Page 594 - ACCCN's Critical Care Nursing

Multiple Organ Dysfunction Syndrome 571

pneumonia. It has also been reported to affect the risk of which components of EGDT are effective is lacking. Trials
developing severe outcomes and higher mortality in currently underway to address this issue include the
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meningococcal sepsis and trauma. Among critically ill ProCESS (Protocolized Care for Early Septic Shock) and
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patients with severe sepsis due to pneumonia, carriers of ARISE study. See Chapter 20 for further discussion of
the PAI-1 4G/5G genotypes have higher risk for MODS resuscitation in septic shock.
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and septic shock. In future, identification of genetic
factors may assist selection of appropriate therapy for the Early Treatment of Infection
patient at risk. Timely treatment of infection appears important in the
prevention and management of MODS, with early anti-
NURSING PRACTICE microbial therapy in septic shock recommended in the
Improvement in patient survival with MODS is thought SSG. The CATSS (Cooperative Antimicrobial Therapy of
to be due to improved shock management, awareness of Septic Shock) Database Research Group identified that:
secondary insults, improved critical care management ● inappropriate initial antimicrobial therapy was associ-
and a better understanding of the risk factors associated ated with a five-fold decrease in survival to hospital
with MODS. Current prevention and management strate- discharge 84
gies therefore focus on efficient shock resuscitation, ● the incidence of early acute kidney injury (AKI)
timely treatment of infection, exclusion of secondary increased with delays in antimicrobial therapy from
inflammatory insults and organ support. 65
the onset of hypotension. 85
Effective Shock Resuscitation Other single centre studies also supported the SSG recom-
A number of interventions have been recommended to mendation of antimicrobial therapy within the first hour
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reduce mortality for patients with MODS due to sepsis. of diagnosing severe sepsis. As early antimicrobial
The surviving sepsis guidelines (SSG) are based on clini- administration may be difficult to achieve given compet-
cal evidence graded according to the quality of evidence ing patient management priorities (e.g. airway manage-
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available, although there is controversy and dissent ment, volume resuscitation, vasopressor administration),
regarding some recommendations, particularly Early systems must be developed to promote early administra-
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Goal Directed Therapy (EGDT) (see Table 21.4) (see tion. Nurses are in a pivotal position to ensure these
Chapter 20 for further discussion). guidelines or processes are developed, implemented and
evaluated.
The multicentre, prospective, observational ARISE study
(Australasian resuscitation in sepsis evaluation) assessed
the resuscitation practices and outcomes in patients pre-
senting to EDs with sepsis with hypoperfusion or septic
shock. Overall in-hospital mortality of 23% was compa- Practice tip
rable to inhospital mortality reported in studies of early Tips for promoting early antimicrobial administration in severe
EGDT. The study confirmed that protocolised ScvO 2 - sepsis/septic shock: 86,89
directed EGDT is not routinely practised in Australia or ● Ensure high priority in severe sepsis/septic shock
New Zealand, and recommended that EGDT not be algorithms
adopted in Australia and New Zealand without further ● Do not delay antimicrobial administration if difficulty sam-
multicentre randomised controlled trials. While some pling blood cultures
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evidence of the benefits of EGDT from a quality improve- ● Ensure adequate supply of antimicrobials in ED and ICU
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ment perspective are emerging, these benefits may be that fit local colonisation patterns
due to increased awareness of sepsis management rather ● Utilise appropriate antibiotics that can be given via IV push
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than EGDT. In addition, the complex invasive technolo- vs longer infusion
gies which underpin EGDT are not practical in resource- ● Emphasise education of staff on the significance of early
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limited low- and middle-income countries. Early administration of initial antimicrobial
resuscitation in severe sepsis does appear to improve ● Consider other potential barriers to early antimicrobial
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patient outcomes, however, the evidence in relation to administration in your facility

TABLE 21.4 EGDT in severe sepsis: initial targets 76
Combination antibiotic therapy may offer a survival
Item Target benefit in septic shock, but may be deleterious to patients
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with a low mortality risk. Certainly antibiotic overuse
CVP 8–12 mmHg and misuse is of concern given the emergence of antibi-
12–15 mmHg in mechanically ventilated patient or otic resistance. Other factors that can lead to antibiotic
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patient with decreased ventricular compliance
failure in the critically ill include increased volume of
MAP ≥65 mmHg distribution secondary to expanded extracellular volume,
Urine output ≥0.5 mL/kg/hr transient increased drug clearance due to elevated cardiac
output (early sepsis) and increased free-drug levels sec-
ScvO 2 / SvO 2 ≥70%/≥65%
ondary to reduced serum albumin. Maximum antibiotic