What should be documented in a sepsis reperfusion exam?

Documentation Requirements for Sepsis Reperfusion Examination

A comprehensive sepsis reperfusion examination should document tissue perfusion markers including capillary refill time, skin mottling, peripheral cyanosis, and other signs of tissue hypoperfusion to guide resuscitation efforts and monitor treatment response. 1

Key Components to Document

Hemodynamic Parameters

• Blood pressure measurements:
  • Systolic blood pressure (target ≥90 mmHg)
  • Mean arterial pressure (target ≥65 mmHg) 2, 1
• Heart rate (noting if >90/min or decreasing with fluid resuscitation) 2, 1
• Respiratory rate (tachypnea) 2

Tissue Perfusion Markers

• Capillary refill time (normal is <3 seconds) 1
• Skin mottling (document location and extent) 1
• Peripheral cyanosis (document location) 1
• Peripheral Perfusion Index (PI) if available (lower values associated with worse outcomes) 3

Mental Status

• Level of consciousness
• Presence of confusion or altered mental status 2

Fluid Status Assessment

• Jugular venous pressure (JVP)
• Presence of pulmonary crackles
• Significant edema or positive fluid balance (>20 mL/kg over 24 hrs) 2, 1
• Signs of fluid overload or intra-abdominal hypertension 2

Urine Output

• Document hourly urine output (target >0.5 mL/kg/hour for adults) 1

Laboratory Values to Reference

• Lactate levels (elevated levels >1 mmol/L indicate tissue hypoperfusion) 2, 1
• Central venous oxygen saturation (ScvO2) if available (target >70%) 1

Organ Dysfunction Markers

• Respiratory: PaO2/FiO2 ratio, oxygen requirements
• Renal: Creatinine levels, urine output
• Hepatic: Bilirubin levels
• Coagulation: Platelet count, INR, aPTT
• Ileus (presence/absence of bowel sounds) 2

Documentation Format

1. Initial Assessment:

   • Document baseline perfusion status
   • Note all abnormal findings from above parameters

2. Reassessment After Interventions:

   • Document changes in perfusion markers after fluid boluses
   • Note response to vasopressors if initiated
   • Record timing of reassessments (recommended every 30-60 minutes during active resuscitation)

3. Trending:

   • Document improvement or deterioration in perfusion markers
   • Note cumulative fluid balance

Clinical Pitfalls to Avoid

• Inadequate documentation of peripheral perfusion: Failure to document capillary refill time and skin mottling can lead to missed opportunities for early intervention 1
• Overreliance on single parameters: Document multiple perfusion markers as no single parameter is sufficient to assess tissue perfusion 1
• Failure to reassess: Document serial assessments to evaluate response to interventions 1
• Missing signs of fluid overload: Document signs of potential fluid overload which may worsen outcomes, especially in patients with generalized peritonitis 2

Special Considerations

• In resource-limited settings, peripheral perfusion markers (capillary refill, mottling, peripheral cyanosis) become even more important to document as they require no special equipment 1
• For patients with septic shock, document vasopressor requirements to maintain MAP ≥65 mmHg and concurrent lactate levels 2
• Consider documenting Peripheral Perfusion Index (PI) when available, as it has been shown to correlate with organ dysfunction and prognosis in sepsis 3

By thoroughly documenting these parameters, clinicians can better track the patient's response to sepsis treatment and make timely adjustments to optimize outcomes.