Question 1

Epidemiology-Severe Sepsis:

Accepted Answer

-Leading cause of death in non-coronary intensive care units -Septicemia rated as the 10th leading cause of death in the United States by the CDC -Mortality rate approaches 50% -Incidence in United States has risen each year since 1979 -Trend expected to continue because of increased elderly and immunocompromised patients

Question 2

Recognition

Accepted Answer

-Extremely important to recognize the connection between infection, sepsis, and secondary organ failure -Signs and symptoms can be subtle -Pt often die in the ICU but sepsis usually begins in the home or on the Med-surg unit

Question 3

Inflammation vs. Infection: Inflammation

Accepted Answer

-Complex reaction to death or injury of cells or tissues -Defense mechanism initiated to control and/or eliminate the offending agent and prepare an environment conducive to healing and repair -Initiated by any type of injury -Microbial -Mechanical -Thermal

Question 4

Infection

Accepted Answer

-Follows the invasion of cells and/or tissues by living organisms -Bacteria -Viruses -Fungi

Question 5

Progression

Accepted Answer

-Systemic Inflammatory Response Syndrome (SIRS) -Sepsis -Severe Sepsis -Septic Shock -Multiple Organ Dysfunction Syndrome (MODS)

Question 6

Systemic Inflammatory Response Syndrome (SIRS)

Accepted Answer

-SIRS is a widespread inflammatory response to a variety of severe clinical injuries -Clinically indicated by the presence of 2 or more of the following: -Temperature >38 C (100.4 F) or  90 -Respiratory rate > 20/min or PaCO2  12,000 or  10% immature (bands) forms

Question 7

Sepsis

Accepted Answer

_In sepsis, the clinical signs of SIRS are present together with definitive evidence of infection

Question 8

Severe Sepsis

Accepted Answer

-Sepsis is considered severe when it is associated with organ dysfunction, hypotension, or hypoperfusion.

Question 9

The manifestations of hypoperfusion include, but are not limited to:

Accepted Answer

-Lactic acidosis -Oliguria -Acute alteration in mental status

Question 10

Septic Shock

Accepted Answer

-Septic shock is sepsis with hypotension despite adequate fluid replacement combined with perfusion abnormalities that may include but are not limited to: -Lactic acidosis -Oliguria -Acute alteration in mental status

Question 11

Septic Shock (cont.)

Accepted Answer

-Patients who require vasopressor or inotropic support despite adequate fluid replacement are in septic shock

Question 12

Multiple Organ Dysfunction Syndrome (MODS)

Accepted Answer

MODS: Refers to the presence of altered organ function in an acutely ill patient that homeostasis cannot be maintained without intervention

Question 13

Multiple Organ Dysfunction Syndrome (MODS)

Accepted Answer

-Hypotension: a systolic BP of < 90mm Hg or a reduction of 40 mm Hg from baseline in absence of other causes for hypotension

Question 14

Multiple Organ Dysfunction Syndrome (MODS)-Risk Factors

Accepted Answer

-Extremes of age ( 65 years) -Malnutrition -Hypothermia -Use of central venous catheters -Endotrachial intubation/mechanical ventilation -Aspiration

Question 15

Multiple Organ Dysfunction Syndrome (MODS)-Risk Factors-Chronic illness

Accepted Answer

-Diabetes -Renal failure -Hepatic failure

Question 16

Multiple Organ Dysfunction Syndrome (MODS)-Immunodeficiency

Accepted Answer

-Aids -Alcoholism -Use of chemotherapeutic agents

Question 17

Multiple Organ Dysfunction Syndrome (MODS)-Risk Factors

Accepted Answer

-Use of surgery or invasive procedures

Question 18

Multiple Organ Dysfunction Syndrome (MODS)-Lab Assessment

Accepted Answer

-Microbiology -Cultures: urine, blood, sputum, any wounds

Question 19

Multiple Organ Dysfunction Syndrome (MODS)-Lab Assessment

Accepted Answer

-CBC- -WBC-\"left shift\" -Platelet ct

Question 20

Multiple Organ Dysfunction Syndrome (MODS)-Lab Assessment

Accepted Answer

-Lactate level

Question 21

Multiple Organ Dysfunction Syndrome (MODS)-Lab Assessment

Accepted Answer

-Coagulation profile -PT -PTT

Question 22

Multiple Organ Dysfunction Syndrome (MODS)-Lab Assessment

Accepted Answer

-D-Dimer -Activated protein C -Specific cytokines

Question 23

Multiple Organ Dysfunction Syndrome (MODS)-Pathophysiology

Accepted Answer

-Sepsis results from a variety of responses to an infectious process, including: -Activation of inflammation -Activation of coagulation -Impairment of fibrinolysis

Question 24

Multiple Organ Dysfunction Syndrome (MODS)-Pathophysiology (Normal)

Accepted Answer

-Antigen (invader) of any type (bacteria, virus, parasite) enters the blood stream -Immune system recognizes the invader -Circulating monocytes release a series of mediators called cytokines -Cytokines isolate the invaders by clotting -Cytokines kill the invader by attracting neutrophils and other components of the immune system -When the invader is destroyed, the mediators signal to each other so that no more are released and the body returns to normal

Question 25

Multiple Organ Dysfunction Syndrome (MODS)-Pathophysiology

Accepted Answer

-In sepsis, the immune system overreacts to the invader

Question 26

Multiple Organ Dysfunction Syndrome (MODS)-Pathophysiology

Accepted Answer

-Reasons are not fully understood: -Large numbers of invaders -Presence of super invaders -Invaders\' resistance to neutrophils -Invaders\' resistance to antibiotics

Question 27

Multiple Organ Dysfunction Syndrome (MODS)-Pathophysiology

Accepted Answer

-In sepsis, the immune system initiates clotting in many places -The body starts attacking normal tissue -Excessive clotting and cellular dysfunction interfere with blood flow and diminish cellular oxygenation -Cells start to shut down (cell stunning) and die  -Then organs start to fail -The patient dies if process not stopped in time

Question 28

Multiple Organ Dysfunction Syndrome (MODS)-Patho-Role of Endothelium

Accepted Answer

-Single layer of cells lining the blood vessels

Question 29

Multiple Organ Dysfunction Syndrome (MODS)-Patho-Role of Endothelium

Accepted Answer

-Normally resists clot formation because : -Endothelial protein C receptors -Local generation and secretion of antithrombotic substances -Also secretes vasodilating substances including nitric oxide

Question 30

Multiple Organ Dysfunction Syndrome (MODS)-Patho-Role of Endothelium

Accepted Answer

-When endothelium injured: -Produces substances that encourage localized clotting -Clots form in the microvasculature further damaging the endothelium

Question 31

Multiple Organ Dysfunction Syndrome (MODS)-Patho-Role of Endothelium

Accepted Answer

-If endothelial damage is extensive: -Fluids can move into the interstitial spaces triggering edema and compounding hypovolemia -Increased secretion of nitric oxide impairs vasoregulation leading to abnormal endothelium dependent vascular relaxation -As sepsis progresses- causes severe vasodilation, refractory hypotension and impaired microcirculation- leading to MODS and death

Question 32

Multiple Organ Dysfunction Syndrome (MODS)-Signs and Symptoms

Accepted Answer

-Alteration in WBC count -Increased number of bands -Alteration in temperature -Chills -Decreased skin perfusion -Decreased urine output -Decreased number of platelets

Question 33

Multiple Organ Dysfunction Syndrome (MODS)-Signs and Symptoms (cont)

Accepted Answer

-Hypo- or hyperglycemia  -Petechiae or purpura -Poor capillary refill -Skin mottling -Tachypnea -Tachycardia -Unexplained change in mental status

Question 34

Markers of Organ Dysfunction-Cardiovascular

Accepted Answer

-Tachycardia -Dysrhythmias -Hypotension -Elevated central venous and pulmonary artery pressures -Decreased systemic vascular resistance -Need for vasopressor support

Question 35

Markers of Organ Dysfunction-Respiratory

Accepted Answer

-Tachypea -Dyspnea -Hypoxemia -Need for mechanical ventilation

Question 36

Markers of Organ Dysfunction-Metabolic

Accepted Answer

-Acidosis -Elevated lactate

Question 37

Markers of Organ Dysfunction-Neurologic

Accepted Answer

-Confusion -Disorientation -Psychosis

Question 38

Markers of Organ Dysfunction-Renal

Accepted Answer

-Oliguria (urine output < 0.5ml/kg/hr is an indicator of renal dysfunction) -Anuria -Elevated creatinine

Question 39

Markers of Organ Dysfunction-Endocrine

Accepted Answer

-Adrenal insufficiency -Hyper- or hypoglycemia

Question 40

Markers of Organ Dysfunction-Hepatic

Accepted Answer

-Jaundice -Elevated liver enzymes -Decreased albumin -Coagulopathy

Question 41

Markers of Organ Dysfunction-Hematologic

Accepted Answer

-Thrombocytopenia -Coagulopathy (septic emboli)(DIC) -Decreased protein C levels -Increased D-dimer levels -Septic emboli

Question 42

Disseminated Intravascular Coagulation (DIC)

Accepted Answer

-Essentially an imbalance between the processes of coagulation and anticoagulation

Question 43

Disseminated Intravascular Coagulation (DIC)

Accepted Answer

-May be directly or indirectly initiated by conditions that trigger one of 4 mechanisms: -Factor XII formation: sepsis, anoxia, burns -Activation of factor II and X: proteolytic enzymes in snake venom -Activation of factor VII: massive trauma -Tissue thromboplastin release: amniotic fluid release entering maternal circulation

Question 44

DIC- Pathophysiology

Accepted Answer

-Primary disease initiates the clotting process -Response is generalized and occurs throughout the vascular system -Creates a state of hypercoagulability -Fibrinolytic processes are then stimulated -Clotting factors become depleted and fibrinolysis continues -State of hypocoagulability develops

Question 45

DIC- Pathophysiology

Accepted Answer

-Most common sequela of DIC is hemorrhage -This is caused by: -Decreased platelets -Depletion of clotting factors II, V, VIII, and fibrinogen in the clotting process -Production of FDPs through fibrinolysis -FDPs act as anticoagulants and increase the hemorrhagic tendency

Question 46

DIC- Clinical Manifestations

Accepted Answer

-Signs/Symptoms: Bleeding -Mucous membranes and tissues -Petechiae and ecchymosis -Oral, GI, GU, & rectal bleeding -Bleeding after injections and venipunctures -Hypoxia, tachypnea, hemoptysis, hypotension, acidosis, and fever may also be present

Question 47

DIC- Diagnosis

Accepted Answer

-Bleeding time-prolonged -Platelet count- decreased -Prothrombin time (PT)-prolonged (elevated) -Partial thromboplastin time (PTT)- prolonged (elevated) -Fibrinogen level- decreased -Fibrinogen/fibrin degradation products (FDPs)- increased -D-Dimer- increased (positive) -Factor assay- decreased levels of factor I, II, V, VIII, X, & XIII

Question 48

DIC- Treatment

Accepted Answer

-Treatment of primary disease -Then goal is to control bleeding and restore normal levels of clotting factors -Blood products -Fresh frozen plasma (FFP) -Platelets -Cryoprecipitate -Fresh whole blood

Question 49

DIC- Treatment

Accepted Answer

-Heparin -Inhibits underlying thrombotic process -Also promotes rather than decreases bleeding -Use is controversial

Question 50

Sepsis \"Bundles\"

Accepted Answer

-Bundling system to encourage change in practice -Checklist for instituting guidelines in a user friendly manner -For sepsis, recommendations are divided into 6 hr and 24 hr with and without shock -Hospitals are using these for making their protocols

Question 51

Sepsis \"Bundles\"

Accepted Answer

-Surviving Sepsis Campaign- -Institute for Healthcare Improvement-100,00 Lives Campaign -Society of Critical Care Medicine, American College of Chest Physicians -http://www.survivingsepsis.org

Question 52

Procedures/Treatments for Sepsis

Accepted Answer

-Volume replacement -Antibiotics -Steroid therapy -Intensive insulin therapy -Protective lung ventilation

Question 53

Procedures/Treatments for Sepsis-Volume Replacement

Accepted Answer

-Fluid resuscitation -Venous dilation causes relative hypovolemia and hypotension -Endothelial damage also allows fluids to escape into the extravascular space, creating edema and contributing to hypotension

Question 54

Procedures/Treatments for Sepsis-Volume Replacement

Accepted Answer

-Fluid Type -Crystalloids - Normal saline -Colloids -Blood replacement- for hematocrit < 30, hemoglobin < 8

Question 55

Procedures/Treatments for Sepsis

Accepted Answer

-Vasopressors -If fluid resuscitation doesn\'t stabilize the patients\' BP, administer an IV vasopressor -Norepinephrine (Levophed) is preferred -Others: Dopamine, phenylephrine, epinephrine, vasopressin -May also need an inotrope (dobutamine) as an adjunct myocardium is depressed

Question 56

Procedures/Treatments for Sepsis

Accepted Answer

-Antimicrobial Therapy -Eliminating the source of infection  -AND -Initiating early, adequate antimicrobial therapy (after obtaining appropriate cultures) is critical

Question 57

Procedures/Treatments for Sepsis

Accepted Answer

-Tight Glycemic Control -Hyperglycemia and insulin resistance commonly develop in sepsis -Hyperglycemia -Has a procoagulant effect -Can interfere with the normal immune response -Impaired neutrophil function -Increased risk of infection -Impaired wound healing

Question 58

Procedures/Treatments for Sepsis

Accepted Answer

-Tight Glycemic Control -Keeping the blood glucose levels below 180mg/dl and preferably 80-110mg/dl by giving insulin (either sliding scale or insulin drip) has been shown to reduce morbidity and mortality

Question 59

Procedures/Treatments for Sepsis

Accepted Answer

-Corticosteroid Replacement -Low dose therapy can be helpful in patients with relative adrenal insufficiency -Hypotensive (need for vasopressors) -Low serum cortisol levels -High dose therapy is not effective -200mg to 300mg of hydrocortisone daily for 7 days as replacement therapy

Question 60

Procedures/Treatments for Sepsis

Accepted Answer

-Protective Lung Ventilation -For patients requiring mechanical ventilation -Avoid high plateau pressures (greater than 30cm H2O) in patients with acute lung injury or acute respiratory distress syndrome (ARDS) to prevent barotrauma -Use low tidal volumes (6ml/kg of ideal body weight) -Elevate HOB 30-45 degrees to reduce incidence of pneumonia and aspiration

Question 61

Procedures/Treatments for Sepsis

Accepted Answer

-Prevention of Sepsis -Use good handwashing techniques -Follow universal precautions -Enforce infection control measures -Institute measures to prevent nosocomial infections: -Oral care, proper positioning -Turning and skin care -Care of invasive catheters -Wound care

Question 62

Nursing Care of Patients with Sepsis

Accepted Answer

-Identify patients at risk -Assign high priority to cultures/pan-cultures (ie. Sputum, blood, urine, wound) for febrile episodes -Provide astute clinical assessments -Detection of Sepsis -Be aware of patients at risk for sepsis -Be Vigilant!

Question 63

Nursing Care of Patients with Sepsis

Accepted Answer

-Detection of Sepsis -Be aware of patients at risk for sepsis -Be Vigilant!

Question 64

Nursing Care of Patients with Sepsis

Accepted Answer

-Physical assessment and monitoring -General: -Fever/hypothermia -Tachycardia -Tachypnea -Hypotension

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