Last Updated on
2/25/2014
So why are we here ?
Building awareness of Sepsis
Improving your ability to recognize sepsis early
Increasing the use of Early Goal Directed Therapy
Educating healthcare professionals
Developing guidelines of care
Using the Code Sepsis Rapid Response System
Building Awareness of Sepsis
Dr. Emanuel Rivers
Formally conceptualized severe
sepsis and/or septic shock in 2001
with a landmark paper
Developed an Algorithm for the
management of Sepsis
EGDT
Early Goal Directed Therapy
Recommendations have been
replicated in many publications
since 2001
European Society of Intensive Care
Medicine and the Society of Critical
Care Medicine
Connect the Dots….
Did you know?
The word “Sepsis” was
derived from the Ancient
Greek for
ROTTEN FLESH AND PUTREFACTION
Did you know?
Sepsis is growing healthcare challenge
1. It is the #1 cause of death in non-coronary ICU
2. 11th leading cause of death overall
3. 28-day mortality: 30- 50%
4. >750,000 US cases annually
5. Long term complications and treatment may
qualify the patient for transfer to an Acute Long
Term Care Hospital
Did you know?
Sepsis is growing healthcare challenge
6. Incidence is growing faster than overall
population
7. Sepsis is the most expensive reason for
hospitalization ($17.0 billion cost of treatment in
the US)
8. Sepsis is a major cause of mortality throughout
the world killing about 1,400 per day
RISK Factors for Developing
Sepsis
Age (Newborn or over 35 years old)
Being pregnant
Having chronic disorders such as Diabetes or
Cirrhosis, Lupus, Cancer, Poly-Substance Abuse
Having a weakened immune system (HIV, taking
immune modulating drugs, chemotherapy, etc.)
Having medical devices inserted into the body
(catheters, tubes, etc).
What is Sepsis?
Sepsis
is defined as a suspected or documented infection in the
presence of two or more Systemic Inflammatory Response
Syndrome Identifiers (SIRS).
Similar to acute MI, Stoke and Poly-trauma, rapid
treatment (within the first few hours) influences the
outcome.
Defining SIRS
The causes of
SIRS are broadly
classified as:
Infectious or
Noninfectious
The Symptoms Associated
with SIRS:
Hypothermia (temp < 97◦) or Fever (temp >100◦)
Tachycardia (HR >100bpm)
Tachypnea (resp>20/min) or Hypocapnia
(arterial CO2 <32mmHg)
Leukopenia or Leukocytosis
AMS
Noninfectious causes of
SIRS include
Trauma
Adrenal Insufficiency
Burns
Pulmonary Embolism
Pancreatitis
Complicated Aortic
Aneurysm
Ischemia
Hemorrhage
Complications of
surgery
Cardiac Tamponade
Anaphylaxis
Drug Overdose
People Admitted To The Hospital With Serious
Diseases Are At The Highest Risk For Sepsis
Because Of:
1. Underlying diseases such as diabetes, cancer, etc.
2. Presence of drug resistant bacteria in the hospital
3. The fact that they often require an Invasive Lines
4. Being Immuno – compromised / Auto-Immune Disease
5. Surgery / Invasive procedure
6. Mechanical ventilation
7. Having wounds or injuries from burns, a car crash or a
bullet
There are 3 Levels of Sepsis
Sepsis:
2 SIRS identifiers with a confirmed source of
infection
Severe Sepsis:
Sepsis plus Organ Dysfunction (24 to 72 hrs)
Septic Shock:
Is Severe Sepsis with persistent hypotension and
hypo-perfusion, which can lead to cell death, endorgan damage, multi-system organ failure and death.
What is Severe Sepsis?
Inflammation + Infection + Organ Dysfunction
The progression:
SIRS: Manifested by two or more of the following:
•
Temp > 100.4 or < 96.9
•
HR > 90 bpm
•
RR > 20 cpm
•
WBC > 12,000 or <4000 or bands >10%
•
AMS
The Symptoms of
Septic Shock:
Hypotension BP< 90 despite fluid bolus of 20 ml/kg.
Map <65
High lactic acid levels > 4mmoL
Hypothermia (temp < 97◦) or fever (temp >100◦)
Tachycardia (HR >100bpm)
Tachypnea (resp>20/min) or hypocapnia (arterial CO2
<32mmhg)
Resp. Rate >20 bpm
Diagnosing Sepsis
Routine screening of potentially infected
patients (12 hrs)
Sudden development of high or low temperature
Rapid heart or breathing rate
Low blood pressure
Positive blood or suspected cultures
Laboratory Data
Use of the sepsis bundles may lead to reduced
mortality and improvement in sepsis care.
Subtle Changes in Your
Patient maybe Sepsis
Tests used to identify Sepsis
Blood tests to measure lactic acid levels
Lactate Levels > 4
Cultures and blood cultures to help determine the type and
site of infection prior to antibiotic administration
CBC with Diff
Elevated Neutrophil Count
Bands > 10%
Pulse oximetry to measure oxygen levels
Temperature
SCVO2 Levels
We Check and Check and
Check Lactatic Acid Levels ?
5.6
>4 is a good
Indicator of Sepsis
3.6
1.3
1.3
Goals for Treatment of Severe
Sepsis and Septic Shock (EGDT)
Early identification
IV access
Treat infection with empiric antibiotics in a timely manner
Source control
Resuscitation with IV fluids and pressors if
necessary(hemodynamic bundle)
Emergency supportive care for acute organ dysfunction
Infection prevention
Treating Sepsis and Septic
Shock with Fluids
Ineffective arterial circulation in patients with severe
sepsis and septic shock is due to vasodilatation
associated with infection
Crystalloid fluid, such as normal saline can be
administered at 30ml/kg over 30 minutes using a
pressure bag.
Sepsis – Be A Member of the
“Golden Hour” Club
“Sepsis Bundle.”
Lactate Levels
Blood Cultures
Antibiotic Use
And Fluid Resuscitation
Items that need to be completed within 6 hours:
Vaso-pressors for BP not responding to fluid,
Measurement of CVP and SCVO2, MAP,
Re-measure lactate if originally elevated.
Empiric Antibiotic Selection
When the potential infection source or pathogen is
not obvious, BROAD SPECTRUM COVERAGE may be
an appropriate empiric choice.
If Pseudomonas is NOT suspected:
Vancomycin + Meropenem or Pip/Taz
If Pseudomonas are suspected:
Vancomycin + 2 of the following
»Meropenem
»Levofloxacin
»Pip/Taz
»Aztreonam
Nurses Role in Sepsis
Severe Sepsis Screening begins on admission !!!
Recognize early signs and symptoms of sepsis
Re-assess patients at least every 12 hours
Utilize the SEPSIS SCREENING TOOL (Meditech)
SPEAK UP
Call a Code Sepsis
My Patient has a Positive Sepsis
Screen – Now what do I do?
Notify your charge nurse / Sepsis Champion to review the
screen
If positive call Code Sepsis
Notify the ER Physician / Hospitalist / Intensivest / PCP
Implement Sepsis Bundle
Move patient up to the next level of care
Add Problem to Plan of Care
Document Implementation of Sepsis Bundle
Increasing the use
of appropriate
treatment
Code Sepsis
1. Obtain a Lactated Level
2. Draw Blood Cultures
3. Give a broad spectrum Antibiotic
4. Normal Saline Bolus at a rate of
30cc / Kg / 30 minutes
5. Prepare for possible transfer to a Higher
level of care: ICU
Increasing the use of
Appropriate Treatment (EGDT)
Severe Sepsis without
Shock
Check lactate q4hrs till less
than 2 mmol / L
Check SCVO2
Optimal value is 70%
Tight Glucose Control
Watch for signs of Clinical
Deterioration
Severe Sepsis with
Shock
Initiate ICU Admission
Airway Management
Arterial Line
Flow-Trac for Hourly Hemodynamic
Monitoring
CVP Placement (Pre-Sep Catheter)
CVP Monitoring
Foley Catheter
Tight Glucose Control
Start of Vasopressors
Why Monitor ScVO2
Tissue hypoxia is often occult, reaching an advanced and
lethal stage before its presence is known and
resuscitation is attempted. Lactic Acid and ScVO2
measurements allow us to monitor occult tissue hypoxia.
Vital signs are inadequate for detecting global tissue
hypoxia and not adequate as a resuscitation end point.
Patients with normal blood pressure can still have global
tissue hypoxia.
Up to 50% of patients resuscitated from shock may have
continued global tissue hypoxia (Elevated lactate and
decreased ScVO2) despite normalized vital signs and
central venous pressure.
Vigileo
Precept Catheter
Flow Trac Catheter
Are you Septic Yet ?