Validación de protocolo asistencial al paciente séptico en la Unidad de Terapia Intensiva

Pedrosa, Karilena Karlla de Amorim; Oliveira, Suelen Alves de; Machado, Regimar Carla

doi:10.1590/0034-7167-2017-0312

Acessibilidade / Reportar erro

Brasil

Revista Brasileira de Enfermagem

Español English

Brasil

Español English

sumário « anterior atual seguinte »

Sumário

RESEARCH • Rev. Bras. Enferm. 71 (3) • May-Jun 2018 • https://doi.org/10.1590/0034-7167-2017-0312 copiar

Validación de protocolo asistencial al paciente séptico en la Unidad de Terapia Intensiva

Autoría SCIMAGO INSTITUTIONS RANKINGS

RESUMEN

Objetivo:

elaborar y validar un protocolo para asistencia del enfermero al paciente séptico en Unidades de Terapia Intensiva (UTI).

Método:

estudio de la validación metodológica de instrumento. Dos etapas fueron seguidas: la elaboración del instrumento y la validación del contenido de acuerdo con la técnica Delphi.

Resultados:

la validación del contenido referente a la asistencia del enfermero al paciente séptico en terapia intensiva fue inicialmente compuesta por dieciocho elementos analizados por los evaluadores/jueces. De este, a través del Índice de Validez de Contenido (IVC), se identificaron trece elementos con fuerte evidencia de validación, IVC=0,79. A continuación, el instrumento fue refinado, siendo pues compuesto por quince elementos, que en la segunda fase Delphi presentó porcentual de concordancia superior al 84% para las variables pertinentes al protocolo.

Conclusión:

el método fue eficaz para validar el contenido de un protocolo para la asistencia del enfermero al paciente séptico en la UTI.

Descriptores:
Sepsis; Enfermería; Estudios de Validación; Protocolos Clínicos; Unidad de Terapia Intensiva

Variable	Yes		No		Total		CVI
Variable	n	%	n	%	n	%	CVI
1. Identifying sepsis	26	76.5	8	23.5	34	100.0	0.76
2. Lactate	28	82.4	6	17.6	34	100.0	0.82
3. Cultures	28	82.4	6	17.6	34	100.0	0.82
4. Venous access	30	88.2	4	11.8	34	100.0	0.88
5. Antibiotic therapy	24	70.7	10	29.4	34	100.0	0.70
6. Volume replacement	26	76.5	8	23.5	34	100.0	0.76
7. Vasopressors	29	85.3	5	14.7	34	100.0	0.85
8. Hemodynamic evaluation	30	88.2	4	11.8	34	100.0	0.88
9. Lactate monitoring	28	82.4	6	17.6	34	100.0	0.82
10. Blood pressure	27	79.4	7	20.6	34	100.0	0.79
11. Focus/Source Control	28	82.4	6	17.6	34	100.0	0.80
12. Inotropic TTT	27	79.4	7	20.6	34	100.0	0.79
13. Ventilation	30	88.2	4	11.8	34	100.0	0.88
14. Hemotherapy	28	82.4	6	17.6	34	100.0	0.82
15. Glycemic control	24	70.7	10	29.4	34	100.0	0.70
16. Nutrition	25	73.5	9	26.5	34	100.0	0.73
17. Prophylaxis DVT	25	73.5	9	26.5	34	100.0	0.73
18. Prophylaxis stress ulcer	25	73.5	9	26.5	34	100.0	0.73

Variable	Yes		No		Total
Variable	n	%	n	%	n	%
1. Identifying sepsis	26	100.0	0	0	26	100.0
2. Lactate	24	92.0	2	8	26	100.0
3. Cultures	26	100.0	0	0	26	100.0
4. Venous access	25	96.0	1	4	26	100.0
5. Antibiotic therapy	21	84.0	5	16.0	26	100.0
6. Volume replacement	25	96.0	1	4.0	26	100.0
7. Hemodynamic evaluation	25	96.0	1	4.0	26	100.0
8. Vasopressors	25	96.0	1	4.0	26	100.0
9. Inotropic treatment	25	96.0	1	4.0	26	100.0
10. Blood pressure	24	92.0	2	8.0	26	100.0
11. Focus/Source Control	25	96.0	1	4.0	26	100.0
12. Hemotherapy	25	96.0	1	4.0	26	100.0
13. Ventilation	24	92.0	2	8.0	26	100.0
14. Glycemic control	24	92.0	2	8.0	26	100.0
15. Nutrition	25	96.0	1	4.0	26	100.0

ITEMS	DESCRIPTION		JUSTIFICATION
1) SEPSIS TREATMENT AND RECOGNITION OF CLINICAL MANIFESTATIONS
Identifying sepsis	1.1.1 To perform routine screening on admission and in all patients with acute, potentially infected, acute diseases. 1.1.2 To know and identify diagnostic criteria of the systemic inflammatory response syndrome (SIRS), sepsis and septic shock:		To favor early diagnosis and treatment⁽¹1 Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli A, Ferrer R, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2016. Intensive Care Med [Internet]. 2017 [cited 2017 Apr 10]; 43:304-77. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28101605 https://www.ncbi.nlm.nih.gov/pubmed/2810... ^,¹⁴14 Instituto Latino Americano para Estudos da Sepse. ILAS. Sepse: um problema de saúde pública [Internet]. Brasília: CFM; 2016[cited 2017 Apr 21]. 90p. Available from: http://www.ilas.org.br/assets/arquivos/ferramentas/livro-sepse-um-problema-de-saude-publica-cfm-ilas.pdf http://www.ilas.org.br/assets/arquivos/f... ⁾. To improve hospital performance in sepsis⁽⁴4 Westphal GA, Lino AS. Rastreamento sistemático é a base do diagnóstico precoce da sepse grave e choque séptico. Rev Bras Ter Intensiva [Internet]. 2015 [cited 2017 Apr 1]; 27(2):96-101. Available from: http://www.scielo.br/pdf/rbti/v27n2/0103-507X-rbti-27-02-0096 http://www.scielo.br/pdf/rbti/v27n2/0103... ⁾;
	SIRS	Presence of two of the following: • central temperature (T) >38.3º C or < 36ºC; • heart rate (HR)> 90 bpm; • respiratory rate (RR) > 20 rpm or partial pressure of carbon dioxide (PaCO2) < 32 mmHg ; • total leukocytes> 12,000/mm or <4,000/mm³ or presence> • 10% of young forms (deviation to the left);
	Sepsis: SIRS+ organic dysfunction	Main organic dysfunctions: • systolic blood pressure (SBP) < 90 mmHg or mean arterial pressure (PAM) < 65 mmHg ou drop in blood pressure (BP) > 40 mmHg ; • oliguria (≤0.5mL/kg/h) or elevated creatinine (> 2mg/dL); • partial oxygen pressure/inspiratory fraction ratio of oxygen <300 (PaO2/ FiO2 <300), need for oxygen (O2) to maintain peripheral oxygen saturation (SpO2)> 90%; • platelet counts <100,000/mm³ or a 50% reduction in the number of platelets in relation to the highest value recorded in last 3 days; • unexplained metabolic acidosis: base deficit ≤ 5.0 mEq/L and lactate> than normal value; • lowering of consciousness level, agitation, delirium; • significant increase in bilirubin (> 2x the reference value)
	Septic Shock	Hypotension refractory to volume replacement
	Note: SIRS criteria are no longer required for the diagnosis of sepsis, but they to increase sensitivity in detecting potentially serious cases⁽³3 Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The third international consensus definitions for sepsis and septic Shock (Sepsis-3). JAMA [Internet]. 2016 [cited 2017 Apr 10]; 315(8):801-10. Available from: http://jamanetwork.com/journals/jama/fullarticle/2492881 http://jamanetwork.com/journals/jama/ful... ^,¹⁵15 Brasil. Ministério da Saúde. Agencia Nacional de Vigilância Sanitária. Segurança do paciente e qualidade em serviços de saúde. Anexo 3: Protocolo de segurança na prescrição, uso e administração de medicamentos [Internet]. Brasilia, DF: Ministério da Saúde; 2013[cited 2017 Apr 21]. 46p. Available from: http://www20.anvisa.gov.br/segurancadopaciente/index.php/publicacoes/item/seguranca-na-prescricao-uso-e-administracao-de-medicamentos http://www20.anvisa.gov.br/segurancadopa... ⁾.
	Source: Instituto Latino Americano Sepse (ILAS), 2016.
2) INITIAL MEASURES PACKAGE FOR SEPSE (FIRST SIX HOURS CONTROL)
Lactate	2.1.1 To collect blood samples for lactate dosing in the first hour of admission to the ICU in order to identify hyperlactatemia. 2.1.2 Perform sequential monitoring of lactate in patients with initial hyperlactatemia, measuring their values every two to three hours until the reduction to normal serum levels (lactate bleaching) (medical conduct).		-To favor the diagnosis of organic dysfunction⁽¹1 Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli A, Ferrer R, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2016. Intensive Care Med [Internet]. 2017 [cited 2017 Apr 10]; 43:304-77. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28101605 https://www.ncbi.nlm.nih.gov/pubmed/2810... ^,³3 Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The third international consensus definitions for sepsis and septic Shock (Sepsis-3). JAMA [Internet]. 2016 [cited 2017 Apr 10]; 315(8):801-10. Available from: http://jamanetwork.com/journals/jama/fullarticle/2492881 http://jamanetwork.com/journals/jama/ful... ⁾; -To evaluate tissue hypoperfusion and adequacy of initial resuscitation operations⁽¹1 Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli A, Ferrer R, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2016. Intensive Care Med [Internet]. 2017 [cited 2017 Apr 10]; 43:304-77. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28101605 https://www.ncbi.nlm.nih.gov/pubmed/2810... ^,¹⁴14 Instituto Latino Americano para Estudos da Sepse. ILAS. Sepse: um problema de saúde pública [Internet]. Brasília: CFM; 2016[cited 2017 Apr 21]. 90p. Available from: http://www.ilas.org.br/assets/arquivos/ferramentas/livro-sepse-um-problema-de-saude-publica-cfm-ilas.pdf http://www.ilas.org.br/assets/arquivos/f... ⁾;
Cultures	2.2.1 To collect two blood cultures at different sites before the start of the antibiotic therapy, preferably one in the peripheral vein and another in a central vascular access device, if present, and if it has been recently inserted (<48 hours), according to the protocol of the unit and/or prescription. 2.2.2 To collect cultures from all sites relevant to the suspected infection focus (uroculture, abscess secretions, catheter tips, tracheal secretions, among others) ideally before antimicrobial treatment begins. 2.2.3 Perform the collection of laboratory tests: arterial blood gas; hemoglobin, coagulogram, creatinine, bilirubin, and C-reactive protein (CRP).		-To identify micro-organism that causes infection for correct antibiotic therapy⁽¹1 Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli A, Ferrer R, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2016. Intensive Care Med [Internet]. 2017 [cited 2017 Apr 10]; 43:304-77. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28101605 https://www.ncbi.nlm.nih.gov/pubmed/2810... ^,¹⁴14 Instituto Latino Americano para Estudos da Sepse. ILAS. Sepse: um problema de saúde pública [Internet]. Brasília: CFM; 2016[cited 2017 Apr 21]. 90p. Available from: http://www.ilas.org.br/assets/arquivos/ferramentas/livro-sepse-um-problema-de-saude-publica-cfm-ilas.pdf http://www.ilas.org.br/assets/arquivos/f... ⁾; -To evaluate organic dysfunction⁽¹1 Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli A, Ferrer R, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2016. Intensive Care Med [Internet]. 2017 [cited 2017 Apr 10]; 43:304-77. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28101605 https://www.ncbi.nlm.nih.gov/pubmed/2810... ^,¹⁴14 Instituto Latino Americano para Estudos da Sepse. ILAS. Sepse: um problema de saúde pública [Internet]. Brasília: CFM; 2016[cited 2017 Apr 21]. 90p. Available from: http://www.ilas.org.br/assets/arquivos/ferramentas/livro-sepse-um-problema-de-saude-publica-cfm-ilas.pdf http://www.ilas.org.br/assets/arquivos/f... ⁾.
Venous Access	2.3.1 To puncture large-caliber peripheral venous access (PVA). 2.3.2 To assist in the passage of a central venous catheter (CVC), when there is indication of the use of vasopressors or the difficulty of peripheral access. Give preferences for double lumen catheter. 2.3.3 To identify and note date and time of CVC insertion. 2.3.4 To perform aseptic dressings on the CVC.		-Safe administration of prescribed medications, fluids, and blood products; -To prevent primary infections bloodstream infections (BSI) associated with the catheter⁽¹⁵15 Brasil. Ministério da Saúde. Agencia Nacional de Vigilância Sanitária. Segurança do paciente e qualidade em serviços de saúde. Anexo 3: Protocolo de segurança na prescrição, uso e administração de medicamentos [Internet]. Brasilia, DF: Ministério da Saúde; 2013[cited 2017 Apr 21]. 46p. Available from: http://www20.anvisa.gov.br/segurancadopaciente/index.php/publicacoes/item/seguranca-na-prescricao-uso-e-administracao-de-medicamentos http://www20.anvisa.gov.br/segurancadopa... ⁾.
ATB	2.4.1 To administer broad-spectrum antibiotics intravenously, ideally within one hour of diagnosis. 2.4.2 To evaluate the possibility of antimicrobial descaling based on the microbiological data (medical team and hospital infection commission).		-To institute early antibiotic therapy, with adequate spectrum for the presented infection⁽¹1 Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli A, Ferrer R, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2016. Intensive Care Med [Internet]. 2017 [cited 2017 Apr 10]; 43:304-77. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28101605 https://www.ncbi.nlm.nih.gov/pubmed/2810... ^,¹⁴14 Instituto Latino Americano para Estudos da Sepse. ILAS. Sepse: um problema de saúde pública [Internet]. Brasília: CFM; 2016[cited 2017 Apr 21]. 90p. Available from: http://www.ilas.org.br/assets/arquivos/ferramentas/livro-sepse-um-problema-de-saude-publica-cfm-ilas.pdf http://www.ilas.org.br/assets/arquivos/f... ⁾.
Volume replacement	2.5.1 To administer and supervise crystalloid infusion (30 ml/kg) as the initial choice fluid as prescribed. 2.5.2 To evaluate examinations and report possible changes.		-To maintain hemodynamic stabilization to prevent tissue hypoperfusion(1,14).
Hemodynamic evaluation	2.6.1 To perform complete hemodynamic evaluations at the bedside during the first six hours, discussing changes with the multidisciplinary team, goals: MAP ≥ 65 mmHg; control of water balance to obtain urinary volume ≥ 0.5 ml/kg/h; to identify abnormalities in HR, RR and distal perfusion. BP, HR,PVA		-To identify clinical complications⁽¹1 Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli A, Ferrer R, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2016. Intensive Care Med [Internet]. 2017 [cited 2017 Apr 10]; 43:304-77. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28101605 https://www.ncbi.nlm.nih.gov/pubmed/2810... ^,⁴4 Westphal GA, Lino AS. Rastreamento sistemático é a base do diagnóstico precoce da sepse grave e choque séptico. Rev Bras Ter Intensiva [Internet]. 2015 [cited 2017 Apr 1]; 27(2):96-101. Available from: http://www.scielo.br/pdf/rbti/v27n2/0103-507X-rbti-27-02-0096 http://www.scielo.br/pdf/rbti/v27n2/0103... ^,¹⁴14 Instituto Latino Americano para Estudos da Sepse. ILAS. Sepse: um problema de saúde pública [Internet]. Brasília: CFM; 2016[cited 2017 Apr 21]. 90p. Available from: http://www.ilas.org.br/assets/arquivos/ferramentas/livro-sepse-um-problema-de-saude-publica-cfm-ilas.pdf http://www.ilas.org.br/assets/arquivos/f... ⁾; -To avoid tissue hypoperfusion⁽¹1 Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli A, Ferrer R, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2016. Intensive Care Med [Internet]. 2017 [cited 2017 Apr 10]; 43:304-77. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28101605 https://www.ncbi.nlm.nih.gov/pubmed/2810... ^,⁴4 Westphal GA, Lino AS. Rastreamento sistemático é a base do diagnóstico precoce da sepse grave e choque séptico. Rev Bras Ter Intensiva [Internet]. 2015 [cited 2017 Apr 1]; 27(2):96-101. Available from: http://www.scielo.br/pdf/rbti/v27n2/0103-507X-rbti-27-02-0096 http://www.scielo.br/pdf/rbti/v27n2/0103... ^,¹⁴14 Instituto Latino Americano para Estudos da Sepse. ILAS. Sepse: um problema de saúde pública [Internet]. Brasília: CFM; 2016[cited 2017 Apr 21]. 90p. Available from: http://www.ilas.org.br/assets/arquivos/ferramentas/livro-sepse-um-problema-de-saude-publica-cfm-ilas.pdf http://www.ilas.org.br/assets/arquivos/f... ⁾; -To evaluate the adequacy of the initial volume replacement⁽¹1 Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli A, Ferrer R, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2016. Intensive Care Med [Internet]. 2017 [cited 2017 Apr 10]; 43:304-77. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28101605 https://www.ncbi.nlm.nih.gov/pubmed/2810... ^,⁴4 Westphal GA, Lino AS. Rastreamento sistemático é a base do diagnóstico precoce da sepse grave e choque séptico. Rev Bras Ter Intensiva [Internet]. 2015 [cited 2017 Apr 1]; 27(2):96-101. Available from: http://www.scielo.br/pdf/rbti/v27n2/0103-507X-rbti-27-02-0096 http://www.scielo.br/pdf/rbti/v27n2/0103... ^,¹⁴14 Instituto Latino Americano para Estudos da Sepse. ILAS. Sepse: um problema de saúde pública [Internet]. Brasília: CFM; 2016[cited 2017 Apr 21]. 90p. Available from: http://www.ilas.org.br/assets/arquivos/ferramentas/livro-sepse-um-problema-de-saude-publica-cfm-ilas.pdf http://www.ilas.org.br/assets/arquivos/f... ⁾.
Vasopressors	2.7.1 To administer adjunctive therapy with vasopressors, according to medical prescription, for stabilization of MAP ≥ 65mmHg if hypotension does not respond to initial resuscitation with fluids. 2.7.2 Attention to care in the administration of vasopressors: strict control of BP, HR, urine output and peripheral perfusion; presence of phlebitis in the administration of vasoactive drugs by PVA; correct identification of infusion vasopressor solutions; administration of vasoactive drugs in distal lumen exclusive to CVC; side effects (decreased cardiac output, sweating, hypertensive peak, peripheral hypoperfusion).		-To maintain hemodynamic stabilization⁽¹1 Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli A, Ferrer R, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2016. Intensive Care Med [Internet]. 2017 [cited 2017 Apr 10]; 43:304-77. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28101605 https://www.ncbi.nlm.nih.gov/pubmed/2810... ^,¹⁴14 Instituto Latino Americano para Estudos da Sepse. ILAS. Sepse: um problema de saúde pública [Internet]. Brasília: CFM; 2016[cited 2017 Apr 21]. 90p. Available from: http://www.ilas.org.br/assets/arquivos/ferramentas/livro-sepse-um-problema-de-saude-publica-cfm-ilas.pdf http://www.ilas.org.br/assets/arquivos/f... ⁾; -To attempt for signs of clinical worsening^(1,14); -To identify adverse drug reactions⁽¹⁵15 Brasil. Ministério da Saúde. Agencia Nacional de Vigilância Sanitária. Segurança do paciente e qualidade em serviços de saúde. Anexo 3: Protocolo de segurança na prescrição, uso e administração de medicamentos [Internet]. Brasilia, DF: Ministério da Saúde; 2013[cited 2017 Apr 21]. 46p. Available from: http://www20.anvisa.gov.br/segurancadopaciente/index.php/publicacoes/item/seguranca-na-prescricao-uso-e-administracao-de-medicamentos http://www20.anvisa.gov.br/segurancadopa... ⁾; -To certify the safety in the administration of medications⁽¹⁵15 Brasil. Ministério da Saúde. Agencia Nacional de Vigilância Sanitária. Segurança do paciente e qualidade em serviços de saúde. Anexo 3: Protocolo de segurança na prescrição, uso e administração de medicamentos [Internet]. Brasilia, DF: Ministério da Saúde; 2013[cited 2017 Apr 21]. 46p. Available from: http://www20.anvisa.gov.br/segurancadopaciente/index.php/publicacoes/item/seguranca-na-prescricao-uso-e-administracao-de-medicamentos http://www20.anvisa.gov.br/segurancadopa... ⁾;
Inotropic TTT	2.8.1 To administer dobutamine with a dose of 2-20 µg/kg/min, according to medical prescription, usually associated with the vasopressor. 2.8.2 To monitor the dobutamine infusion, considering: arrhythmias, excessive oscillations of BP, hypothermia, headache, nausea, anxiety, tremors and hypokalemia.		-To Improve myocardial dysfunction⁽¹1 Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli A, Ferrer R, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2016. Intensive Care Med [Internet]. 2017 [cited 2017 Apr 10]; 43:304-77. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28101605 https://www.ncbi.nlm.nih.gov/pubmed/2810... ^,¹⁴14 Instituto Latino Americano para Estudos da Sepse. ILAS. Sepse: um problema de saúde pública [Internet]. Brasília: CFM; 2016[cited 2017 Apr 21]. 90p. Available from: http://www.ilas.org.br/assets/arquivos/ferramentas/livro-sepse-um-problema-de-saude-publica-cfm-ilas.pdf http://www.ilas.org.br/assets/arquivos/f... ⁾; -To attempt for clinical signs of complication; -To identify adverse drug reactions⁽¹⁵15 Brasil. Ministério da Saúde. Agencia Nacional de Vigilância Sanitária. Segurança do paciente e qualidade em serviços de saúde. Anexo 3: Protocolo de segurança na prescrição, uso e administração de medicamentos [Internet]. Brasilia, DF: Ministério da Saúde; 2013[cited 2017 Apr 21]. 46p. Available from: http://www20.anvisa.gov.br/segurancadopaciente/index.php/publicacoes/item/seguranca-na-prescricao-uso-e-administracao-de-medicamentos http://www20.anvisa.gov.br/segurancadopa... ⁾.
BP monitoring	2.9.1 To provide arterial access for continuous monitoring of pressure. Maintain MAP> 65 mmHg (between 65 and 80 mmHg). 2.9.2 Caring for arterial catheter maintenance; 2.9.3 Constantly evaluate the punctured member for perfusion, T, pulse width and staining.		- Monitorar sinais indicativos de instabilidade hemodinâmica⁽¹⁴14 Instituto Latino Americano para Estudos da Sepse. ILAS. Sepse: um problema de saúde pública [Internet]. Brasília: CFM; 2016[cited 2017 Apr 21]. 90p. Available from: http://www.ilas.org.br/assets/arquivos/ferramentas/livro-sepse-um-problema-de-saude-publica-cfm-ilas.pdf http://www.ilas.org.br/assets/arquivos/f... ⁾; -Identificar complicações relacionadas ao dispositivo arterial⁽¹⁶16 Brasil. Ministério da Saúde. Agência Nacional de Vigilância Sanitária. Segurança do paciente e qualidade em serviços de saúde. Medidas de prevenção de infecção relacionada à assistência à saúde vol. 4[Internet]. Brasília, DF: Ministério da Saúde; 2017[cited 2017 Apr 21]. 92p. Available from: http://portal.anvisa.gov.br/documents/33852/271855/Medidas+de+Preven%C3%A7%C3%A3o+de+Infec%C3%A7%C3%A3o+Relacionada+%C3%A0+Assist%C3%AAncia+%C3%A0+Sa%C3%BAde/6b16dab3-6d0c-4399-9d84-141d2e81c809 http://portal.anvisa.gov.br/documents/33... ⁾; -Manter cateter permeável⁽¹⁶16 Brasil. Ministério da Saúde. Agência Nacional de Vigilância Sanitária. Segurança do paciente e qualidade em serviços de saúde. Medidas de prevenção de infecção relacionada à assistência à saúde vol. 4[Internet]. Brasília, DF: Ministério da Saúde; 2017[cited 2017 Apr 21]. 92p. Available from: http://portal.anvisa.gov.br/documents/33852/271855/Medidas+de+Preven%C3%A7%C3%A3o+de+Infec%C3%A7%C3%A3o+Relacionada+%C3%A0+Assist%C3%AAncia+%C3%A0+Sa%C3%BAde/6b16dab3-6d0c-4399-9d84-141d2e81c809 http://portal.anvisa.gov.br/documents/33... ⁾.
Focus/Source Control	2.10.1 To identify and control infectious disease: abscess drainage, necrotic tissue debridement, removal of potentially infected invasive device (delayed bladder probe, CVC), early weaning from mechanical ventilation, with definitive control of the source of microbial contamination within the hours after diagnosis. 2.10.2 To evaluate and report possible outbreaks of infection;		-To identify infectious focus to institute appropriate treatment⁽¹1 Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli A, Ferrer R, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2016. Intensive Care Med [Internet]. 2017 [cited 2017 Apr 10]; 43:304-77. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28101605 https://www.ncbi.nlm.nih.gov/pubmed/2810... ^,¹⁴14 Instituto Latino Americano para Estudos da Sepse. ILAS. Sepse: um problema de saúde pública [Internet]. Brasília: CFM; 2016[cited 2017 Apr 21]. 90p. Available from: http://www.ilas.org.br/assets/arquivos/ferramentas/livro-sepse-um-problema-de-saude-publica-cfm-ilas.pdf http://www.ilas.org.br/assets/arquivos/f... ⁾; -To stop invading the patient to minimize the risk of reinfections⁽¹⁶16 Brasil. Ministério da Saúde. Agência Nacional de Vigilância Sanitária. Segurança do paciente e qualidade em serviços de saúde. Medidas de prevenção de infecção relacionada à assistência à saúde vol. 4[Internet]. Brasília, DF: Ministério da Saúde; 2017[cited 2017 Apr 21]. 92p. Available from: http://portal.anvisa.gov.br/documents/33852/271855/Medidas+de+Preven%C3%A7%C3%A3o+de+Infec%C3%A7%C3%A3o+Relacionada+%C3%A0+Assist%C3%AAncia+%C3%A0+Sa%C3%BAde/6b16dab3-6d0c-4399-9d84-141d2e81c809 http://portal.anvisa.gov.br/documents/33... ⁾.
3) SUPPORT TREATMENT
Hemotherapy	3.1.1 To provide and administer the blood component, respecting its maximum time of infusion, according to medical prescription. 3.1.2 To verify and record vital signs (VS): T, HR, BP and RR according to service protocol. 3.1.3 To check the patient's identification data on the bag identification label with the medical record and the medical prescription; 3.1.4 To use PVA or lumen of the exclusive CVC during transfusion; 3.1.5 To identify and report adverse reactions during and up to 24 hours after transfusion; * RESOLUTION COFEN-306/2006; PORTAL Nº 158/2016.		-To maintain hemodynamic stabilization⁽¹⁴14 Instituto Latino Americano para Estudos da Sepse. ILAS. Sepse: um problema de saúde pública [Internet]. Brasília: CFM; 2016[cited 2017 Apr 21]. 90p. Available from: http://www.ilas.org.br/assets/arquivos/ferramentas/livro-sepse-um-problema-de-saude-publica-cfm-ilas.pdf http://www.ilas.org.br/assets/arquivos/f... ⁾; -To collect safety requirements in the administration of the blood component⁽¹⁷17 Conselho Federal de Enfermagem. Cofen. Resolução COFEN nº 306/2006: Normatiza atuação do enfermeiro em hemoterapia [Internet]. 2006[cited 2015 Jul 12]. Available from: http://site.portalcofen.gov.br/node/4341 http://site.portalcofen.gov.br/node/4341... ^-¹⁸18 Brasil. Ministério da Saúde. Portaria nº 158, de 04 de fevereiro de 2016 (nº 25, Seção 1, pág. 37). Redefine o regulamento técnico de procedimentos hemoterápicos [Internet]. Brasília (DF); 2016 [cited 2017 Apr 23]. Available from: http://portalarquivos.saude.gov.br/images/pdf/2016/abril/12/ PORTARIA-GM-MS-N158-2016.pdf http://portalarquivos.saude.gov.br/image... ⁾; -To identify transfusion reactions and institute treatment⁽¹⁷17 Conselho Federal de Enfermagem. Cofen. Resolução COFEN nº 306/2006: Normatiza atuação do enfermeiro em hemoterapia [Internet]. 2006[cited 2015 Jul 12]. Available from: http://site.portalcofen.gov.br/node/4341 http://site.portalcofen.gov.br/node/4341... ^-¹⁸18 Brasil. Ministério da Saúde. Portaria nº 158, de 04 de fevereiro de 2016 (nº 25, Seção 1, pág. 37). Redefine o regulamento técnico de procedimentos hemoterápicos [Internet]. Brasília (DF); 2016 [cited 2017 Apr 23]. Available from: http://portalarquivos.saude.gov.br/images/pdf/2016/abril/12/ PORTARIA-GM-MS-N158-2016.pdf http://portalarquivos.saude.gov.br/image... ⁾.
Ventilatory support	3.2.1 To observe breathing parameters: SpO2, PaCO2, PaO2 and pH; skin color - cyanosis, capillary perfusion and RR. 3.2.2 To indicate mechanical ventilation (MV) for acute respiratory distress syndrome (ARDS) induced by sepsis (multidisciplinary team); 3.2.3 To minimize VM risks: hand hygiene; monitor ventilatory parameters; care for the ventilation circuit (presence of dirt, leaks, periodicity of the exchange); monitor cuff pressure of the orotracheal tube every 12 hours, maintaining values of 20 to 30 mmHg (physiotherapist); apply good practices in upper airway and upper airway aspiration; keep the head of the bed between 30 and 45; perform oral hygiene with 0.12% chlorhexidine, 3x daily.		-To minimize acute lung injury⁽¹1 Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli A, Ferrer R, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2016. Intensive Care Med [Internet]. 2017 [cited 2017 Apr 10]; 43:304-77. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28101605 https://www.ncbi.nlm.nih.gov/pubmed/2810... ^,¹⁴14 Instituto Latino Americano para Estudos da Sepse. ILAS. Sepse: um problema de saúde pública [Internet]. Brasília: CFM; 2016[cited 2017 Apr 21]. 90p. Available from: http://www.ilas.org.br/assets/arquivos/ferramentas/livro-sepse-um-problema-de-saude-publica-cfm-ilas.pdf http://www.ilas.org.br/assets/arquivos/f... ⁾; - To avoid hypoxia⁽¹1 Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli A, Ferrer R, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2016. Intensive Care Med [Internet]. 2017 [cited 2017 Apr 10]; 43:304-77. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28101605 https://www.ncbi.nlm.nih.gov/pubmed/2810... ^,¹⁴14 Instituto Latino Americano para Estudos da Sepse. ILAS. Sepse: um problema de saúde pública [Internet]. Brasília: CFM; 2016[cited 2017 Apr 21]. 90p. Available from: http://www.ilas.org.br/assets/arquivos/ferramentas/livro-sepse-um-problema-de-saude-publica-cfm-ilas.pdf http://www.ilas.org.br/assets/arquivos/f... ⁾; -To prevent ventilator-associated pneumonia (VAP)⁽¹1 Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli A, Ferrer R, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2016. Intensive Care Med [Internet]. 2017 [cited 2017 Apr 10]; 43:304-77. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28101605 https://www.ncbi.nlm.nih.gov/pubmed/2810... ^,¹⁴14 Instituto Latino Americano para Estudos da Sepse. ILAS. Sepse: um problema de saúde pública [Internet]. Brasília: CFM; 2016[cited 2017 Apr 21]. 90p. Available from: http://www.ilas.org.br/assets/arquivos/ferramentas/livro-sepse-um-problema-de-saude-publica-cfm-ilas.pdf http://www.ilas.org.br/assets/arquivos/f... ^,¹⁶16 Brasil. Ministério da Saúde. Agência Nacional de Vigilância Sanitária. Segurança do paciente e qualidade em serviços de saúde. Medidas de prevenção de infecção relacionada à assistência à saúde vol. 4[Internet]. Brasília, DF: Ministério da Saúde; 2017[cited 2017 Apr 21]. 92p. Available from: http://portal.anvisa.gov.br/documents/33852/271855/Medidas+de+Preven%C3%A7%C3%A3o+de+Infec%C3%A7%C3%A3o+Relacionada+%C3%A0+Assist%C3%AAncia+%C3%A0+Sa%C3%BAde/6b16dab3-6d0c-4399-9d84-141d2e81c809 http://portal.anvisa.gov.br/documents/33... ⁾.
Glycemic control	3.3.1 To monitor glycemic levels every 1 to 2 hours and after glycemic stabilization every 4 hours. Initiate insulin therapy after two consecutive levels of blood sugar greater than 180 mg/dL. 3.3.2 To follow protocol for hyperglycemia/hypoglycemia of the institution. 3.3.3 To observe signs and symptoms of dehydration, hyperglycemia, hypoglycemia, hydroelectrolytic imbalance, among others.		-To maintain blood sugar≤ 180 mg/dL glucose to prevent hypoglycaemia and large oscillations⁽¹1 Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli A, Ferrer R, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2016. Intensive Care Med [Internet]. 2017 [cited 2017 Apr 10]; 43:304-77. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28101605 https://www.ncbi.nlm.nih.gov/pubmed/2810... ⁾.
Nutrition	3.4.1 To administer oral feeding, according to medical indication and tolerated by the patient. 3.4.2 To avoid absolute fasting. 3.4.3 To insert nasogastric (NG) or nasoenteral (NE) probe, for feeding in severe patients with digestive tolerance, by medical prescription. 3.4.4 To care in enteral diet administration: confirm gastric or post-pyloric positioning of the probe; administering the diet continuously or intermittently - 3/3h; keep head of bed elevated; evaluate presence of abdominal distension, vomiting and characteristic of bowel movements; blood glucose values and gastric residue, if prescribed. 3.4.5 To administer parenteral nutrition prescribed by CVC.		-To prevent malnutrition(19); -To prevent complications due to absolute fasting⁽¹⁹19 Cohen J, Chin WD. Nutrition and sepsis. World Rev Nutr Diet [Internet]. 2013 [cited 2017 Apr 20]; 105:116-25. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23075593 https://www.ncbi.nlm.nih.gov/pubmed/2307... ^-²⁰20 Batista RS, Gomes AP, Velasco CMMO, Araujo JNV, Vitorino RR, Rinco UGR, et al. Nutrição na sepse. Rev Bras Clin Med [Internet]. 2012 [cited 2017 Apr 20]; 10(5):420-6. Available from: http://files.bvs.br/upload/S/1679-1010/2012/v10n5/a3139.pdf http://files.bvs.br/upload/S/1679-1010/2... ⁾; -To avoid bacterial translocation⁽²⁰20 Batista RS, Gomes AP, Velasco CMMO, Araujo JNV, Vitorino RR, Rinco UGR, et al. Nutrição na sepse. Rev Bras Clin Med [Internet]. 2012 [cited 2017 Apr 20]; 10(5):420-6. Available from: http://files.bvs.br/upload/S/1679-1010/2012/v10n5/a3139.pdf http://files.bvs.br/upload/S/1679-1010/2... ⁾.

Associação Brasileira de Enfermagem SGA Norte Quadra 603 Conj. "B" - Av. L2 Norte 70830-102 Brasília, DF, Brasil, Tel.: (55 61) 3226-0653, Fax: (55 61) 3225-4473 - Brasília - DF - Brazil
E-mail: reben@abennacional.org.br

Acompanhe os números deste periódico no seu leitor de RSS

[1] CORRESPONDING AUTHOR: Suelen Alves de Oliveira E-mail: suelencreste@gmail.com