Sepsis Prevention

1. Sepsis Prevention MSN 621: Advanced Physiology and Pathophysiology Tutorial Project Presented By: Morgan Maves

2. Instructions • Clicking on the icon will restart the tutorial and bring you back to the table of contents. • The following navigation icons are available to jump forward or backward from the current slide: Clicking the icon will advance you one slide. Clicking the icon will send you back one slide.

3. Objectives… • Gain an understanding of the basics of infection and how they pertain to sepsis • Learn to identify the signs and symptoms of early and late sepsis • Value why sepsis identification and prevention is important for the health care world and us as nurses. • Understand what to do when you suspect sepsis and interventions to apply once sepsis is diagnosed.

4. Table of Contents Implications of Sepsis Basics of Infection Nursing Interventions & Guidelines What is Sepsis Stress Response Aging and Genetics Signs & Symptoms Case Studies

5. The basics of infection… • An infection is the “colonization of a host organism by a foreign species” where “the infecting organism seeks to utilize the host’s resources to multiply, usually at the expense of the host” (Modric, 2009). • The factors or chain of events that lead to an infection include several steps which include the infectious agent, reservoir, susceptible host, portal of entry, mode of transmission and portal of exit (Modric, 2009). Picture from ClipArt

6. Why even have an Inflammatory Response?... • The inflammatory process is self-contained by feedback mechanisms (Steen, 2009, p. 51). • This self containment leads to inherent checks and balances which permit the body to remain in homeostasis (Steen, 2009, p. 51). • Homeostasis is the body’s ability to maintain equilibrium within itself by adjusting internal factors (Steen, 2009, p. 51). • Because of the inflammatory process, individuals often maintain homeostasis continuously without the individual even being aware of it (Steen, 2009, p. 51).

7. So where does the problem arise? • Although inflammation in and of itself is necessary and is a beneficial defense mechanism for an individual, “when an individual starts to display symptoms of illness and physiological deterioration, the inflammatory process is no longer localized to the site of injury and is having a systemic effect. At this point, a person can be described as having sepsis or systemic inflammatory response syndrome (SIRS)” (Steen, 2009, p. 51). Picture from ClipArt

8. Stress Response… • The stress response is a collection of physiological changes that occur when the body’s demands outweigh its resources. • Through a variety of nerve and hormonal signals, the body’s adrenal gland releases a surge of hormones including adrenaline and cortisol. • Adrenaline: increases heart rate, elevates blood pressure and initially boosts energy supplies. • Cortisol: increases glucose in the bloodstream, enhances availability of substances to repair tissues, alters immune system response, curbs nonessential functions Information from Mayo Clinic, 2010

9. Question Time… 1. What hormones play a role in the stress response and its development into sepsis? Cortisol Adrenaline Estrogen Correct! It’s main function is to increase the amount of glucose in the bloodstream. Great Job! The release of this would account for the tachycardia associated with sepsis. Try again…This is a female hormone produced by the ovaries. 2. The inflammatory process is self contained by ___________. Feedback Mechansims Down Regulation Homeostasis Incorrect…This is the process by which cells decrease the quantity of a cellular component. Great Job! Negative and positive feedback loops help contain inflammation. Try again…This is the body’s ability to maintain equilibrium.

10. Stress Response & Sepsis… • Generally, plasma cortisol levels tend to be higher in septic patients and are associated with increased mortality. • Studies have shown that increased cortisol levels in septic patients are unable to control the inflammatory response. • The functionality of the hypothalamic-pituitary-adrenal (HPA) axis is the greatest determinant of the host’s response to stress. In the case of sepsis, the HPA axis is in over drive and presents with an increase in corticotropin and subsequently high plasma cortisol levels. These increased levels are known as relative adrenal insufficiency (RAI) and are responsible for the inability to control inflammation. • It is important to note that there is contradictory opinions in the area of cortisol levels and septic patients. In an article by Annetta, Maviglia, Proietti & Antonelli, it is reported that cortisol levels may be high or low, but are, nonetheless, insufficient to meet the body’s metabolic needs. Above information from: Yi, Y., Ling, L., Bo. Z., Mao-qin, L., Bin, W., Zheng, Y., Qin, G., Hua, S., Hai-bo, Q. (2007).

11. What is sepsis? • In the most basic sense, sepsis, or septicemia, refers to the presence of microbial toxins in the blood (Porth & Matfin, 2009, p.335). • Sepsis refers to a systemic inflammatory response that arises from an infective process; This infection may be caused by bacterial, viral or fungal invasion that provokes an inflammatory response (Steen, 2009, p.49). • Because many of the signs and symptoms that are associated with sepsis can be caused by other diseases and diagnoses than sepsis itself, there are no formal diagnostic criteria for sepsis.

12. Review… • Sepsis refers to the presence of antigens in the tissue. TRUE or FALSE? • 2) The chain of events associated with infection include infectious agent, reservoir, susceptible host, portal of entry, mode of transmission and portal of exit. TRUE or FALSE?

13. What is sepsis? • Sepsis can also be defined as, “the combination of pathologic infections and physiological changes known collectively as the systemic inflammatory response syndrome” (Martin, Mannino, Eaton & Moss, 2003, p. 2). • The inflammation arises as a result of either tissue ischemia or tissue damage” which may result from a variety of circumstances (Steen, 2009, p. 49). Picture from ClipArt

14. What is the systemic response to infection? • The initiation of the Systemic Inflammatory Response Syndrome (SIRS) is what causes the clinical signs and symptoms of sepsis. This response is produced by the body’s production of antibodies in such cases as burns, severe trauma, surgery or myocardial infarctions to name a few. • Although SIRS and sepsis are closely related, unlike sepsis, SIRS is not always activated in response to an infection.

15. Breaking it all down… • Sepsis is closely linked to SIRS. SIRS is an inflammatory response that affects the whole body. It is frequently seen in response to infection and is closely related to sepsis (Modric, 2009). • Sepsis and SIRS characteristics are similar in most instances and may include, but are not limited to: • body temperature less than 36 degrees C or greater than 38 degrees C • heart rate greater than 90 beats per minute • tachypnea (high respiratory rate) • white blood cell count less than 4000 cells/mm3 or greater than 12,000 cells/mm3 Keep clicking for more information!  Picture from ClipArt

16. Basic Equation of Sepsis… Body’s Response (Inflammation) Disease (Sepsis/systemic inflammatory response syndrome/signs and symtpoms of infection) Mechanism of Injury (Infection of tissue) + = Information taken from Steen, C. (2009).

17. Review… 1) Sepsis occurs due to an infective process caused by: A) Bacteria Try again… B)Fungal Try again… C) Viral Correct Try again… D) All of the above 2) SIRS is a result of the body’s production of _________. Antigens Antibodies Hormones Picture from ClipArt Nope…This stimulates the production of antibodies. Incorrect…These are the body’s chemical messengers. Correct!!!

18. Early Signs & Symptoms • Fever • Increased heart rate • Tachypnea • Alteration in white blood cell count (Bone, Balk, Cerra, Dellinger, Fein, Knaus, Schein & Sibbald, 2010, p.1646) Keep clicking for more information! 

19. Severe or later signs & symptoms • Organ dysfunction • Hypoperfusion • Hypotension • Lactic acidosis • Oliguria • Acute alteration of mental status (Bone,et.al., 2010, p.1646) Picture from ClipArt Keep clicking for more information! 

20. Factors we can’t change…Age and Genetics • In the U.S., elderly patients (> or = to 65 years of age) accounted for 12% of the total population and 64.9% of sepsis cases. • Elderly patients were also more likely to have Gram-negative infections, especially in association with pneumonia and to also have co-morbid medical conditions. • With increased age, there was an linearly increase in rates of case-fatality. • “Elderly sepsis patients died earlier during hospitalization and elderly survivors were more likely to be discharged to a non-acute health care facility.” • The incidence of sepsis is disproportionately increased in elderly adults and age is an independent predictor of mortality. (Information from Martin, Mannino & Moss, 2006, pgs.15-21) Keep clicking for more information! 

21. Age Continued… • Incidence of sepsis “increased > 100 fold with age (0.2/1,000 in children to 26.2/1,000 in those greater than 85 years old).” • Mortality related to sepsis also shows a correlation with age with an increase from 10% in children to 38.4% in those >85 years old. • The number of cases of sepsis is projected to continue to rise substantially due to the aging U.S. population. (Information from: Angus, D.C., Linde-Zwirlbe, W. T., Lidicker, J., Clermont, G., Carcillo, J. & Pinksky, M. R., 2001). Keep clicking for more information! 

22. Aging Images from ClipArt Increased Risk of Sepsis

23. Quick Review… • Early signs and symptoms of sepsis are? Click on all that apply… Altered Mental Stauts Fever Increased Heart Rate Try Again Correct!! Correct!! Dizziness Tachypnea Change in WBC count Try Again Try Again Correct!!

24. Genetics… • Infection is the basic building block which leads to sepsis. “Genetic polymorphisms in the immune response to infection have been shown to be associated with clinical outcomes.” • Studies which involve genetic polymorphisms in essential genes have provided important insights into the pathways and logistics involved in the pathogenesis of sepsis-induced organ dysfunction. (Information from: Arcaroli, J., Fessler, M. B. & Abraham, E., 2005) Picture from ClipArt Keep clicking for more information! 

25. Genetics… • Genotyping will provide “valuable information on the interaction of multiple allelic variants and clinical outcome.” • With the ability to differentiate which genes/alleles are more susceptible to infection and subsequently, sepsis, physicians will be better able to target those exact points of infection and ultimately lead to prevention and/or earlier clinical treatment of sepsis. (Information from: Arcaroli, J., Fessler, M. B. & Abraham, E., 2005) Keep clicking for more information! 

26. Genetics… • The study completed by Wunderink and Waterer was explicit in the fact that there is a genetic component to the risk of developing sepsis which subsequently, results in additional complications. • Confirmation of the findings [in their study] and associations with other genetic polymorphisms await large-scale population studies and further validation of the physiologic significance of the variant alleles to prove their validity and generativity. Picture from ClipArt

27. Pop Quiz • Due to their immature immune systems, newborns and infants are at greater risk for developing sepsis than the geriatric population. 2) With the ability to differentiate which genes/alleles are more susceptible to infection and subsequently, sepsis, physicians will be better able to target those exact points of infection and ultimately lead to prevention and/or earlier clinical treatment of sepsis. TRUE or FALSE TRUE or FALSE = Correct = Incorrect Picture from ClipArt

28. So, what’s the big deal?... Picture from ClipArt • One study found that individuals who developed sepsis post-operatively stayed in the hospital 11 days longer and cost $33,000 more than those who did not develop it (Sequeira, M. & Campbell, K., 2010). • Sepsis is the “second leading cause of death among patients in noncoronary intensive care units (ICUs) and the 10th leading cause of death overall in the United States” (Martin, et. al., 2003, p. 2). Keep clicking for more information! 

29. Why do we care? • The incidence of sepsis has steadily increased over time and is expected to continue to rise “as a result of an increasing ageing population, underactive immune systems arising from chemotherapy, organ transplantation, complex co-morbidities such as heart disease and diabetes, human immunodeficiency virus and drug-resistant invading organisms” (Steen, 2009, p. 48).

30. National Guideline Clearinghouse • The following guidelines are all from the National Guideline Clearinghouse and are interventions to be carried out by the Registered Nurse… • “A postoperative assessment should be carried out when the patient returns.” • “The first postoperative assessment should determine: intraoperative history and postoperative instructions, circulatory volume status, respiratory status and mental status.” • “Any patient with circulatory disturbance should be catheterised and the urine output measured hourly.” Keep clicking for more information!  Picture from ClipArt

31. National Guideline Clearinghouse Continued… • “Postoperative blood pressure should always be reviewed with reference to the preoperative and intraoperative assessments.” • “Further assessment is required for patients with: heart rate below 50bpm, heart rate above 100 bpm or blood pressure below 100 mm Hg systolic.” • “Oxygen saturation should be maintained above 92%.” Picture from ClipArt Keep clicking for more information! 

32. Question time… 1) The incidence of sepsis is predicted to continue to rise due to several risk factors including, but not limited to (select all that apply): A) Organ Transplantation B) Diabetes C) Drug-resistant Organisms D) Cancer 2) It’s important when assessing a post-operative patient to compare those findings to both their pre- and intra-operative assessments. TRUE or FALSE Correct!! Although there are guidelines to follow in regards to assessments, each person is an individual and must be compared against their baseline Try again…Although there are parameters a physician may indicate as being abnormal for any patient, individualized care must be utilized to determine a true change in condition.

33. National Guideline Clearinghouse Continued… • “Respiratory rate, pulse rate, and conscious level should be monitored routinely to identify postoperative respiratory complication.” • “The patient should be encouraged to sit up.” • “Hand washing/glove use.” National Guideline Clearinghouse, 2007, p.2-6. Keep clicking for more information!  Picture from ClipArt

34. Nursing Interventions… • Prevention through aseptic technique whenever indicated • Removal of invasive intravenous and urinary catheters that are no longer needed • Early mobilization/ambulation • Encouraging use of incentive spirometery • Maintaining adequate hydration and nutrition Picture from ClipArt Keep clicking for more information! 

35. The sepsis six treatment pathway… • The following treatment pathway is taken from the 2009 Surviving Sepsis Campaign and explained from Steen’s article: • Oxygen therapy • Fluid resuscitation • Measurement and monitoring of urine output • Blood cultures • Antibiotic therapy • Lactate, hemoglobin and routine blood monitoring Keep clicking for more information! 

36. Case Studies… Case studies are a wonderful way to look at potentially real life situations and examine how you would approach them. Let’s look at two of them and discuss what your actions would be. Picture from ClipArt

37. Case Study #1 • After getting report at the start of your shift you decide to see your patient in room 10 first. Mr. Johnson is a 77 y.o. male admitted for altered mental status from the nursing home in which he has lived for the past 6 years. The night nurse had no remarkable notes regarding Mr. Johnson in her report. Upon doing your initial set of vital signs, you find that Mr. Johnson’s blood pressure is 92/60 which is a significant decrease from his baseline of 130’s/80’s. He is unable to tell you his name, where he is or what the date is. Additionally, according to the documentation, Mr. Johnson has not voided since 0100 and it is currently 1000. What do you do?

38. Case Study #1 Points to Consider… • It is important to remember to do a complete assessment so that you are able to present as much clinically appropriate information to the doctor as possible. Consider the following questions: 1) What components of your assessment do you think the physician will want specific information on? 2) What orders do you anticipate to receive from the physician; both nursing and medical interventions?

39. Case Study #1 Follow-up Answers... 1) Components of your assessment that the physician will be most interested in: • Respiratory Rate, Pulse Rate, Oxygen Saturation and/or Blood Pressure: Should theses be greatly increased or decreased from the patient’s baseline it could be indicative of compensatory mechanisms within the body; early signs and symptoms of sepsis. • Conscious Level: If a person’s conscious level decreases from their baseline, this is a cause for concern. In the later stages of sepsis, blood flow to vital organs begins decreasing and could lead to altered levels of consciousness. This is a serious condition and should be addressed immediately. • Urine Output: Typically, physicians look for patients to have a minimum of 30cc urine/hour. If the rate falls below this, it may be an indication that the kidneys are not functioning properly and/or the body is compensating for a decrease in blood pressure, increased heart rate, ect. by retaining fluid.

40. Case Study #1 Follow-up Answers... 2) Depending on the physician and the specific patient situation, there are some orders that you may expect to receive in this situation. • Due to the fact that Mr. Johnson has not voided in several hours, the physician may ask you to bladder scan the patient and dependent upon the results, straight cath or insert a foley catheter. • With the decrease in urine output and drop in blood pressure, administering a IV fluid bolus would also be an expected order at this time. • Dependent on the patient’s respirations and oxygenation saturation, administering oxygen via a nasal cannula would also be appropriate to maintain his saturation level above 92%. • Frequent re-orientation will also be required to assess whether or not the interventions being applied are benefiting his level of consciousness.

41. Case Study #2 • You receive a 47 y.o. female s/p total abdominal hysterctomy. The day of and the day following surgery, the patient is unmotivated to ambulate. The patient begins spiking temperatures every night, complains of some SOB and both her heart rate and respirations have increased significantly from their pre-op baseline. 1) What could possibly be occurring with the patient? A) The patient had a heart attack overnight. B) The patient has an infection at the surgical site that is causing her to become septic. C) The patient has atelectasis in her lungs which is affecting her vital signs. 2) What nursing interventions would you implement to prevent any further complications? Encourage Ambulation Teach to Cough & Deep Breathe Fluid Bolus Chest X-ray

42. Case Study #2 Additional Review… • There are a number of explanations for the patient’s signs and symptoms. The patient’s unwillingness to ambulate could be resulting in atelectasis and subsequent fevers, increase in heart rate and respirations. These same signs and symptoms could be an indication of infection. Using your clinical assessment and judgment skills are critical in determining (along with the physician) what is occurring with this patient. Remember, early recognition of infection is the key to preventing sepsis. • Nursing interventions would include: continual education with patient regarding importance of ambulation, use of IS (Incentive spirometer), encourage PO (oral) intake and frequent vital sign assessment. • Most likely, the doctor will also give you some medical orders such as; ask you to encourage ambulation, IS and C&DB (cough and deep breathing), possible order for fluid bolus if intake is inadequate, strict I&O’s (intake and output) to measure urine output (possible foley placement if UO (urine output) is minimal) and/or blood cultures. Keep clicking for more information! 

43. References • Angus, D.C., Linde-Zwirlbe, W. T., Lidicker, J., Clermont, G., Carcillo, J. & Pinksky, M. R. (2001). Epidemiology of severe sepsis in the United States: Analysis of incidence, outcome, and associated costs of care. Critical Care Medicine 29(7) p. 1303-1310. • Annetta, M., Maviglia, R., Proietti, R. & Antonelli M. (2009). Use of corticosteroids in critically ill septic patients: A review of mechanisms of adrenal insufficiency in sepsis and treatment. Curr Drug Targets 10(9), p. 887-894. • Arcaroli, J., Fessler, M. B. & Abraham, E. (2005). Genetic polymorphisms and sepsis. Division of Pulmonary Sciences and Critical Care Medicine 24(4) p. 300-312. • Bone, R.C., Balk, R.A., Cerra, F.B., Dellinger, R.P., Fein, A.M., Knaus, W.A., Schein, R.M. & Sibbald, W. J. (2010). Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. CHEST 101(6), p. 1481-1483. • Levy, M. M., Fink, M. P. & Marshall, J. C. (2003). Sepsis syndromes. Retrieved from: http://emcrit.org/065-132/132-sepsis.htm. • Martin, G.S., Mannino, D. M., Eaton, S., & Moss, M. (2003). The epidemiology of sepsis in the United States from 1979 through 2000. The New England Journal of Medicine 348(16) p. 1- 20. • Martin, G. S., Mannino, D. M. & Moss, M. (2006). The effect of age on the development and outcome of adult sepsis. Critical Care Medicine 34(1) p. 15-21. • Mayo Clinic (2010). Stress: Win control over the stress in your life. Retrieved from: http://www.mayoclinic.com/health/stress/sr00001. • Modric, J. (2009). Infection-Definition, causes, transmission, symptoms and signs. Retrieved from http://www.healthhype.com/infection-definition-causes-transmission-symptoms-signs.html.

44. References Continued… • National Guideline Clearinghouse (2007). Postoperative management in adults. A practical guide to postoperative care for clinical staff. • National Guideline Clearinghouse (2007). Postoperative management in adults. A practical guide to postoperative care for clinical staff. • Sequeira, M. & Campbell, K. (2010). New study shows sepsis and pneumonia caused by hospital-acquired infections kill 48,000 patients; cost 8.1 billion to treat. Retrieved from: http://www.rff.org/News/Press_Releases/Pages/New-Study-Shows- Sepsis-and-Pneumonia-Caused-by-Hospital-Acquired-Infections-Kill- 48,000-Patients;Cost-$81-Billion-to-Treat.aspx • Steen, C. (2009). Developments in the management of patients with sepsis. Nursing Standard 23(48) p. 48-55. • Wheeler, A. P. & Bernard G. R. (1999). Treating patients with severe sepsis. The New England Journal of Medicine 340(3) p. 1-20. • Wundrink, R. G. & Waterer, G. W. (2003). Genetics of sepsis and pneumonia. Current Opinion in Critical Care 9(5) p. 384-389. • Yi, Y., Ling, L., Bo. Z., Mao-qin, L., Bin, W., Zheng, Y., Qin, G., Hua, S. & Hai- bo, Q. (2007). Relationship between adrenal function and prognosis in patients with sever sepsis. Chinese Medical Journal 120(18), p. 1578- 1582.