CSI Case Study –

Severe Sepsis/
Septic Shock

Summer Gupta, MSN, RN

Sepsis Coordinator UCLA Health
09/13/2016

1
 Objectives

• Identify TOP for Severe Sepsis/Septic Shock

• Know how to activate the nurse driven protocol and notify
provider
• Activate the bundle in a timely manner and anticipate order for
abx and IVF bolus

2
 What you already know…
• Continuum
• Sepsis = 2 SIRS + Infection
• Severe Sepsis = Sepsis + New or Acute Organ Dysfunction
• Septic Shock = Severe Sepsis + Persistent Hypotention OR lactate ≥
36
• Bundle Elements
• Blood Cultures x 2 sets
• Lactate and Repeat Lactate
• IV Broad Spectrum Abx
• IVF Bolus
• Vasopressors
• Tissue Perfusion Assessment

3
 Case Study 1
• 83-year-old female presents to ED 04/09 with c/o gradual
onset of productive cough x 1 month.
• History of asthma and psoriasis.
• Associated symptoms included generalized weakness,
decreased appetite, weight loss, SOB, dizziness, and
jaundice.
• Initial Vital Signs
•T 36.6
• BP 127/58
• HR 90
• RR 18

4
 Case Study 1
• Admit diagnosis by ED Provider – Acute renal failure, Acute
jaundice
• Pt transferred to floor
• Blood cultures drawn while in ED = Negative
• 04/13, WBC noted to be 20.26 but no other SIRS present
• 04/15, WBC noted to be 20.65, HR 104, RR 24
• RN Screen answered YES to Infection 04/15
• BP previously normal dropped to 70/36 04/15
• Severe Sepsis documentation by MD on 04/16

5
Sepsis Audit Tool

6
Sepsis Audit Tool

7
Sepsis Audit Tool

8
 What is the Time of Presentation (TOP)?
• SIRS
• HR 104 @ 1317
• RR 24 @ 1317

• Infection
• RN Screen @ 0845

• Organ Dysfunction
• BP 70/36 @ 1317

9
 What would you do next?
• Implement the Nursing Protocol
• Draw blood cultures
• Draw initial lactate
• Anticipate repeat lactate

• Call physician
• Anticipate order for IV Broad Spectrum Abx
• Anticipate order for IVF Bolus 30ml/kg

10
Case Study 2
• 59-year-old male who presented to ED 07/23 with c/o
gradual onset AMS per caregiver.
• History of metastatic breast cancer, obstructive
jaundice, and ascites. Per EMS, pt was picked up for
BP 60/30.
• Initial BG was 24. Pt given D50 and BG improved to
124. Pt remains unresponsive.
• Initial vital signs
•T unknown
• HR 78
• RR 16
• BP 90/60

11
Sepsis Audit Tool

12
Sepsis Audit Tool

13
What is the TOP?
• SIRS
• RR 24 @ 1045

• Infection
• Septic Shock documentation by ED Provider @ 1015

• Organ Dysfunction
• BP 76/49 @ 1045

14
 What would you do next?
• Implement the Nursing Protocol
• Draw blood cultures
• Draw initial lactate
• Anticipate repeat lactate

• Call physician
• Anticipate order for IV Broad Spectrum Abx
• Anticipate order for IVF Bolus 30ml/kg

15
Case Study 3
• 53-year-old female presents to ED 08/06 with c/o
sudden onset fever.
• History of HTN, hyperlipidemia, and large B cell
lymphoma. Last chemo 07/27.
• Pt was at clinic in the am for lab draw and was informed
to come to ED for hemoglobin of 6. At this time, the
fever was identified.
• Initial vital signs
•T 38.9
• HR 118
• RR 16
• BP 104/66

16
Sepsis Audit Tool

17
Sepsis Audit Tool

18
What is the TOP
• SIRS
• HR118 @ 1527
• WBC 13.49 @ 1629

• Infection
• RN Screen @1528

• Organ Dysfunction
• Lactate 20 @ 1603

19
 What would you do next?
• Implement the Nursing Protocol
• Draw blood cultures
• Draw initial lactate
• Draw repeat lactate

• Call physician
• Anticipate order for IV Broad Spectrum Abx

20
Thank you

Questions?

Summer Gupta, RN, MSN

424.259.8534
X 98534

21