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Nursing Update:Recognition & Management of Sepsis in Patients with Cirrhosis
Cherie Navarro MSN, ACNP-BC
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Objectives
1. Describe signs and symptoms of sepsis syndrome
2. Recognize signs of sepsis to respond quickly
3. Summarize management strategies
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Sepsis Part of a disease spectrum ranging from infection to septic shock
Accounts for 1,000,000 cases in the United States with a mortality of 200,000 patients annually
Results from a dysregulated host response to infection causing
life-threatening organ dysfunction
If not treated aggressively leads to multiple organ failure & death
Angus, & Van der Poll, (2013), European and American Societies of Critical Care Medicine (2016)
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Sepsis Definition
A “life-threatening organ dysfunction caused by a dysregulated host response to infection.”
Singer et al., 2016
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Sepsis Background
(Singer et al., 2016)
Based on administrative claims data, sepsis mortality was 15 to 140% higher than estimates using death certificate
Serial markers for MI: troponins
HF: brain natriuretic peptide (BNP)
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Sepsis Background
No validated diagnostic test to diagnose sepsis
Clinicians must suspect infection with early recognition to preventing organ dysfunction
Even small degrees of organ dysfunction cause increases in hospital mortality
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Risk Factors for Sepsis
Compromised Immune Status
Neutropenia, Cirrhosis, AIDS & Chronic Illness
Invasive procedures
Surgery or instrumentation
Extremes in age
Elderly-(more likely to have underlying disease)
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Risk Factors for Sepsis
Males > 40, females 20-45
Antibiotic usage
Immunosuppressive drugs with broad-spectrum antibiotics
Miscellaneous
Trauma, Intestinal Ulceration, Childbirth, & Septic Abortion
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Sepsis Signs
Oliguria - UO < 0.5 ml/kg/hr.), increase in BUN (7-18)/Creatinine(0.6-1.2)
Mental status changes
Increased O2 requirement- tachypnea, hypoxemia; Spo2 < 90%
Hypotension: SBP < 90, or a reduction of 40 mm Hg from baseline, MAP <65
Nausea, vomiting, diarrhea
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Sepsis Signs
Systemic Hypoperfusion seen with lactic acidosis
Lactate > 2 mmol/L -a marker for tissue hypoperfusion
Bilirubin >2.0
Thrombocytopenia (Platelet <100,000)
Coagulopathy INR >1.5 PTT > 60
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Hypotension despite adequate fluid resuscitation
SBP < 90 mmHg - or a decrease of 40 mmHg from baseline- as in a normally HTN patient
Needing vasopressors to maintain a mean arterial pressure (MAP) of ≥65 mmHg
Change in mental status
Lactic acidosis (serum lactate level >2 mmol/L)
Oliguria (UO < 0.5 ml/kg/hr), increase in BUN (7-18)/Creatinine(0.6-1.2)
Septic Shock
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From a Small Scrape to Sepsis
▪Rory dived for a ball playing at recess & got a scrape on his arm
▪By next morning had a high fever & was vomiting▪Thought was viral infection & was sent to the ED
to treat dehydration ▪ In ED, fluids, labs including WBC, then sent home▪Worsening condition at home & returned to ED
with direct admit to ICU in septic shock ▪He died within 48 hours of streptococcal sepsis
from a bacterial skin infection
http://www.sepsisalliance.org/faces/
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Cirrhosis
Cirrhosis a condition in which the liver does not function properly due to long-term damage
Replacement of normal liver tissue by scar tissue
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Cirrhosis
▪Not only a risk factor for sepsis BUT an independent mortality risk factor in patients with septic shock
▪May lead to acute liver dysfunction – identified as acute-on-chronic liver failure (ACLF) & results in jaundice & prolongation of prothrombin time (PTT)
▪ ICU mortality with patients having cirrhosis and septic shock is 65%
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Symptomsof
Cirrhosis
▪ Weakness▪ Fatigue▪ Pruritis ▪ Swelling ▪ Jaundice▪ Ecchymosis▪ Ascites - can become spontaneously infected ▪ Esophageal varices (bleeding from dilated veins
in the esophagus or dilated stomach veins) ▪ Hepatic encephalopathy (confusion to
unconsciousness)
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Common physiological changes in
patients with cirrhosis
▪ Liver impairment (worsening of liver function tests, including a rise in bilirubin, INR & thrombocytopenia from baseline tests)
▪ Baseline tachycardia (secondary to hyperdynamic circulation)
▪ Tachypnea (attributed to hepatic encephalopathy (HE)▪ Oliguria (may indicate renal dysfunction)▪ Serum creatinine (falsely low) r/t sarcopenia &
malnourishment (creatinine comes from muscle)▪ High serum lactate levels r/t Impaired hepatic lactate
clearance ▪ Baseline Hypotension▪ Reduced white blood cell count (attributed to
hypersplenism)
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Patients with Cirrhosis
Temperature Heart Rate Respiratory Rate
White Blood Count (WBC)
Systemic Inflammatory Response Syndrome (SIRS)
>38°C or<36°C
>90 bpm >20/min or pCO2 <32 mm Hg
>12,000 cells/µL or <4,000 cells/µL
Baseline features in cirrhosis
Blunted temperature regulation
Tachycardia (hyperdynamic state)
Tachypnea r/t Hepatic Encephalopathy & ascites
Leukopenia r/t hypersplenism
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Risk factors for Sepsis in Patients
with Cirrhosis
Baseline hypotension
Poorly functioning white blood cells
Bacterial translocation from intestine
Third space fluid in abdomen (ascites) & chest as reservoirs of infection
Poor functional state
Impaired cognition
Poor wound healing due to edema, sarcopenia
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Recognizing Sepsis in Patients with Cirrhosis
High Serum lactate levels r/t Impaired hepatic lactate clearance
Serum creatinine (falsely low) r/t sarcopenia & malnourishment (creatinine comes from muscle)
Low protein fluid in reservoirs- edema
Ascites
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Ascites
Must determine if ascites is the source i.espontaneous bacterial peritonitis (SBP)
Diagnosed with paracentesis at the bedside
SBP confirmed with more than 250 polymorphonuclear leukocytes, or a positive culture
IV antibiotics & albumin
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Sequential Organ Failure Assessment Score (SOFA score)
▪A morbidity severity score & mortality estimation tool
▪Used in ICU to determine the extent of organ dysfunction
▪Based on 6 different scores one for each of the following systems
▪ Respiratory▪ Cardiovascular▪ Hepatic▪ Coagulation▪ Renal ▪ Neurological systems
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SOFA Score
Each organ system is assigned a point value
0 (normal)
4 (high degree of dysfunction/failure)
Score ranges from 0 to 24
The higher the score the higher the organ dysfunction involvement
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Organ Dysfunction is Represented by an
Increase in the SOFA Score of 2 Points or
More
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SOFA SCORING 1 2 3 4
Respiratory (PaO2/FiO2)
<400 <300 <200With respiratory support
<100With respiratory support
Coagulation(Platelets x ×10to3/μ/L)
< 150 <100 <50 <20
Liver Bilirubin (mg/dL) 1.2-1.9 2.0-5.9 6.0-11.9 >12
Cardiovascular hypotension or vasoactive agents (μg/kg/min)
MAP < 70 mm Hg Dopamine ≤5 or dobutamine (any dose)(Any dose)
Dopamine >5, epinephrine ≤0.1 or norepinephrine ≤0.1(Agents administered for at least 1 hour)
Dopamine >15, epinephrine >0.1, or norepinephrine >0.1(Agents administered for at least 1 hour)
Central nervous system Glasgow Coma Scale
13-14 10-12 6-9 < 6
Renal creatinine (mg/dL) or urine output (mL/day)
1.2-1.9 2.0-3.4 3.5-4.9 or < 500 >5.0 or < 200
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Sepsis Management
Think Sepsis for Fever, Hypotension, Leukocytosis
Within the first 6 hours:
Blood Cultures
Lactic Acid measures (goal < 2 mmol/L)
CBC with Diff
Antibiotics - within 1 hours of
presentation
Broad-spectrum initially
Fluid Administration
30 mg/kg
Hypotension (SBP < 90, MAP < 65) or a reduction of 40 mm Hg from baseline)
IN cirrhosis MAP of ≥ 60 mm Hg,
Vasopressors
Hypotension not responding to fluid
resuscitation
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Considerations in Cirrhosis
Each hour delay in antimicrobial therapy increases mortality by
1.86 times
Intravenous albumin infusion reduced
mortality in:
Spontaneous bacterial peritonitis
Hepatorenal syndrome
Improve outcomes following large-
volume paracentesis
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Fluid Resuscitation
Goal approach to Fluid
Resuscitation
Urine output > 0.5 mL/kg/hr CVP 8-12 mmHg
MAP 65 to 90 mmHg
Central venous oxygen
concentration saturation
(ScvO2) > 70%
Lactic acid < 2 moles/L
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Vasopressors
Hypotension not responding to fluid resuscitation
Titrate to MAP > 65 mm Hg; Map may be too low in a patient with uncontrolled hypertension
Norepinephrine first choice
Vasopressin (up to 0.03 U/min); Not recommended as single initial agent. High doses associated with cardiac, digital & splanchnic ischemia
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Final Points
Sepsis can lead to death within hours
A high index of suspicion for sepsis, early recognition & treatment are critical to mitigate organ failure & death
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References
• Simonetto, D. A., Piccolo Serafim, L., Gallo de Moraes, A., Gajic, O., & Kamath, P. S. (2019). Management of Sepsis in Patients with Cirrhosis: current evidence and practical approach. Hepatology, 70(1), 418-428.
• Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 2016;315:801-810.
• Rochwerg B, Alhazzani W, Sindi A, Heels-Ansdell D, Thabane L, Fox-Robichaud A, et al. Fluid resuscitation in sepsis: a systematic review and network meta-analysis. Ann Intern Med 2014; 161:347-355.
• Xu JY, Chen QH, Xie JF, Pan C, Liu SQ, Huang LW, et al. Comparison of the effects of albumin and crystalloid on mortality in adult patients with severe sepsis and septic shock: a meta-analysis of randomized clinical trials. Crit Care 2014;18:702.