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Slide 7 Despite aggressive fluid management with colloid and crystalloid fluids, further hypotension ensued and blood gases indicated worsening organ perfusion. Escalation of noradrenaline helped improve blood pressure but empirical data was needed to help medical and nursing staff manage the deteriorating cardiovascular situation more effectively. Non invasive cardiac monitoring [access to the heart is not required to obtain data] provides data that tells the clinician how effectively the heart is pumping [CO and CI] and how vasodilated/vasoconstricted [SVR] the vascular system is. Fluid and noradrenaline are titrated to maximum effect to raise blood pressure and improve organ perfusion. With an agreed plan of haemodynamic management the nurse is able to manipulate therapies to maximum effect. Interpretation and management using this new data requires experience and competence form both nurse and doctor. Constant information sharing from all those involved is vital at this critical time in order to stabalise cardiovascular collapse.

Slide 8 An anuric state precipitated by hypotension leads to acute renal failure. Despite maximising cardiovascular function with fluids and noradrenaline, a rapidly deteriorating base deficit with a life threatening acidotic pH together with a lack of urine made urgent instigation of continuous venous-venous heamodiafiltration [CVVHDF] a necessity. A grossly raised lactate level seen on blood gas is indicative of poor perfusion and prompts the choice of lactate free solutions with 8.4% sodium bicarbonate buffer cover. Following insertion of the appropriate cannula [vascath] it is the nurses responsibitity to instigate CVVHDF. During the instigation process the patient becomes grossly hypotensive and requires rapid colloid fluid bolus and increase in noradrenalline. The patient stabalises and tolerates near maximum CVVHDF therapy. CVVHDF is managed by the bedside nurse who notes improvements in pH, base deficit and lactate as seen on blood gas results. Initially pyrexial, with the instigation of CVVHDF [extra corporeal circuit] the patient temperature drops well below normal limits. Use of warming blanket, head coverage and CVVHDF warmer are strategies the nurse employs to aim to elevate temperature to near normal levels.

Slide 9 Enteral feeding is commenced as a matter of urgency. The aim is to meet the metabolic needs of the patient who is in a hypermetabolic state owing to sepsis and, to maintain gut integrity. This will decrease the possibility of gut ischaemia and translocation of bacteria into the blood stream. After the initial hypoglycaemic blood glucose level is elevated using 50% dextrose the blood glucose levels are kept strictly between 4 - 7 mmmol/l using sliding scale insulin. This has been shown to positively influence outcome in sepsis. The nurse manages enteral feeding using a locally developed nasogastric feeding protocol and the blood sugars are monitored hourly with arterial blood gases. They are kept within the designated parameters using a unit devised sliding scale insulin protocol.

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