Eka Yulia Fitri Y

Departemen Gawat Darurat & Kritis

Program Studi Keperawatan
Bagian Keperawatan Fakultas Kedokteran
Universitas Sriwijaya
 What is Sepsis?

SEPSIS arises when the body’s

response to an infection
injuries its own tissue and
STAGE 1

organs. It may lead to shock,

MOF, and death, especially if
not recognized early and
treated promptly.

From A Local Infection to a Body-Wide Injury

A local infection, such as pneumonia, overcomes the body’s local
defense mechanisms. Invading microorganisms and the toxin they
produce leave the original site of the infection and induce a
powerful body-wide immune response and enter the entire
circulatory system. Source: world-sepsis-day.org
 What is Sepsis?

General Inflammatory Response

This immune response to

STAGE 2

infection can be so
intense that the body can
lose control of it. The
dysregulated response
can result in injury to
tissues and organs, and
starts to deteriorate and
may completely fail, is
known as sepsis.
Source: world-sepsis-day.org
 What is Sepsis?

Septic Shock & MOF

STAGE 3

Cardio circulatory failure

occurs, leading to a
sudden drop in blood
preasure.

Several organs then stop

functioning sequentially or
simultaneously.
Source: world-sepsis-day.org
 Common Causes
• Most types of
microorganisms can
cause sepsis,
(bacteria, fungi,
viruses, and
parasites).
• It may also be
caused by infections
with seasonal
influenza viruses,
dengue viruses, and
highly transmissible
pathogens of public
health concern; such
as avian and swine
influenza viruses,
Ebola, and yellow
fever viruses.
Source: world-sepsis-day.org
Sepsis at a Glance
 Sepsis is a medical emergency . .
minutes matter
Every hour a
patient in septic
shock doesn't
receive antibiotics,
the risk of death
increases by 7.6%.

Source: Advisory Board Company: “Why sepsis screening isn't one-size-fits-all” Expert Insight | December 11, 2013
The Signs & Symptoms
The Signs & Symptoms
 NEWEST GUIDELINES
Sepsis is life threatening organ dysfunction caused by a
dysregulated host response to infection

The usage of SIRS criteria to identify

sepsis was considered to be unhelpful

Organ dysfunction is defined as an

increase of SOFA score ≥ 2.

Septic shock is defined as a subset of sepsis in which

underlying circulatory and metabolic abnormalities are
profound enough to substantially increase mortality
 SEPTIC SHOCK
Data indicate mortality rates for patients
with these two conditions are in excess of
Sepsis with these clinical
40 percent, or four times greater than criteria:
patients with sepsis. • Persisting hypotension
requiring vasopressors to
maintain MAP ≥65 mm
Hg
AND
• Blood lactate >2
mmol/L despite
adequate volume
resuscitation
 OLD AND NEW
DEFINITION OF SEPSIS
 OLD AND NEW
DEFINITION OF SEPSIS
SOFA SCORE
Q-SOFA

Source: USMLE Clinic,

JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287
• ANTIBIOTICS
• Apply the 1st dosage of antibiotics within one hour
after sepsis diagnosis. In general, broad-spectrum
carbapenems (i.e., meropenem, imipenem/cilastatin
or doripenem) or extended-range penicillin/β-
lactamase inhibitor combination (i.e.,
piperacillin/tazobactam or ticarcillin/clavulanate) can
be recommended as 1st choice drugs.
• Patients with a very high risk of mortality such as septic
shock should receive a multidrug therapy to broaden
the antimicrobial spectrum.
• RESUSCITATION
• Crystalloids as first-choice fluid for fluid resuscitation
with an initial bolus of at least 30 mL/kg
• RBC transfusion should only occur in hemoglobin levels
<7.0 g/dL (exclusion: myocardial ischemia, severe
hypoxemia, acute hemorrhage)
• Norepinephrine as first-choice vasopressor to achieve
a target mean arterial pressure of at least 65 mmHg
• NUTRITION
• Initiate early enteral nutrition but no early
parenteral nutrition in patients who can be
fed enterally
• No parenteral nutrition within the first 7 days in
patients who cannot be fed enterally (maybe
IV glucose; try enteral feeding as tolerated)
• No omega-3 fatty acids as immune
supplement
• No high dosage IV selenium
• No glutamine
• MECHANICAL VENTILATION
• Mechanical ventilation with a tidal volume of
6 mL/kg PBW in sepsis-induced ARDS
• Prone position in sepsis-induced ARDS with a
PaO2/FiO2 ratio <150 mmHg
• 30°–45° elevation of mechanically ventilated
patients
 3-Hour Bundle
To be completed within 3 hours of time of
presentation*:
1. Measure lactate level
2. Obtain 2 sets of blood cultures prior to
administration of antibiotics from 2 different sites.
3. Administer broad spectrum antibiotics
4. Administer 30ml/kg crystalloid IVF for hypotension
or lactate ≥ 4 mmol/L

* “Time of presentation” is defined as the time of earliest chart annotation consistent with all
the elements of severe sepsis or septic shock ascertained through chart review.

http://www.survivingsepsis.org/SiteCollectionDocuments/SSC_Bundle.pdf
 6-Hour Bundle
To be completed within 6 hours of time of presentation

1. Apply vasopressors (for hypotension that does not respond to

initial fluid resuscitation) and titrate pressors to a mean arterial
pressure (MAP) ≥ 65 mm Hg.

2. In the event of persistent hypotension after initial fluid bolus

(MAP < 65 mm Hg) or if initial lactate was ≥ 4 mmol/L, re-assess
volume status and tissue perfusion and document findings.

3. If initial lactate is elevated > 2, re-measure lactate within 6

hours.

http://www.survivingsepsis.org/SiteCollectionDocuments/SSC_Bundle.pdf
 6 - HOUR SEVERE SEPSIS/
SEPTIC SHOCK BUNDLE
• Vasopressors:
• Early Detection:
• Obtain serum lactate – Hypotension not
level. responding to fluid
– Titrate to MAP > 65
• Early Blood Cx/Antibiotics: mmHg.
• within 3 hours of
presentation. • Septic shock or lactate > 4
mmol/L:
– CVP and ScvO2 measured.
• Early EGDT:
– CVP maintained >8 mmHg.
• Hypotension (SBP < 90, MAP < – MAP maintain > 65 mmHg.
65) or lactate > 4 mmol/L:
• initial fluid bolus 20-40 ml of • ScvO2<70%with CVP > 8
crystalloid (or colloid
equivalent) per kg of body mmHg, MAP > 65 mmHg:
weight. – PRBCs if hematocrit < 30%.
– Inotropes.
 Rhode Island Hospital EGDT Data

Time from Entering ED Time from Entering

to Receiving Antibiotics ED to Catheter Time from Entering
Insertion ED to Transfer to
MICU
Reduced by 42%
Reduced by 60%
Reduced by 51%
200 350
185 500

180
450
300
160
148 400

140 250
350

120 11 300
106 200

100 95
90 250

150
80 200

60 150
100

100
40
50
50
20
 KEYS TO SURVIVAL
 Early Identification
• Subtle signs and symptoms
• Don’t wait until your patient is hypotensive!
 Appropriate antibiotics in a timely manner
• For every hour antibiotics are delayed during septic
shock, the patient’s risk of death increases by 7.6%
• The single most important intervention in treating
sepsis
 Source Control
• Antibiotics
• Surgery
 IV Fluids and vasopressors if necessary (hemodynamic
stability)
 Emergency supportive care for acute organ dysfunction
• Ventilator
• Continuous Renal Replacement Therapy (CRRT)
• Prone positioning
 24 - HOUR SEVERE SEPSIS
AND SEPTIC SHOCK BUNDLE
• Glucose control:
• maintained on average <150 mg/dL (8.3 mmol/L)
• Drotrecogin alfa (activated):
• administered in accordance with hospital
guidelines
• Steroids:
• for septic shock requiring continued use of
vasopressors for equal to or greater than 6 hours.
• Lung protective strategy:
• Maintain plateau pressures < 30 cm H2O for
mechanically ventilated patients
 PATIENT’S JOURNEY DOES
NOT END AT DISCHARGE
Other symptoms
can include:
• Sleep
disturbance,
including
insomnia
• Extreme
tiredness and
fatigue
• Inability to
concentrate
• Loss of
confidence
and self-belief

1_ Kessler RC, Sonnega A, Bromet E, et al.: Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen
Psychiatry, 52: 1048–60, 1995. // Davydow DS, Gifford JM, Desai SV, et al.: Posttraumatic stress disorder in general
intensive care unit survivors: a systematic review. Gen Hosp Psychiatry, 30: 421-434, 2008.
 HEALTHCARE PROVIDERS
CAN . . .
Prevent infections.
• Hand washing = #1 way to prevent infection
• Sterile Technique and Maintenance
• Foley insertion (and maintenance)
• Line insertion and draws (and maintenance)
• Invasive procedures
• Vaccines
• Flu and pneumonia shots
Reassess patient management. Check patient progress
frequently. Reassess antibiotic therapy 24-48 hours or sooner to
change therapy as needed (narrow the spectrum). Be sure the
antibiotic type, dose, and duration are correct.
Educate patients and their families. Stress the need to prevent
infections, manage chronic conditions, and seek care if signs of
severe infection or sepsis are present.
 NURSING CARE PLAN
Desired Outome
• Lessening the immune
response
• Prevention cellular death,
resolution of infection
• Minimizing damage from
cellular oxygen deprivation
and lactic acid build up
• Maximizing cardiac output
and resolution of the
condition.
NURSING CARE PLAN
 NURSING CARE PLAN
Intervention
• Prompt lab draws
• Labs in sepsis diagnosis and treatment are very time
sensitive. It is imperative the nurse is drawing labs
promptly, as this evaluates the effectiveness of treatment
and determines next steps.
• Appropriate administration of IV antibiotics
• Baseline blood cultures must be drawn prior to the
initiation of antibiotics to ensure the appropriate
pathogen is identified. Drawing the labs, then starting
antibiotics as ordered is the nurse’s responsibility.
 NURSING CARE PLAN
Intervention (cont.)
• Optimize fluid-volume status
• Patients suffering from sepsis usually require massive fluid
resuscitation.
• Assess, monitor, and optimize cardiac output
• Cardiac output is typically compromised in sepsis. The nurse
must communicate with the MD about this and how to treat
it, as some may need more fluid, or vasopressors, or both.
Non-invasive cardiac output monitoring (NICOM) or central
venous pressure monitoring (CVP) are options.
• Assess, monitor, and support oxygen status
• Septic patients may need significant respiratory support,
depending on severity. Oxygen delivery and utilization is
severely impaired, therefore the nurse must assess frequently
(ABG’s, SpO2) and work with medical team on interventions
 NURSING CARE PLAN
Intervention (cont.)
• Prevent infection
• This patient already has a heightened inflammatory
response, we don’t want to make it worse with another
pathogen. Asepsis is KEY with all patient care but in
particular the septic patient. Frequently septic patients will
require a central venous catheter and foley catheter. These
are invasive lines that can easily get infected but are
necessary when a patient is that ill.
• Assess, monitor, and manage body temp
• Their body temp may be high or low, and we want to warm
them if they’re too cold (increase room temp, warming
blankets) or cool them if their fever is too high (antipyretic,
cooling blanket, decrease room temp). Many septic
patients with fluctuating body temps may have continuous
temperature monitoring (via foley, rectal tube, or
endotracheal tube)
 NURSING CARE PLAN
Intervention (cont.)
• Communicate with and educate patient and loved one
• Sepsis is serious and scary. It is essential to educate the
patient and their support system at every step of the way
so they are able to let you know if they feel/act
differently, if things change, and also to prevent them
from unnecessarily worrying or interfering with very
needed interventions.
 REFERENCES
Tiffany M. Osborn, MD.University of Virginia.
ACEP Chair Critical Care Section. ACEP Representative
Surviving Sepsis Campaign

Frank Bloos. Diagnosis and theraphy of sepsis. J

Emerg Crit Care Med 2018;2:3.
http://dx.doi.org/10.21037/jeccm.2017.12.08

Singer,M et al. The Third International Consensus

Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA.
2016;315(8):801-810. doi:10.1001/jama.2016.0287