December 17, 2014 - WSHA

Patient SafetySafe Table Webcast: Sepsis (Part III and IV)December 17, 2014

Presented at the WSHA Safe Table Webcast on December 17, 2014

Presenters

Mark Blaney, RNRegional Nurse EducatorCHI Franciscan Health

Karen LautermilchDirector, Quality & Performance ImprovementWashington State Hospital Association


35.2% decrease in mortality rate.

13 fewer deaths per week due to severe sepsis or septic shock, saving $96.8million.


Friday, December 5th (Sessions 1 & 2)

Session 1: Recognition & Pathophysiology• Describe the importance of the early identification of Sepsis. • Differentiate between SIRS, Sepsis, Severe Sepsis, and Septic Shock. • Recognize the progression of the inflammatory response in Sepsis. • Identify three signs and symptoms that can help with the early identification of Sepsis.

Session 2: Initial Treatment• Define your role in the care of the Septic patient. • Explain the rationale for each element in the Surviving Sepsis Campaign 3‐hour bundle.

• Apply the steps of Sepsis care into your practice.


Friday, December 17th 10:00 a.m. –11:30 a.m. (Sessions 3 & 4)Session 2: Initial Treatment

Session 3: Septic shock Treatment • Define your role in the care of the Septic patient.• Explain the rationale for each element in the Surviving Sepsis bundle.

• Apply the steps of Septic Shock care into your practice.

Session 4: Sepsis Recognition for Nursing Assistantsand ER Techs

• Recognize the importance of the early identification of Sepsis. • Define your role as a member of the Sepsis care team. • Identify three signs and symptoms that patients could display during the progression of Sepsis.


SEPSISWhat is it? How do we find it? How do we fix it?

Mark Blaney RN, BSN, CENWSHA Training - 2014

P


SEPSISSession 3: 6-Hour Bundle

Mark Blaney RN, BSN, CENWSHA Training - 2014Presented at the WSHA Safe Table Webcast on December 17, 2014

Session 3 Objectives

• Define your role in the care of the Septic patient

• Explain the rationale for each element in the Surviving Sepsis Campaign 6-hour bundle

• Apply the steps of Septic Shock care into your practice


CARE OF THE SEPTIC PATIENT


Role in Sepsis Care• Prevention• Assessment and recognition• Advocating for your patient• Team work

Consider calling a Code Rapid Response early


Role in Sepsis Care• RNs must be severe sepsis experts:

Have knowledge of risk factorsRecognize classic & atypical signs and symptomsUnderstand potential diagnostic tests and their useKnow potential differential diagnoses and include sepsis as one of themUnderstand evidence-based standards of care for sepsis


3-Hour Bundle ReviewMeasure lactate levelObtain blood cultures prior to antibioticAdminister broad-spectrum antibioticAdminister 30ml/kg crystalloid for hypotension or lactate ≥4 mmol/L

Surviving Sepsis Campaign, 2012Presented at the WSHA Safe Table Webcast on December 17, 2014

Sepsis Care Overview• Step 1: SIRS + Infection (Sepsis)

Notify Provider nowRequest labs: lactate, CBC, blood cultures x2, etc.Ask: “Do you want to start an antibiotic now?”

• Step 2: MAP <65, SBP <90, lactate > 2?Ask: “Do you want a 30ml/kg fluid challenge?”

• Step 3: Fluid challenge ineffective? (MAP <65, lactate ≥4)

Request transfer to ICU if not done already (6-Hour Bundle)Presented at the WSHA Safe Table Webcast on December 17, 2014

6-Hour BundleIf hypotension persists despite volume

Utilize vasopressors to maintain MAP ≥65If hypotension persists or initial lactate ≥4

Measure CVPMeasure ScvO2

Remeasure lactate

Surviving Sepsis Campaign, 2012


6-Hour Bundle

Target: CVP ≥8 mm Hg, ScvO2 ≥70%, normalization of lactate



Sepsis Care Overview• Step 1: Continue fluid administration

• Step 2: If MAP <65 mmHg despite adequate fluid administration:

Initiate vasopressors to target MAP ≥65 mmHg

• Step 3: If hypoperfusion persists:Initiate inotropic therapy


Sepsis Care Overview• Step 4: Consider mechanical ventilation

• Step 5: Consider blood product administration


Sepsis Care• Step 1: Continue fluid administration if there is

continued hemodynamic improvementCentral Venous Pressure (CVP)**Pulse PressureStroke Volume Variation (SVV) or Pulse Pressure Variation (PPV)Arterial Blood Pressure (ABP)Heart rate


Sepsis Care – Step 1• Central Venous Pressure (CVP)**

Static preload assessmentLimited use as a marker for intravascular volume status and potential fluid responsiveness

Right ventricle is very compliant and adjusts to meet cardiovascular needs

Dellinger, et al., Critical Care Medicine, 2013; 588


Sepsis Care – Step 1• Central Venous Pressure (CVP)**

A low CVP can be relied on to support continued volume resuscitationWill not give us an effective endpoint for fluid resuscitation

Dellinger, et al., Critical Care Medicine, 2013; 588


Sepsis Care – Step 1• SVV & PPV

Dynamic assessmentCan be used to assess fluid responsivenessRequires patient to be mechanically ventilated with controlled tidal volumesEquipment:

PPV: arterial lineSVV: special monitor (FloTrac, Vigileo) and an arterial line

Dellinger, et al., Critical Care Medicine, 2013; 597Enomoto TM, Harder L. Crit Care Clin. 2010;26(2): 307-21


Sepsis Care – Step 1• Fluid responsiveness:

PPV: >13% difference in systolic peak between inspiration and expiration

SVV: >13% difference in SVV



Sepsis Care – Step 1• SVV & PPV

Utility is limited:Atrial fibrillationRight heart failureSpontaneous breathing (modern ventilation techniques)Low pressure support ventilationLow tidal volumes (<10 ml/kg)



Sepsis Care – Step 1• What if your patient is spontaneously

breathing?Inferior vena cava ultrasound

Looks at collapsibility of the vesselPassive leg raise

Bolus the patient from their own systemic circulation

Enomoto TM, Harder L. Crit Care Clin. 2010;26(2): 307-21


Sepsis Care – Step 1• Passive leg raise

Raise legs to 45˚ for 2 minutesBoluses 100-300 ml into central circulation


Sepsis Care – Step 1• Passive leg raise

Does the stroke volume or MAP improve?9% increase in stroke volume10% increase in pulse pressure10% increase in mean arterial pressure (MAP)

If yes, patient is likely fluid responsive

Enomoto TM, Harder L. Crit Care Clin. 2010;26(2): 307-21


Sepsis Care – Step 1• Goals of fluid administration

MAP >65 mmHgCVP ≥8 mmHg



Sepsis Care• Step 2: If MAP <65 mmHg despite

adequate fluid administration:Initiate vasopressors to target MAP ≥65 mmHg

1st choice: Norepinephrine2nd choice: Norepinephrine + epinephrine

orNorepinephrine + vasopressin


Sepsis Care – Step 2• Norepinephrine

Initial vasopressor of choicePrimarily α1 with few β1 effects

Vasoconstriction increasing SVR & MAPMinimal impact on heart rate

Titrate every 5-15 minutes to reach a target MAP of ≥65 mmHg

Allen, Journal of Infusion Nursing, 2014; 82-86


Sepsis Care – Step 2• Vasopressin

Given in combination with norepinephrineVasopressin levels may be lower in Septic ShockV1 receptor agonist causing vasoconstriction in high doses

Recommended dose: 0.03 units/minTarget MAP ≥65 mmHg

Allen, Journal of Infusion Nursing, 2014; 82-86Dellinger, et al., Critical Care Medicine, 2013; 597


Sepsis Care• Step 3: If hypoperfusion persists despite

adequate fluid volume & adequate MAP:Initiate inotropic therapy

• Dobutamine



Sepsis Care – Step 3• Dobutamine

Inotropic agent of choiceβ1 adrenergic agonist

Increases cardiac contractilityTitrate up to 20 mcg/kg/minTitrate every 5-15 minutes to reach target ScvO2 of ≥70%

Allen, Journal of Infusion Nursing, 2014; 82-86Dellinger, et al., Critical Care Medicine, 2013; 597


Sepsis Care – Step 3• ScvO2

Mixed venous oxygen saturationMeasurement of the relationship between O2consumption & deliveryMeasured in the superior vena cava or right atriumA decrease in O2 supply or increase in O2demand will lead to a deviation of ScvO2 from the normal range


Sepsis Care – Step 3

Normal: 65-80%Goal in Septic Shock: ≥70%


• ScvO2


Sepsis Care• Step 4: Consider mechanical ventilation

Especially in patients with Sepsis-Induced Acute Respiratory Distress Syndrome (ARDS)Recommended tidal volume of 6 ml/kgRecommended to utilize PEEP to avoid alveolar collapse



Sepsis Care• Step 5: Consider blood product

administrationOnce tissue hypoperfusion is resolved, transfuse for Hgb <7 g/dLGoal Hgb = 7-9 g/dL or Hct ≥30%



Endpoints of Resuscitation• Lactate normalization• ScvO2

• Base Deficit

• The use of a combination of endpoints is likely the goal


Endpoints of Resuscitation• Lactate normalization

Measure of cellular level hypoperfusion**Recommended when ScvO2 is not availableProlongation of lactate clearance is associated with increased mortalityExample:

<24 hours – Survival24-48 hours – 25% mortality>48 hours – 86% mortality

Surviving Sepsis Campaign, 2012Abramson, D. J Trauma, 1993, 35, 584-599


Endpoints of Resuscitation• Lactate normalization

Cautions**:Lactate is also a marker of metabolic stress and not only related to tissue hypoxiaIncreased lactate may be an important adaptive survival response in sepsisMay be a better marker of disease severity rather than a treatment endpoint

Marik PE, Bellomo R. OA Critical Care, 2013, Mar 01; 1(1):3

Endpoints of Resuscitation

Normal: 65-80%Goal in Septic Shock: ≥70%


• ScvO2


Endpoints of Resuscitation• Achieving a reduction in lactate with an

ScvO2 ≥70% is associated with improved outcomes



Endpoints of Resuscitation• Base Deficit

Indicator of anaerobic metabolismReflective of serum bicarb utilization to buffer acidosis (amount required to titrate 1L of blood to normal pH)

Resuscitation measures to restore tissue perfusion and cellular oxygenation should produce a reduction in base deficit as acidosis resolves


Endpoints of Resuscitation• Base Deficit

Normal: +2 to -2Mild: -3 to -5Severe: >-10

Base deficit >-6 mmol/L is associated with severe injury and potential higher mortality

Davis, JW et al. J Trauma, 1998, 45, 873-877


Resources• International Guidelines for Management of Severe Sepsis and Septic Shock: 2012

(Surviving Sepsis Campaign)Dellinger et. al, Crit Care Med. 2013, 41(2): 580-637

• Understanding Vasoactive MedicationsAllen, JM. Journal of Infusion Nursing, 2014, 37(2): 82-86

• Lactate clearance as a target of therapy in sepsis: A flawed paradigm.Marik PE, Bellomo R. OA Critical Care, 2013, Mar 01; 1(1):3

• Lactate clearances and survival following injuryAbramson, D. J Trauma, 1993, 35, 584-589

• Base deficit in the elderly: a marker of severe injury and death.Davis et. al, J Trauma, 1998, 45, 873-877

• AACN Advanced Critical Care Nursing, 2009


SEPSISWhat is it? How do we find it? How do we fix it?



SEPSISSession 4: Sepsis Recognition for

Ancillary Staff



Session 4 Objectives• Recognize the importance of the early

identification of Sepsis

• Define your role as a member of the Sepsis care team

• Identify 3 signs and symptoms that patients can display during the progression of Sepsis


• You are caring for a 84 y/o female admitted to Med-Surg with a urinary tract infection. She’s been in the unit for 2 days.

• You go in to take a set of vitals and notice that she’s acting more confused than she was a few hours ago.

• Vitals: HR 98, RR 22, BP 98/55, T 38.4˚C


• You inform the RN who then calls the provider. Before you know it, labs are being drawn, and IV fluid is being hung.

• After the IV fluids are completed, you are asked to complete a few more sets of vital signs.

• Shortly after, your patient is transferred up to the Critical Care Unit.


• What happened?


WHY SHOULD WE CARE ABOUT SEPSIS?


Sepsis

• 6th leading reason for hospitalization in the USA (2009)

836,000 cases annually (primary diagnosis)

829,500 cases annually (secondary diagnosis)

• 210,000 deaths per year

Why do we care?

$15.4B per year

Agency for Healthcare Research

& Quality, 2011


Sepsis

• Mortality:Severe Sepsis: 30-50%Septic Shock: 50-60%

• Mortality has changed little since the 1960s (until recently).

Why do we care?


Sepsis• Every hour of delay in antibiotic

administration reduces survival by 7.6%

Recommendation is to give antibiotics within 1 hour of sepsis recognition Must be given within 3 hours to be compliant with the 3-hour bundle

Why do we care?


Dellinger, 2004; Kumar, 2006


SepsisWhy do we care?

• Takeaways:Early recognition is critical to patient outcomeVital sign abnormalities and changes in patient condition can be useful to help identify Sepsis early


WHAT IS SEPSIS?


Sepsis• “a systemic, deleterious host response to an

infection.” (Dellinger, et al., Critical Care Medicine, 2013, 583)

• Must be treated like a medical emergencyCan progress rapidly to severe sepsis & septic shock within 24 hours (AACN Practice Alert, 2010)

• Healthcare workers have just hours to deliver the right care


Sepsis• Sepsis is a disease state continuum :

SIRS (as a result of an infection)SepsisSevere SepsisSeptic ShockDeath


Condition Definition

Systemic Inflammatory

Response Syndrome(SIRS)

Temp < 36°C (97°F) or > 38.3°C (101°F)HR > 90 beats/minRR > 20 breaths/min or PaCO2 < 32 mm HgWBC > 12,000 cells/mm3 (leukocytosis) or < 4,000 cells/mm3 (leukopenia) or Bands > 10% immature (band) forms

Sepsis Infection + ≥ 2 SIRS criteria

Severe Sepsis Sepsis + organ dysfunction, hypoperfusion, or hypotension

Septic ShockSevere Sepsis + hypotension despite adequate fluid

resuscitation, + presence of perfusion abnormalities that requires pharmacological intervention (vasopressors and/or inotropic agents)


Sepsis• Risk Factors for Severe Sepsis or Septic Shock:

<1 and >65 years oldPost surgeryMalnourishmentBroad spectrum antibiotic useChronic illnessDiabetesImmunodeficiency (AIDS, immunosuppressive agents, etc)CancerChronic Renal FailureEtc…


Pathophysiology1. A bacterial infection releases endotoxins which initiate an

inflammatory response (pneumonia, UTI, etc)

2. The inflammatory response triggers the:a) Release of white blood cellsb) Injury and vasodilation of the blood vessels c) Amplification of the immune response d) Creation of fibrin strands and the development of clots


Pathophysiology3. This systemic inflammatory response can lead to

maladaptive SIRS (usually in patients with risk factors)

4. These components act on vascular endothelium causing:a) Blood vessel injuryb) Capillary leakagec) Microthrombi formationd) Impaired fibrinolysis


Pathophysiology5. This damage results in a systemic imbalance between

cellular O2 supply and demand leading to global tissue hypoxia

Global Tissue Hypoxia is a central concept in the understanding of the

sepsis continuum.


SEPSIS SIGNS & SYMPTOMS


Signs & Symptoms• Sepsis:

SIRS symptoms• Temperature alterations (T <36 or >38.3˚C)• Tachypnea (RR >20)• Tachycardia (HR >90)• ↑ or ↓ white count

WeaknessInfection source-specific signs and symptoms

Most common: Urinary Tract Infection & PneumoniaPresented at the WSHA Safe Table Webcast on December 17, 2014

Signs & Symptoms• Severe Sepsis & Septic Shock:

Vital signs alterationsTachycardia (HR >90)Tachypnea (RR >20)Hypotension (SBP <90)Hypoperfusion (MAP <65)


Signs & Symptoms• Severe Sepsis & Septic Shock cont.:

Skin signs Color: Pale or mottledTemperature: Cool or coldMoisture: Clammy or wet

Organ dysfunctionConfusionDecreasing urine output


SEPSIS TREATMENTS


Sepsis Treatments• Sepsis

Lab draws (CBC, blood cultures, lactate)AntibioticsFrequent vital signs


Sepsis Treatments• Severe Sepsis

Frequent vital signsVolume resuscitation

“Fluid Challenge” – Normal saline 30 ml/kg @ 2L/hr


Sepsis Treatments• Septic Shock

Transfer to Critical CareFrequent vital signsContinued IV fluid administrationIV medications to improve blood pressure and perfusion statusPotential intubationPotential blood product administration


ROLE IN SEPSIS CARE


Role in Sepsis Care• Sepsis

Frequent vital signsFacilitate lab draws

• Severe SepsisFrequent vital signsObtain IV tubing, IV pumps, pressure bags, or rapid infuserAssist with other patients in your assignment


Role in Sepsis Care• Septic Shock

Frequent vital signsAssist with other patientsFacilitate transport to Critical Care Unit


Resources• International Guidelines for Management of Severe Sepsis and Septic Shock: 2012

(Surviving Sepsis Campaign)Dellinger et. al, Crit Care Med. 2013, 41(2): 580-637

• Understanding Vasoactive MedicationsAllen, JM. Journal of Infusion Nursing, 2014, 37(2): 82-86

• Lactate clearance as a target of therapy in sepsis: A flawed paradigm.Marik PE, Bellomo R. OA Critical Care, 2013, Mar 01; 1(1):3

• Lactate clearances and survival following injuryAbramson, D. J Trauma, 1993, 35, 584-589

• Base deficit in the elderly: a marker of severe injury and death.Davis et. al, J Trauma, 1998, 45, 873-877

• AACN Advanced Critical Care Nursing, 2009Presented at the WSHA Safe Table Webcast on December 17, 2014

Upcoming Safe Table Events

• January 28, 2015: Safe Table Web Conference ‐ Radiology

• February 10, 2015: Safe Table – Obstetrics

• February 17, 2015: Safe Table Web Conference – Infections

• February 25, 2015: Safe Table ‐ Radiology

• http://www.wsha.org/events.cfm


Documents

December 17, 2014 - WSHA