Sepsis

CHAPTER 21

Sepsis LEARNING OBJECTIVES

• Recognize warning signs of maternal sepsis. • Identify initial treatment strategies for maternal sepsis.

DEFINITIONS Systemic Inflammatory Response Syndromes (SIRS) Defined by two or more of the following: • Temperature >38 or <36 C • Heart rate >90 beats per minute • Respiratory rate >20 breaths/minute or PaCO2 <32 mmHg

• White blood cells >12,000 cells/mm3 or <4000 cells/mm3 or >10% bands1,2

Sepsis Defined by SIRS with a source of infection.

Severe Sepsis Defined by sepsis with end organ dysfunction (Fig. 21.1).

FIG. 21.1 Maternal sepsis can result in multisystem organ failure.

Safety Training for Obstetric Emergencies. https://doi.org/10.1016/B978-0-323-69672-2.00021-7 Copyright © 2019 Elsevier Inc. All rights reserved.

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SURVIVING SEPSIS GUIDELINES • Within first 3 hours • • • •

Measure lactate level Obtain blood cultures Begin antibiotics Resuscitate with 30 mL/kg crystalloid if mean arterial pressure 65 mmHg or lactate  4 mmol/L • Within first 6 hours • Begin vasopressors if mean arterial pressure (MAP) does not respond to fluid boluses • Begin with norepinephrine 0.05e0.1 mcg/kg/ minute and titrate up to 1 mcg/kg/minute for MAP  65 mmHg • If MAP does not respond to fluid boluses or initial lactate  4 mmol/L, measure central venous pressure and central venous oxygen saturation • Repeat lactate if initial measurement elevated3,4

CHOOSING ANTIMICROBIALS3,5 • Resistant Gram positives / Vancomycin, daptomycin, linezolid

• Resistant Gram negatives / Piperacillin/tazobactam, carbapenemases • Cytomegalovirus / Valgancyclovir • Fungal infections / Echinocandins, amphotericin B

REFERENCES 1. Chebbo A, et al. Maternal sepsis and septic shock. Crit Care Clin. 2016;32(1):119e135. 2. Parfitt SE, et al. Sepsis in obstetrics: pathophysiology and diagnostic definitions. MCN Am J Matern Child Nurs. 2017;42(4):194e198. 3. Barrier KM. Summary of the 2016 international surviving sepsis campaign: a clinician’s guide. Crit Care Nurs Clin N Am. 2018;30(3):311e321. 4. Parfitt SE, Bogat ML, Roth C. Sepsis in obstetrics: treatment, prognosis, and prevention. MCN Am J Matern Child Nurs. 2017;42(4):206e209. 5. Plante LA. Management of sepsis and septic shock for the obstetrician-gynecologist. Obstet Gynecol Clin N Am. 2016; 43(4):659e678.

Sepsis Simulation MATERIALS NEEDED • Manikin or volunteer to act as standardized patient KEY PERSONNEL • Attending obstetrician • Resident physician (if available in your institution) • Two nurses SAMPLE SCENARIO A 25-year-old G3P2112 at 37 weeks 2 days gestation presents with abdominal pain, diarrhea, and decreased fetal movement. She was treated for a urinary tract infection 3 weeks ago. She states she has been leaking fluid for approximately 2 weeks. Speculum exam does not demonstrate any fluid. Her vitals are as follows: BP 90/60, HR 140, T 39.1, SpO2 99%. DEBRIEFING AND DOCUMENTATION • Potential sources of infection • Systemic Inflammatory Response Syndrome criteria • Evidence of organ dysfunction • Initial resuscitation • Antimicrobials • Plan for ongoing monitoring and management • Communication with patient and family

CHAPTER 21

Sepsis

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Simulation Checklist Time Initial response

Obtained history and physical Obtained vital signs Clearly stated the problem Called for help Requested specific personnel and supplies

Airway

Checked for airway compromise

Breathing

Checked breathing Administered high-flow oxygen

Circulation

Started 2 large-bore IVs Collected blood for labs (including CBC, lactate, blood cultures)

Interventions

IV fluids (30 mL/kg) Oxygen Broad spectrum antibiotics

Monitoring

Blood pressure Respirations Oxygen saturation Urinary output Fetal heart rate (after mother stabilized)

Documentation

Timing of events Medications administered Persons present

Communication

Directed communication Closed-loop communication

Comments

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Safety Training for Obstetric Emergencies

Technical and nontechnical skill sets with regards to maternal sepsis.