim involved. The patient will likely be on antibiotics for 7-10 days. Septic patients may also get low dose steroids to help control the inflammatory response and they will also need tight glucose control. The goal for glucose range is 70-150. Other Thoughts CVP: Central venous pressure is an indicator of fluid status. Septic patients have a goal CVP of greater than or equal to 8. Arterial line: Continuous blood pressure monitoring is extremely helpful when you are titrating vasopressors. It also allows you to draw arterial lactate samples and blood gases. Central line: It is helpful for your patient to have a central line if they are receiving vasopressors and/or antibiotics as both of these are caustic to veins. Central lines are also beneficial because they allow for multiple medications to be administered at the same time through different ports. Reference: Surviving Sepsis Campaign www.survivingsepsis.org
