Sepsis Simulation Prep

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NURS200

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Feb 20, 2024

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Simulation Prep • Discuss the presenting signs and symptoms would you expect of someone in septic shock.  Hypotension: A significant drop in blood pressure is a hallmark sign of septic shock  Altered Mental State: Patients may become confused or disoriented  Rapid Heart Rate: Tachycardia, with a heart rate significantly above normal, is common  Fever or Hypothermia: Septic shock can cause high fever or, paradoxically, a low body temperature  Increased Respiratory Rate: Patients often have rapid, shallow breathing.  Organ Dysfunction: This can include dysfunction of the kidneys, liver, or other organs  Skin Changes: Warm, flushed skin early on, which may progress to cool, clammy skin  Elevated Lactate Levels: Increased blood lactate levels are a common finding References Rhodes, A., Evans, L. E., Alhazzani, W., Levy, M. M., Antonelli, M., Ferrer, R., Dellinger, R. P. (2017). Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Medicine, 43(3), 304-377. Seymour, C. W., Liu, V. X., Iwashyna, T. J., Brunkhorst, F. M., Rea, T. D., Scherag, A., Angus, D. C. (2017). Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA , 315(8), 762-774. • Discuss the hemodynamic profile (Cardiac output (C.O.); Heart rate; Mean arterial pressure (MAP); Central Venous pressure(CVP)/ Right atrial pressure (RAP))would a patient in early septic shock likely present with. In early septic shock the cardiac output and heart rate may increase while mean arterial pressure can decrease. Central venous pressure and right arterial pressure can also vary depending on the patients condition. Elevated Central Venous Pressure (CVP) or Right Atrial Pressure (RAP) in sepsis can indicate several potential issues and may not have a single definitive cause. Here are some potential interpretations: Fluid Overload: Elevated CVP/RAP could suggest that the patient is experiencing fluid overload, which is common in sepsis due to aggressive fluid resuscitation. Impaired Cardiac Function: Elevated CVP/RAP may indicate that the heart is struggling to pump blood effectively, which can occur in septic shock due to myocardial depression. Increased Venous Return: In sepsis, there might be an increase in venous return to the right side of the heart due to systemic vasodilation, leading to increased CVP/RAP. Pulmonary Hypertension: Elevated CVP/RAP can also be a sign of pulmonary hypertension, which can occur as a complication of severe sepsis. References

Seymour, C. W., Liu, V. X., Iwashyna, T. J., Brunkhorst, F. M., Rea, T. D., Scherag, A., Angus, D. C. (2017). Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA , 315(8), 762-774. • Discuss the mortality rate of severe sepsis. In general, severe sepsis has been associated with mortality rates ranging from 20% to 50% or higher. The mortality rate of severe sepsis can vary depending on a variety of factors, including the patient's age, overall health, comorbidities, and how quickly it can be treated. References Mohamed, A. K. S., Mehta, A. A., & James, P. (2017). Predictors of mortality of severe sepsis among adult patients in the medical Intensive Care Unit. Lung India : official organ of Indian Chest Society, 34(4), 330–335. https://doi.org/10.4103/lungindia.lungindia_54_16 . •Discuss the laboratory and diagnostic studies that assists in diagnosing septic shock. Complete Blood Count: This test measures WBC count, hemoglobin, and platelet count. An elevated WBC count or a decrease in platelet count can be indicative of infection. Blood Cultures: Blood samples are taken to identify the specific bacteria causing the infection. This helps in selecting the right antibiotics. Lactate Levels: Elevated lactate levels in the blood are a sign of tissue hypoxia, which is common in septic shock. Arterial Blood Gas: This test assesses oxygen and carbon dioxide levels in the blood, helping to evaluate the extent of tissue oxygenation and acid-base balance. Coagulation Profile: Assessing clotting factors, such as PT and APTT can help evaluate the risk of DIC, a complication of septic shock. Inflammatory Markers: Tests like CRP and procalcitonin can be elevated in response to infection and inflammation, aiding in the diagnosis and monitoring of septic shock. Renal Function Tests: Monitoring serum creatinine and blood urea nitrogen levels can help assess kidney function, which may be compromised in septic shock. Liver Function Tests: Abnormal liver enzymes, such as elevated ALT and AST, can be seen in severe sepsis. Imaging Studies: Imaging, such as X-rays or CT scans, may be used to identify the source of infection and assess organ damage. Reference

Fan, S. L., Miller, N. S., Lee, J., & Remick, D. G. (2016). Diagnosing sepsis - The role of laboratory medicine. Clinica chimica acta; international journal of clinical chemistry , 460 , 203–210. https://doi.org/10.1016/j.cca.2016.07.002 • Discuss “red flag” signs or indications that indicate your patient’s condition was worsening.  loss of consciousness.  severe breathlessness.  a high temperature (fever) or low body temperature.  a change in mental state – like confusion or disorientation.  slurred speech.  cold, clammy and pale or mottled skin.  a fast heartbeat.  fast breathing. Reference Kopczynska, M., Sharif, B., Cleaver, S., Spencer, N., Kurani, A., Lee, C., Davis, J., Durie, C., Joseph-Gubral, J., Sharma, A., Allen, L., Atkins, B., Gordon, A., Jones, L., Noble, A., Bradley, M., Atkinson, H., Inns, J., Penney, H., Gilbert, C., … Welsh Digital Data Collection Platform Collaborators (2018). Red-flag sepsis and SOFA identifies different patient population at risk of sepsis-related deaths on the general ward. Medicine , 97(49), e13238. https://doi.org/10.1097/MD.0000000000013238 . • Discuss the positive inotropes ((dobutamine, milrinone) and vasopressors (dopamine, phenylephrine, norepinephrine, and vasopressin) used as therapy in septic shock. Discuss the common vasodilator nitroglycerin & nitroprusside IV agents used in septic shock. Vasopressors such as dopamine, phenylephrine, norepinephrine, and vasopressin are used within the first hour after a patient is diagnosed with septic shock when fluid administration is not sufficient to achieve the hemodynamic resuscitation goals. Dobutamine is an inotropic agent that stimulates beta receptors and results in increased cardiac output. In theory, it can enhance tissue oxygen delivery in patients with septic shock who have received adequate fluid resuscitation and vasopressor support. IV infusion of nitroglycerin and nitroprusside improves peripheral perfusion and oxygenation in shock patients. References Shi, R., Hamzaoui, O., De Vita, N., Monnet, X., & Teboul, J. L. (2020). Vasopressors in septic shock: which, when, and how much?. Annals of translational medicine , 8 (12), 794. https://doi.org/10.21037/atm.2020.04.24 • Discuss vasoactive IV agents titration the patient’s response parameters that guide the titration and discontinuation/weaning.

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Titration: The titration of vasoactive IV agents is a careful and dynamic process. It involves adjusting the infusion rate to achieve target hemodynamic parameters. These parameters may include MAP, CO, CVP, or SvO2. Patient's Response Parameters: The response parameters that guide titration depend on the specific vasoactive agent and the patient's condition. For example: For norepinephrine, the primary goal is to maintain a target MAP (65-75 mm Hg). For dobutamine, the focus may be on improving cardiac output and oxygen delivery. For epinephrine, it might be about balancing blood pressure and cardiac output. Titration Process: Continuous monitoring of the patient's vital signs and hemodynamic parameters is crucial during titration. Nurses and healthcare providers carefully adjust the infusion rate based on the patient's response. Frequent reassessment is essential to avoid over- or under-dosing, as well as to prevent adverse effects. Discontinuation or Weaning: The decision to discontinue or wean vasoactive agents depends on the patient's improvement and stabilization. Key considerations include: Achieving and maintaining target hemodynamic parameters. Resolving the underlying condition or cause of hemodynamic instability. Monitoring for any signs of tolerance or dependence on the medication. • Develop medication cards identify the indications, contraindications, and side effects associated with pharmacological therapy in shock, bring to simulation Dobutamine  Indications : Dobutamine is used in cases of acute heart failure or cardiac stress testing.  Contraindications : It should be avoided in patients with certain heart conditions, such as idiopathic hypertrophic subaortic stenosis.  Side Effects : Common side effects include increased heart rate, palpitations, and decreased blood pressure. Vasopressin  Indications : Vasopressin is used to treat vasodilatory shock and certain types of diabetes insipidus.  Contraindications : Avoid in patients with known hypersensitivity to vasopressin and some cardiac conditions.

 Side Effects : Side effects may include decreased blood flow to extremities and changes in blood sodium levels. Epinephrine (Adrenaline)  Indications : Epinephrine is used to treat severe allergic reactions (anaphylaxis), cardiac arrest, and life-threatening arrhythmias.  Contraindications : Avoid in patients with known hypersensitivity to epinephrine, as well as certain cardiac conditions like ventricular fibrillation.  Side Effects : Common side effects include increased heart rate, hypertension, anxiety, and tremors. Norepinephrine (Noradrenaline)  Indications : Norepinephrine is primarily used to treat severe hypotension (low blood pressure) and shock.  Contraindications : It should be avoided in patients with known hypersensitivity to norepinephrine and those with certain heart conditions.  Side Effects : Common side effects include hypertension, reduced blood flow to extremities, and arrhythmias. Nitroglycerin  Indications : Nitroglycerin is used to treat angina (chest pain) and manage acute coronary syndrome.  Contraindications : Avoid in patients with severe anemia, hypotension, or hypersensitivity to nitroglycerin.  Side Effects : Common side effects include headaches, flushing, and a drop in blood pressure. Milrinone  Indications : Milrinone is used in the management of acute heart failure and certain types of heart conditions.  Contraindications : It should be avoided in patients with hypersensitivity to milrinone and those with significant aortic or pulmonic valvular disease.  Side Effects : Common side effects include arrhythmias, hypotension, and increased heart rate. Reference

Vallerand, A. H., & Sanoski, C. A. (2021). Davis’s Drug Guide for Nurses (17 TH ed.). F.A. Davis Company. • List the five key elements in the treatment of sepsis as outlined in the Surviving Sepsis Campaign International Guidelines. Early Recognition Early Antibiotics Fluid Resuscitation Vasopressors Source Control • The norepinephrine intravenous (IV) infusion 4 mg/250 ml 5% dextrose in water (D5W) your patient is infusing has been titrated up to 4 mcg/minute. What would be the correct rate to set the IV pump at? 15ml/hr • All of the following are considered essential components of early goal directed therapy in septic shock EXCEPT with rationale: a) IV fluid resuscitation b) IV vasodilator infusion c) IV vasopressor infusion d) Transfusion of packed red blood cells (RBCs). b) IV vasodilator infusion Rationale: According to the EGDT of septic shock, only if the MAP is greater than 90 mm Hg, vasodilators are given until it was 90 mm Hg or below. Reference Zhang, Z., Hong, Y., Smischney, N. J., Kuo, H. P., Tsirigotis, P., Rello, J., Kuan, W. S., Jung, C., Robba, C., Taccone, F. S., Leone, M., Spapen, H., Grimaldi, D., Van Poucke, S., Simpson, S. Q., Honore, P. M., Hofer, S., & Caironi, P. (2017). Early management of sepsis with emphasis on early goal directed therapy: AME evidence series 002. Journal of thoracic disease , 9 (2), 392–405. https://doi.org/10.21037/jtd.2017.02.10. • Recombinant human activated protein C (rhAPC) has been shown in large trials to reduce mortality in patients with septic shock. What is one of the absolute contraindications to the administration of this treatment? One of the absolute contraindications to the administration of rhAPC is active internal bleeding. • A dopamine infusion had to be titrated up to15 mcg/kg/minute in order to sustain a patient’s blood pressure. What is the maximum recommended dosage in mcg/kg/minute and what are the consequences to the patient with high dose dopamine administration?

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Maximum recommended dosage of dopamine is 20-30 mcg/kg/minute. The consequences to the patient with high dose dopamine administration is that dopamine can lead to peripheral vasoconstriction resulting in gangrenous extremities and cardiac arrhythmias. Reference Sonne J, Goyal A, Lopez-Ojeda W. (2023). Dopamine. In: StatPearls. Treasure Island (FL): StatPearls Publishing ; 2023 Jan-. Retrieved on September 9, 2023 from https://www.ncbi.nlm.nih.gov/books/NBK535451/.

Sepsis Simulation Prep

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