Hi, thank you very much and thank you for tuning in this evening, everybody. So hopefully, this will be interesting for you. And I have got two springers but this one isn't mine luckily, luckily for her anyway.
OK, so. Today we're gonna be talking about sepsis and first of all, we'll just go through a couple of definitions of SARS and sepsis. And then we will go through some basic physiology behind sepsis and why patients become septic.
And I'm also going to just talk you through some current research into sepsis recognition in the human hospitals, and how it might relate to our patients. We'll also go through some clinical signs associated with our patients when they become septic, and then we'll just talk about how as nurses, we can really make them the most comfortable and treat them as best we can. OK, so it's just some definitions that we're going to be using throughout the webinar.
So SARS, SARS is a systemic inflammatory response syndrome, and I'm sure that you've probably all heard that's bandied about quite a bit. And sepsis is a term that's used to describe a patient suffering from SARS but with the added element of infection. Septic shock is defined as a septic patient, but that is also suffering with a life threatening organ dysfunction.
And when that becomes multiple organs that starts to dysfunction, we, we call that dysfunction syndrome, so mods. Sometimes this is referred to as MOF as well, multiple organ failure. ARDS is acute respiratory distress syndrome, and again, that is something, basically in an organ failure, so your lungs start to fail and we'll go through that a bit later on.
But more definitions and everything can be found with surviving sepsis Committee, which is a big organisation. So now just some physiology. So what happens when a patient experiences an insult, so sort of anything that can happen, and that's including anything surgical that we do to these patients.
They have an acute reaction. So all the anti-inflammatory mediators are released by the immune system. And this lasts a few days, so the tissues will begin to repair themselves and that's a very normal reaction to any insult.
They then move on into the subacute stage, and this is our neutrophils, so that our neutrophils are released. And they start to perform vagocytosis. So vagocytosis, so you probably remember from when you started training, but you'll have an invading organism and in our septic patients, this is will be our bacteria.
And the neutrophils will come along and they'll attach themselves via the proteins on the surface of the bacteria. And then once they've done that, they're attached to that bacteria and they'll start to move around it. And that's called engulfing.
So basically just move around the whole of the bacteria until the bacteria is inside the cell itself. Once it's inside that cell, the cell will release lots of different enzymes and chemicals, and that will basically eat up that organism inside the neutrophil. Macrophages will go around eradicating all of the damaged cells and tissue, and that's so that new tissue can grow in the same place.
And that's the subacute stage. So when that's prolonged, that's counted as chronic and this will lead to cells. So what is that?
So when we have this trauma, the skin will react. It'll be warm to the touch, red and swollen. And even if you've done something very sort of, normal, so you have a patient in a cat's bay, for example, just by cutting that skin, you'd all set off all of that acute and subacute phase.
And that's really normal for the skin to sort of have an acute reaction. But then that will reduce, and that reaction will normally stay localised to the area of insult. It's when the inflammation then spreads and there are further systemic signs, that's when it becomes SARS and I guess the clue is in the name.
So, you know, SARS is systemic inflammatory response syndrome. So it's basically the whole patient will become SERSy and sort of reactive to something that started in one place. And once we move on into our sepsis, our inflammatory cycle will start the coagulation cascade.
And once that's triggered, you get little microthrombi, so tiny little clots are released and they travel via all of your vessels around the body. And these block capillaries, leading to diffuse cell damage and death. And that's when we get a reduced organ function because parts of our organs will be dying off and that's including our, our lungs.
So you'll get little bits of tissue that aren't working properly and that's when you start to get organ failures. And as platelets are exhausted from all of these little micro funbi, they then don't become available for when the patient suffers a further trauma. So even if you do just a venna puncture on these patients, they might bleed out.
And further on is disseminated into vascular coagulopathy, and that is just sort of when this stage has really taken its toll, and there's this sort of bleeding and all over the patients, you get lots of ecchymosis, and peti in the the mouth and gums. OK, so moving on, we'll just go through a bit of current research. So, mortality in human medicine, is between 40, 30 to 40%, sorry, for severe sepsis in hospitals and for patients with septic shock, it's between 40 and 50%.
So that is very high. And we can sort of assume that actually this is similar in our patients. It's just very difficult for us to, to gather that data.
It's been shown that early recognition of sepsis will improve the survival rates for our patients. And in human hospitals this is done in a few ways. So they introduced sepsis bundles, which we'll go through shortly.
They'll educate their nursing staff primarily, so they normally put all of the staff through the same training programmes, but what they really want is that these sepsis bundles are nurse-led. So as a patient comes into the hospital, the nurses take the lead on their bundle. So they really educate those nursing staff so that they have as much compliance as possible.
So bundles are basically a little tool that's used for a variety of conditions. So you'll see when you go in, if you go into hospitals, they're quite hot on sepsis, especially now because it is one of the biggest killers. And they will have these bundles and basically all hospitals will be following these bundles for several conditions.
And it basically is a table of clinical parameters. And if a patient meets those clinical parameters, then it will go through a flow chart of treatment. So, it will have some diagnostic tools and treatments and, and they will be nurse led.
And when these are followed appropriately, then actually survival has been shown to increase by about 50%. So it's really huge. So sepsis 6 was one of the first bundles and actually brought in to get patients treated promptly, which in Human Hospital is within 6 hours of admission, so that's what they aimed for to begin with.
Included on this 6 hour bundle, they had to be administered high flow oxygen. They had to take blood cultures from two different areas and then start them on broad spectrum antibiotics. Fluids are given and when there's hypotension.
So if these patients are septic, they're normally hypotensive. And we also measure serum, lactate levels, haemoglobin, and urine output. And then they decided actually 6 hours is quite a long time.
Sepsis can be quite a quickly progressing situation. So we actually want to try and get these patients seen a bit more quickly. So they came up with sepsis 3.
So they want people to follow this within 3 hours of admission and then complete the 6 hour bundle afterwards. But it's actually quite common now, so patients with SARS, it's expected that actually over 90% of patients in an ICU in human hospitals actually have SARS. And so they really didn't want to use that term a lot in terms of prognosis.
So they've moved on to this sofa scoring, which is sequential organ failure assessment, and they basically just assume that everybody's got SARS, but if they do have the added element of infection that they're septic, and once they've got that infection, they then will score them on their sofa score to give them a good prognosis or maybe a guarded prognosis. So here's just an example of a bundle used in human hospitals. So you can see up here, we have a patient here, it's got a known or suspected infection.
It's quite easy to follow. You perform an initial evaluation, do labs, cultures, and a blood lactate, and that's standard for everybody. And then the question is, do they meet two of the SARS criteria?
So that's 2 of these clinical parameters up here. If they don't just treat that infection and start those antibiotics and just monitor all of their clinical parameters. But if they do, then that patient is septic.
So now is to just determine whether they're severely septic or in septic shock. So then you'll go to these two tables here and if they meet these, then you follow the table down here. So if they are in severe sepsis, the 3 hour bundle just says you need to get 2 sets of blood cultures, start antibiotics and do your first lactate measurement.
Then once you've done that, you repeat the lactate if that was high initially. With the septic shock patients, again, you'll do the two sets of blood cultures, start them on antibiotics, do the lactate measurement, but also these patients are hypotensive, so you'll give them a crystalloid bolus, and that is just prescribed as a 30 mL per kilo for a human patient. And then within that 6 hours you'll definitely be repeating that lactate if that was high, starting vasopressors if they're not responding to their fluids, and then go back and reassess them and it's basically a continual cycle through this table.
OK, so here's a poll question. Right, folks, I am launching the poll for you now. It's very, very simple.
All you need to do is just go and click click on the answer that you feel best represents what you believe is being asked by Katie. So the question is, in human studies, early recognition of sepsis has been shown to improve survival of these patients by up to what percentage? Simply click on the answer that you feel is the right one.
And we'll give you about a minute to respond to that and then we will reveal the answers. Please remember that these are anonymous. So don't feel shy if you can't remember what Katie said in her slide, then, take a guess.
Let's let's have a look and see. . It is anonymous so it's no reflection back on you.
But what it does do is it just maybe if you're not sure just prompts you to, to concentrate a little bit more shall we say. Right. It's another couple of seconds.
We've got a few stragglers that haven't voted yet. Right, Katie, let's end that poll quickly and let's share those results. Can you see those?
Yes, I can. Yeah. So yeah, so, 75% of you have got that answer correct.
So yes, it is 50%. And actually that's really great. So if you think that these, these are nurse-led protocols, then actually as veterinary nurses, it might mean that we can make this difference for our patients in In the hospital, so it's really important.
OK. So we'll just go through our clinical signs that we associate with veterinary patients with sepsis. So as I said, SARS is very, very common.
And we, if we have a patient admitted to the hospital, and we think that they might have an infection somewhere, then we really should be thinking about sepsis all the time. It's really important that as nurses, we're making good notes. It's important for everybody that's clinical with every patient to make good notes, and it is a legal requirement as well.
But I'm going to be going on about trends, over the next sort of few slides, because observing trends is really, really important with our patients in sepsis. So, if we are looking after our patient for 12.5 hours on our shift, that's great.
And We're probably following those trends really well. But then what happens when that patient then transfers hands into another nurse, and another veterinary surgeon? You want to be able to say, you know, you've made a good enough notes so that, that next person can see where the patient is going and actually make sure that they're also following the right, the right trends.
And we'll also be monitoring the bloods and their organ function, very, very carefully throughout their stay. So this is a table, which actually is the first table brought about for clinical parameters for patients in SERS, veterinary patients. And, it actually is still very relevant today.
So I think it's still very helpful to sort of have about. And it is just showing you that the basic parameters that we will look at for a patient that we think is SASi. So looking at the temperature for our dogs and cats, so if they are hypothermic, under 37.2, and also So if they are perxic of over 39.4.
It's also very common if a patient has SARS slash sepsis, that they will be tachycardic, so sort of parameters here, but also cats because they like to be different, will often present bradycardia actually with a heart rate of under 140. So it's just really important to remember that. They will often be tachypnic, so have a respirator of over 24 for dogs and over 40 for cats, and that's because of the increased oxygen demand on the cells while they've got an infection there.
And obviously they will have an increased white blood cell count as their body is trying to fight the infection. OK, so just a quick slide on cats, really. So cats are not small dogs and they often try to hide how sick they're feeling until it's a little bit too late.
So they normally get to us much sicker than the dogs. And they also become sick quite quickly due to their smaller intravascular volumes, and they have a poor regenerative capability as well. Say cats will often present to us in lateral recumbency.
They will be hypothermic, and kittens will obviously take the worst hit. So they'll be hypothermic, often hypoglycemic, unable to maintain that, that glucose, and they will be bradycardic as well. It is really rare to see cats with SARS because they do tend to sort of go, go about their daily business feeling a bit unwell until actually they just can't do it anymore.
So tend to present to us, in sepsis. And due to this, they do have a higher mortality rate compared to dogs. So some clinical signs.
So you've just quickly said about the heart rate, but this is variable depending on the stage of sepsis. So with SAS, we have a tachycardia, but also with septic patients, especially felines, there'll be bradycardic and actually canine patients can also be bradycardia with sepsis, but it's normally a later stage of sepsis. They will normally be to Kipnick because of an increased use of oxygen in the tissues.
And once our patients are really in severe sepsis and septic shock, that's when we'll start to really be concerned about ours. So our acute respiratory distress syndrome, and that's just because we'll be thinking about our organ. Dysfunction syndrome and actually have is our patient started that coagulation cascade and is their lungs struggling a little bit if it's got cell damage.
And those patients will really start to have an increased respiratory effort as well as rate. So it's just really important to keep that in mind. Blood pressure is another really good point.
So, most of our septic patients will be hypotensive. And initially we'll treat this with, fluid therapy and crystalloids are normally the, the fluid of choice, whilst monitoring our blood pressures. So we'll try to do fluid challenges with these patients.
So in dogs, we'll go up to 60 to 90 mL per kg bonuses, but we'll only do that in 5 to 10 mL per kilo, sort of bonuses at the time, just to check that they're coping with that. And cats obviously much lower, so 40 to 60 mL per kilo, and again, we'll do that in 5 to 10 mL per kilo lots just so that we can see if they're coping. And it's also because actually, if they haven't started to respond at all by by getting to the 60 to 40 to 60 mL per kilo, then actually maybe the these patients aren't going to respond to our fluids and we might need to be thinking about vasopressors.
And obviously this is a lot of fluids to give a patient, so we need to monitor really closely for signs of overload. And cats especially can be very asymptomatic for heart disease. So we want to be auscultating the chest a lot, checking for crackles, checking that respiratory rate and effort.
So these patients will have an increased white blood cell count as the body is in fighting an infectious agent, so really important to get baseline bloods on admission of our patients. And lactate as well. So a blood lactate of 2.5 millimoles per litre over will indicate a hypo perfusion before the body is kind of caught up.
So even if you've got a patient that's come in, you're suspecting sepsis, but actually, you know, they've got a normal heart rate, and they've got a normal respiratory rate, but they have a high blood lactate, that might just indicate that everything's being hypo perfused before they've sort of started to show other signs. And following trends of blood lactate will give a really good indication of prognosis. So it's actually more important to watch the trend of a lactate than it is to look at the number.
So we can have a patient, for example, I had a patient last week who had a lactate of 22 initially, and actually with a lot of fluid. Challenges and vasopressors, and a good support that lactate came down quite quickly, into sort of under 10, which is a better prognosis than a patient who might come in and have a blood lactate of 8, but that doesn't really respond to any treatment that we're giving them. We can also do fluid lactate on different fluid aside from blood.
So if the fluid that you're testing contains bacteria, the lactate will be really high because of anaerobic respiration. So for example, if you've got a patient that's come in and they've got a belly fluid fluid and they're collapsed and we think they might be septic, then actually it can be a really good diagnostic tool to test the lactate of a cent sample from their abdomen. And that was shown in about 2003 was that study and, and that's been like consistent.
So moving on to blood glucose, patients in sepsis will often be hypoglycemic. And that's because the cells and the bacteria in the body will be consuming that glucose as a higher demand of glucose in the cells. And as well as the blood, we can again test the glucose levels of any cents fluid.
So similar to the lactate and it was done in the same study. It showed that blood glucose levels were always higher than the blood glucose than the fluid levels in the fluid sample. In both dogs and cats in septic fluids.
But in non-septic effusions, the glucose was either the same or higher than the peripheral value. So again, that can be used as a diagnostic tool. Then hyperglycemia.
So it's actually, you can't really rule out a patient, even if a patient, if a patient looks septic and they come in and you do a blood glucose and they're hyperglycemic, you can't rule out sepsis. So some patients do, do present hypoglycemic, and that's thought to be due to insulin resistance brought on by the inflammatory cascade, but it's not really well understood, and it is quite rare for it to happen. But if you do have a patient that's not diabetic and they, they do become hyperglycemic, then again, that should be something maybe on your radar.
And it has been shown in many studies that maintaining a normal glucose is shown to decrease the morbidity and mortality rate. So we often do this with a continuous rate infusion of dextrose, sometimes insulin just to try and maintain an adequate level of glucose in the blood. And this should always be done in as a stabilisation so that we get these patients as stable as possible before they might have to have a surgery.
So neurological signs as well. In human patients, they're found to have an altered mentation in sepsis due to loss of cerebral blood flow. And this is even something down as a UTI.
So a urinary tract infection in a patient. It has been known that actually this often will cause confusion, and sort of they won't know sort of where they are, and it will all be down to this urinary tract infection. So it's really not unreasonable to expect that even though our patients are dogs and cats, that they might have some altered mentation if they are septic.
This must much be more difficult to assess because we can't sort of understand if they're feeling confused a lot of the time. A lot of our patients will present stuporous or obtunded, especially those cats. And as I said, it is difficult in veterinary patients, you know, these patients don't get up every day, go to work, you know, it's very difficult to know whether a cat or a dog is, is not feeling themselves.
So in order to try and help us, we will use a Glasgow Coma school, so modified Glasgow Coma school. It can be quite subjective, but it hopefully does limit the amount of confusion that we have when doing this, and it will also be able to give us a prognosis if they're, they're getting better or if they're getting worse on their MGCS. So we'll just follow trends.
And again, it kind of helps when we switch over from shift to shift. So you've looked after that patient all day and you've got to know that patient really well. But how, how will that next person, you know, they might never have met this patient, they're gonna come in and they'll think, gosh, you know, he looks terrible.
But actually, you know, by doing your Glasgow Coma Scale that actually they have really improved, or vice versa. So C-reactive protein, that's an inflammatory marker used in human medicine and it's used all the time. CRP is synthesised by the liver and it's part of the acute phase response by the pro-inflammatory cytokines.
So in human medicine, they'll use this as a sepsis marker and if you've got a high CRP they'll often think this person's septic. We have used it in veterinary studies and you can do it on your patients really regularly. It has been found, as long as you're counting other signs to be somewhat useful in determining sepsis.
But it hasn't yet shown a really good correlation between rates of survival in septic patients, and it's not used very commonly. So another thing that we will monitor will be our liver and our renal parameters. So we should be doing regular blood tests to monitor the values of both and again watching trends.
Get an increase of just 0.5 a me per deciliter might indicate an acute kidney injury, again, which we'll be thinking, is this patient, you know, becoming severely septic? And are they developing multi-organ dysfunction syndrome?
And coagulation, as I discussed earlier, might be triggered by our sepsis. So we have hypercoagulation initially, where they get all these microthrombi, which damaged the organ functions, and then that leads down to hypocoagulation. And in our hospitals, we're very lucky.
We can check our collate, sorry, we check our clotting times very quickly, and I think they are becoming more prevalent in practise, but we'll often check a prothrombin time and an activated partial thromboplastin time. And if either of these are elevated, we might be thinking this this patient is, you know, have a coagulopathy and they might lead to DIC. And DIC is obviously when these microthrombi damage all the organ cells.
And so when a patient then suffers another trauma, they start to have a haemorrhage because they can't hemostas appropriately. And then leading into our multi-organ dysfunction syndromes. So unfortunately, this patient here, as you can see, I think we're on 9 infusions in total, was definitely in the later stages of multi-organ dysfunction.
So monitoring all of those above clinical parameters meant that there was cell damage and ultimately death in all of those organs. And once that is reached, the mortality and morbidity rate is, is very high. And as I might have mentioned earlier, up to 90% of human admissions to ICU are confirmed sirs, so they will take any infection in their patient as an agreement that that patient is septic.
So that's something that we really need to be thinking of more in our patients. And a new definition in 2016 was brought on that sepsis was actually a life threatening organ dysfunction caused by this regulated host response to infection. So here's our second poll question.
Right, folks, so the same story, we're launching the poll here and if you can just answer what you feel is the appropriate correct answer. The question being, of course, which of these is a contraindication for placing a central catheter in a septic patient? Hypertension, hypotension, coagulopathy, or ARDS.
Again, we'll give you about a minute or so to click on these. Remember, it's, it's completely anonymous. We don't know who's voting what so.
If you're not sure, put your brain to work and have an educated guess at what you think the right answer is. Alright, another 10 seconds and then we're going to reveal those answers. Couple of stragglers.
Sitting on the fence here, Katie. I think they, you've got the brains working on this one. There we go, we're getting a few more coming in now.
Come on, folks, another 5 seconds and then we're gonna end this one. Off the fence, take a chance. And let's end the poll and then share those results for you.
Great. So, yes, it's coagulopathy. So most of you got that.
And yes, apologies. I haven't actually discussed a central catheters with you yet, but I just thought I'd throw that in there to see if I could get your brains working. So, yeah, that's really well done.
So, if you have a coagulopathy in your patient, that means obviously, they are, they're bleeding if they suffer any, any sort of trauma. So placing a catheter into their jugular vein might not be the best idea at the time. OK, so now the nursing stuff, so that's what we're all really interested in.
For the nursing process, so really back to basics, so. Assessment, planning, implementation and evaluation. This is something we've all been taught, and actually this is something that we might not think about on a day to day basis, but subconsciously, this is something that's going on in our heads all the time when we're looking after our patients.
And this might or may or may not be something you've heard of before, but the rule of 20 is quite useful in our critical nursing of patients. So, it was Rebecca Kirby's rule of 20 they're all listed here on the right hand side. And these are basically 20 clinical parameters which have been decided to be assessed at least daily for every critical patient.
In practise. It's very comprehensive and it's ensuring that each patient has all their needs met. So I think that actually, although this is veterinary driven, and this was developed for critical veterinary surgeons, and it's actually really important for us to kind of think about these things all the time so that we can include them in our nursing care plans for our patients.
So, Nursing care is one of them. But just to make sure that our patients are really receiving really holistic care. They're getting everything that they can possibly need.
Because I think often it's very easy to get distracted and carried away with a, with, especially with a critical patient about the thing that they're really sick with. And very easy to forget, actually 3 days down the line that we've not really thought about nutrition, for example, with this patient. So, Something that I think is really worth having a look at.
So critical care nursing has been defined as the care taken or required in response to a crisis. And sepsis is a rapidly progressing condition. These patients can present to us, 1 minute and within half an hour, be really, really poorly and require maybe resuscitating.
They might need minute by minute care and for that reason, they're best nursed in a 24 hour facility such as an ICU. But these patients can be well looked after in 24 hour hospitals all over the country. They just need the appropriate nursing care, so that we have, we have somebody sat with this patient a lot, able to sort of pick up when things changes.
And I think it's really important as nurses, we're the advocate for our patients, and it's really hard for the surgeons to be looking after these animals and really notice everything that changes. We sit with our patients a lot, and we get to know them. And for example, the mentation changes, somebody might not pick that up if they've only met that dog twice, but if we sat with that patient and we've nursed them and, and we know that that patient.
If you think, actually this, this patient's mentation has changed, they're acting a bit strangely, then that's something that we really need to be voicing. And I think again, Along with this, it's really important that we have a good clinician, nurse understanding and trust so that this relationship can go both ways so that we feel confident enough to say, hey, I'm really worried about this patient. Can you just have a look?
Even if there's nothing really specific, and really important that vice versa, that vet, is able to kind of trust us to look after that patient. So A lot of nursing is monitoring parameters. And actually, we can think, TPRs, they sound really boring.
We do them all the time. We do them every day, but there's a reason that we do TPRs every day. So taking rectal rectal temperatures regularly is super important.
We can pick up on temperature changes really quickly. Doing regular heart rate and respiratory rate and respiratory effort checks. And if you have the availability, then actually putting these patients on a multi parameter monitor is really good for constant monitoring of all of the above things.
And actually nicer for the patient as well, because it means you're not having to interfere with them all the time. These patients are feeling very sick, they're not feeling well at all, and especially having a temp. Which are taken every 15 minutes, 30 minutes, is isn't pleasant.
So if we have the availability of these monitors, then actually why shouldn't we use them? And I think alongside good nursing care, they're really invaluable. And again, I've mentioned before, but good patient notes are really important.
They are a legal document, and they can be requested by the client at any time. So I just think that we really need to be making a good concerted effort to be making good clinical notes. And also for these all follow these trends, you might know this patient really well, but unless you've written that down, actually, once you've left the hospital, it doesn't mean very much.
And report to a clinic when changes. So as I said before, really important that we have that good bond with our clinicians, and that we have a mutual trust, and it should be good that you feel confident to be your patient's advocate and say something's really not quite right. Here, and vice versa, and watching these trends.
And it is really difficult, especially in general practise, if you've got your vet looking after this patient, but also consulting or doing surgeries, and they don't have the time to spend with a patient that actually needs their care really full on. And then, yeah, it's really good for, for the nurses to be trusted enough to alert them when necessary. So what else as nurses can we do with these patients?
Is it just TPRs? Well, no, we can, we can do a lot. So we can place and maintain lots of different tubes, lines and drains in our patients.
And this comes down to the ones that we do every day. So our intravenous catheters, so really quick and easy and we're all trained to do that, and that's really important. We can also, with extra training central venous catheters, and we can also place arterial catheters.
And we'll use a peripheral catheter to give medications through. We'll obviously give fluids through that. And if we do place a central venous catheter, then actually that gives us the possibilities of putting higher fluid rates and volumes down there and also medications.
We can put more of them down and higher. Concentrations are safer in a to a jugular vein than into a peripheral vein, especially in these patients that might require a really high percentage of glucose. We can put a really high percentage of glucose into that vein and not worry about it, whereas we wouldn't put anything of over 7.5% glucose into a peripheral vein at a push.
Having a central venous catheter also means we can do regular venous blood samples without having to stick these patients a lot. So, again, we've got this septic patient. We're not sure how sick they might get.
They might become a septic shock. They might have a coagulopathy. And so if we've already placed the central line, it will stop us from having to keep repeatedly sticking our patient for regular blood blood checks.
We might want to place an arterial catheter if our patient's quite immobile. And again, that will give us a good port for regular sampling of arterial blood gases, which will enable us to check this patient's oxygenation status. And it will also enable us to put them on an invasive blood pressure monitoring, which can be a constant blood pressure monitor on our multi-parameter monitors.
So again, they're really useful. And even if we can't place all of these things in every patient, we need to just make sure that any line that these patients do have need dressing really well. They need to be checked at least twice daily, especially in septic patients.
So fluids and medications. Got the tree of life there on the right hand side. So we want to ensure that we're putting the correct fluid type into the patient at all times.
So as I said before, crystalloids are normally the, the fluid of choice, but if our patient has a coagulopathy, they might require fresh frozen plasma. And I think it's really important that we get into habits of labelling everything that we put on patients. So even if you are just putting on a bag of saline 0.9%, like, get that checked with somebody and label it because fluids can make such a difference in these patients if they're done wrong.
These patients should have been started on antibiotics very early on. They will probably be on pain relief for something. And I've put here opioids versus non-steroidals because I just want you to have a think really.
I guess opioids are very safe. We use a lot of them, methadone, fentanyl, CRIs. But we probably wouldn't use a non-steroids or iniseptic patient.
And that is because we are worried about our hypo perfusion and we don't want to compromise the renal function any more than is might already be happening. These patients might be on vasopressors, especially if they've had septic shock and they've not responded to any fluid challenges. And we need to make sure again that these are, these are checked and labelled.
So anything that's on a CRI, we want to calculate it well, double check it with another member of qualified staff and get that labelled up really, really well. And then as nurses, we're obviously attaching all of these drugs to the patient, and it's worth giving it a thought whether they are all compatible with each other. If we're putting them into the same line, is anything going to happen before we get to the patient?
And again, by labelling lines clearly and having separate lines for separate things, we can avoid incompatible combinations. And also another thing to really be a aware of is accidental bolusing of dangerous medications. So, if you've got this patient, which may be having several fluid bolus, it might be worth sticking a separate IV catheter in there, just so that you can get fluid bolus through that one catheter.
Because if they're on vasopressors and they accidentally have a bolus of that, then actually, that could be really dangerous for them. So, really label everything and, and make sure that you're not going to be doing that. And then something else to really think about.
And again, this comes back to our Kirby's rule of 20 is nutrition. So initially, we obviously want to be stabilising these patients, and nutrition doesn't always come into it in the first few hours. But if this patient hasn't been eating for, for several days a week, then we really need to start about thinking nutrition.
And a way that we can give these patients nutrition without really compromising how sick they're feeling, we, we could maybe give them enteral nutrition. So it's really worth, worth having in the back of your head. We can place our urinary catheters.
So we'll often place an indwelling foley in in all, in all of our dogs, . And it's really good for monitoring our urine output and our specific gravity. And we can do this as regularly as we need to, which is really good for assessment of our renal function.
So if there is a severe drop in urine output, or change in our SG, then we can alert our clinician. And if the urine output has dropped in line with the increase in creatinine, then maybe we have some AKI going on there. We want to take extra care of these patients in cleaning the catheters.
It's quite common that septic patients will be neutropenic, so we want to wash these catheters really well, and they are a risk for UTI. So in our hospital, we'll do 4 hourly cleaning, with gloves on, obviously, and dilute hippie, and we'll start at the vulva or prep use and wipe down the whole closed system, but we will never go back up. And that is how we prevent tracking of bacteria up the outside of the system.
We will never open the system either, unless we're emptying the bag, obviously, which we do aseptically, unless the patient is known to have sort of a risk for blocking, if we know that that patient has stones and there is a drop in urine output and it's significant, and we're worried about that, then we might do that really aseptically open it up and flush and sort of see if there is a blockage or whether that is a true drop in urine output. And actually, Foley catheter can be used as a faecal collection system. And this is at the vet's discretion.
It's not done very often. But if a patient really has watery diarrhoea, if it's hemorrhagic, and they're really suffering and soiling themselves really regularly, and actually it's really good to Place a catheter to collect all that faeces so that we're not having to bath these patients really regularly. You know, they're not going to get sores and just for their benefits as well, no patient likes lying in their own faeces, as well as their urine and actually, it might just make them feel a bit better.
OK, so moving on to some drains. So drains are typically placed by surgeons, normally when they're doing surgeries of some kind. So our chest drains can be in place, and we're allowed to drain these.
So we'll do this aseptically, so normally wearing sterile gloves. And I don't know if you can see here at the top of the picture, we tend to use, needle-free bungs as a way to Prevent any incidences of human error with a three-way tap because people do get very confused with 3 taps. And just so that we don't have any errors with that.
And once we drain our chest drains, we will measure the output and we'll write down whether that was air versus fluid. And we'll also write down if we do get fluid off our chest drains, what the fluid looks like. So if that fluid is er sanguinous, if that fluid is purulent, if it looks pussy, if it has like flocculent material in, then we'll write that all down.
And that again is following a trend because we might start out with something that looks quite clear and quite safe to something that really doesn't look well at all. And by monitoring that trend, we can say, hey, actually, this, this chest is becoming infected. Can we have a look at it?
And because we're taking these, doing these chest strains aseptically, we can rely on those samples to be taken for culture to check if they are septic. If we do have a pyothorax, as well as draining the chest, we will sometimes flush in saline to help reduce the volume of bacteria in the chest. So we'll normally do that in 10 mL quantities at a time so that we don't lose too much fluid in there, and we'll flush in warm saline and draw that back out.
And that's just hoping to reduce the volume of bacteria. We'll also be caring with these patients with wound drains, and that's quite common in our septic patients. So we have obviously different types of drains, active versus passive.
You won't ever find a passive drain in a septic abdomen. It will always be an active drain. And normally, a Jackson Pratt, or a grenade is normally best so that we can have some pressure on there to really suck out that fluid, because especially when they've been septic, we do not want that fluid sitting in there.
And to drain them, we want to do that aseptically as well. So wearing gloves, it's really important to prevent bacteria entering the drain and tracking upwards. We really want to be removing infection, not introducing any more.
OK, so feeding tubes as well. So as nurses, we can place our feeding tubes. And obviously there are a multitude of ways that we can do so, but the only one I'm going to talk about is nasogastric because I think that actually in septic patients, these are the best.
So we can place these. So obviously, we measured to the last rib, and that's to ensure that we're getting them into the stomach. Then using local anaesthetic and lubricant will aid that placement, and a lot of the time these patients are very sick and they tolerate it really well.
We will suture or staple them into place. I personally prefer a suture, but everybody has different preferences, and we'll label them really clearly. And then we'll do a really thorough check to ensure that they're in the stomach and not the airway.
It's easier to see that these are in the stomach because they're nasogastric. So, there's sort of less chance of them being in the airway than, an N. No tube because that's not going down as far.
But gold standard would be to X-ray these patients. We can also stick a catnograph on the end of any feeding tube, because if there is any danger of that feeding tube being in an airway, then our catnograph will give us a trace. But if it's in the oesophagus or the stomach, there'll be no movement of air and there won't be a catnograph trace at all.
And then finally, if you have this, tube in the stomach, we can aspirate, hopefully the gastric contents. If the patient is mobile, then we can put a buster colour on to prevent them from any interference, and we label the lines to avoid confusion. And the reason I think these are the best for septic patients is because they're often quite nauseous, and we can aspirate that gastric fluid, which will reduce the nausea feeling and just make them feel a bit better.
And I'm all for making these patients just feel a bit more comfortable. So if we can do that, then actually that's really great. And also, once they're stable enough and the vet has decided that they're happy, we can actually start to trickle feed a sensitive diet, into the tube, virus CRI normally to prevent further nausea.
So we're not bowless feeding these patients. You know, they might not have eaten for several days, and so bolus feeding them can make them feel much worse. So just by doing a CRI, so over 24 hours, just a trickle of a couple of mLs an hour, it's really good to start getting them into their nutrition, without making them feel too sick.
So, other mentation that these patients may have. So if we're using a multi-parameter monitor, then we can place ECG pads on the feet of the thorax. Often they will tolerate a temperature probe and that will enable us to not have to take too many temperatures.
If they are obtunded or stuporous, I'll use an SPO2 probe and pink mucus membranes are best at getting readings and I'm sure you're all used to using these in anaesthetics and things. So the tongue is very useful, but also the ear pinner. And if you have an SPO2 reading of 95 or below, then that actually does indicate a hypoxemia.
And it's equivalent to a PAO2 of 90 millimetres of mercury. And a PO2 in a healthy patient should be above 95. So, you know, SP reading of 95 is important and I know that sometimes it's kind of brushed off, because you think it's a pulse ox and they're not always that accurate, but we really should be supplementing all of our septic patients with oxygen.
And if the SPO2 reading is 90% or below, and that's actually severe hypoxemia, which is equivalent to 60 millimetres on arterial blood gas. And if we have a patient with a PO2 of 60, then that indicates that we need to be mechanically ventilating this patient, and we really should be thinking about odds in our septic patients. So as I said, these patients have an increased demand for oxygen because their cells are working overtime with all this bacteria.
So even if this patient looks quite bright, we will probably use a mask and just give them some oxygen flow by. And if they will tolerate it a bit more, we might put some prongs or some cannulae down their nasal passages so that we can get a higher concentration of oxygen down there. We don't really want to be putting these patients in oxygen cages, because these patients can rapidly deteriorate.
And if we've shut them in a kennel, with oxygen, then that's great. They're getting the oxygen, but they, they won't be getting any of the other nursing care and you might not be checking them as often. So it's actually really important that we have these patients out of oxygen if possible.
And if our patients are sick enough that they have to be intubated, then we'll use capnography. OK, so just some upptic patient care that we really need to be thinking about as nurses. So these patients, if they're recumbent, will need regular turning to avoid any ulcers.
We'll also do some passage range of movement, some effloage and some petrisage to try and get these muscles working so that we don't get too much wastage. We will nebulize our patients, especially if they're on 02 supplementation, or if they have a respiratory pathology. So if we believe that the septic focus is an aspiration pneumonia, for example, we'll nebulize these patients thoroughly.
If they've got any wounds, then we want to be making sure we change the bandages really regularly and checking for strike through but hopefully changing them before they do become struck through. We want to be doing oral care, so if we have an intubated patient, we will go and suction their airway. But even if our patient isn't intubated and they're just recumbent, we'll do regular cleansing of the mouth and teeth with either very diluted lhexidine or a diluted corsidil solution.
And the theory behind this is obviously to make them feel a bit more comfortable, but also to reduce the amount of bacteria in the oral cavity, because if we've got a buildup of bacteria in the oral cavity and these patients are recumbent, then they might aspirate that bacteria in their mouth, and give themselves further issues. And we want to also be looking after their eyes. Regular lubrication, especially if they're not, they're on opiate analgesia, and regular saline flushes as well.
And then again, thinking about our nutrition. So whether we need to start these patients on a partial parentinal nutrition, or whether we want to get feed them enterally is something else we should be thinking about in a long term sick patient. And in every septic patient that comes into the hospital, we need to be barrier nursing them, so wearing aprons and gloves at all times and being bare below the elbow.
So we're very strict in our hospital. We don't allow any jewellery or watches, and everybody has to be wearing the appropriate PPE to nurse these patients. OK, so our last poll question.
Right, let's see if we can get that poll launched quickly. I'm battling a little bit here to get it open. Bear with me one second.
There we go. Launching the poll quickly. So the question is, why should recumbent patients be turned regularly?
To reduce the risk of pressure sores, to reduce the risk of hypostatic. Pneumonia as a part of physiotherapy or all of the above. Come on, you know by now simply click on the appropriate answer and there's no need to sit on the fence.
It's all anonymous. Give us a click, let's see what you've been listening to and or how well you've been listening to Katie. Katie, it's been absolutely fabulous and fascinating.
So I'm sure everybody has riveted with what you're saying. Come on folks, another 10 seconds and then we'll stop that pole. We've got the usual stragglers not not coming in.
Come on, give it a go, click that's an answer. Right, 5 more seconds. Right, let's end that poll and I'm very pleased that everybody's been listening to you.
There's the result that. Great. Yes, so it is all of the above, so everything on that list is important as the next.
So yeah, well done. No. OK, so just a really quick review.
I hope that you've enjoyed it. So by now, hopefully you will understand the definitions of sepsis, . Says septic shock, odds and multi-organ dysfunction syndrome.
Hopefully you have a good basic understanding of why our patients can go from having this sort of seemingly normal trauma such as a surgical wound to then becoming septic. Hopefully now you'll be able to recognise clinical signs relating to sepsis in our patients and when to alert the vet to changes or concerns over the patients. And I really hope sort of how you've, what you've taken from this is how best to nurse these patients and how important your role can be.
Because by understanding sepsis, and how it shows itself, we will pick this up earlier and treat the symptoms which, like we've shown in the human, research, will increase the patient's likelihood of survival. And as nurses, we can make such a big difference. So hopefully, that's what we can do.
Any questions? Right. Katie, as I said to you just now, this has been absolutely fascinating and riveting and I have to tell you as a vet myself, nurses, I always call them little green angels or little blue angels depending on the uniform because really they, they are the ones that make the difference.
And I think in a lot of these cases, it's, it's the nurses that pull them through rather than the vets because the vets just go do this, do that. But it's the nurses that get in there and care for them, care for them and love them and and and follow through on everything else. And the monitoring is, is absolutely critical, so that's really great.
Yes, I totally agree. Right, folks, in your, question and answer box or in the chat box or I say, Dawn has popped in a survey. When you logged in on the screen that you logged in on, the surveyMonkey is also there.
Do us a favour when we're finished and just, either click on the link or Follow the server monkey on the screen that was open for you. And it really does help us to give us feedback and also on topics or comments that you've got, it really is, it really is an important thing for us to develop the channel to be giving you the CPD that you want. .
The there's a comment or a question that's come through. David Hopper has said, as a vet, I found this talk very informative. Thanks Katie.
Yeah, no, it, it really is nice because, and I think also, you know, as vets don't tend to think as much about what the nurses do. And as I say, I, I'm a huge nurse fan. I really am.
And, and advocate for nurses because they are the ones that really implement what needs to be done. So it's, it's really nice to be able to understand better what the nurses are getting up to. Thank you.
I think as well it's really important that nurses understand that that their role isn't sort of boxed up into all these different things and actually by by learning more and taking an interest in all these things, we can make such a difference. And we don't just have to sort of be the ones just doing TPRs every 2 minutes. We can sort of understand what's going on and why.
I think it it comes down to enjoyment as well. You know, if you understand and know what's going on, you can enjoy your job more. And I, I really don't have a problem if a nurse comes and goes, Listen, you said this, this and this.
What about that or have you thought about or I've just been to the patient and this is happening, I need you to look and I think that's so key, you know, that that nurses are a vital, vital part of the team. And, and can make more of a difference in a lot of these septic cases than the vets do, quite honestly. Definitely.
And I think as well it's not, it's just two heads are better than one in any situation, aren't they? And I think everybody, it's human nature to kind of maybe have one idea and go down one idea, but sort of having and valuing input from all members of the team is really helpful. And is the key word there it really is.
Well, Katie, it looks like you've answered all the questions. There's there's lots of comments about great webinar and very informative and thanks very much. So yeah, that's fabulous.
From my side, it just leads me to say thank you for a very, very informative talk and I can't wait to have you back on the webinar talking to us again. Oh, thank you very much. It's been a pleasure.
