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Severe SepsisSevere SepsisInitial recognition and resuscitationInitial recognition and resuscitation
Issued August 2010Issued August 2010
Severe Sepsis: Initial recognition and resuscitation 2
Expected Practice
Assess all patients and immediately notify physician when a patient presents with risk factors for sepsis.
Severe Sepsis: Initial recognition and resuscitation 3
Clinical Findings
Documented or suspected infection
Two or more SIRS criteria
At least one indicator of tissue hypoperfusion or related acute organ dysfunction
Severe Sepsis: Initial recognition and resuscitation 4
SIRS criteria
Heart rate > 90 beats per minuteTemperature < 36°C (98.8°F) or >
38.3°C (100.4°F)Respiratory rate > 20 breaths per
minute White blood cell count > 12,000/mm3 or
< 4000 mm
Severe Sepsis: Initial recognition and resuscitation 5
Tissue hypoperfusionSepsis related acute organ failure
Acute altered mental status
SBP <90mmHg or MAP < 70mmHg or SBP Decrease of 40 mmHg
Blood glucose > 140 mg/dL, non-diabetic patients
Arterial hypoxemia
Acute oliguriaCreatinine increase
above baselineCoagulation
abnormalitiesIleusThrombocytopeniaHyoperbilirubinemia
Severe Sepsis: Initial recognition and resuscitation 6
Expected Practice
Obtain serum lactate measurements. Hyperlactatemia is defined as lactic acid level > 4.
Obtain blood cultures as well as cultures from all potential sites of infection prior to initiating broad spectrum antibiotics
Blood cultures should be drawn prior to initiation of antibiotic therapy and within 1 hour of sepsis diagnosis
Severe Sepsis: Initial recognition and resuscitation 7
Expected Practice
Evaluate for and remove other potential sources of infection
Severe Sepsis: Initial recognition and resuscitation 8
Maintain Therapeutic Endpoints
MAP at >65 mmHgCVP 8-12 mmHgCentral venous or mixed venous
oxygen saturation > 70%
Severe Sepsis: Initial recognition and resuscitation 9
Expected Practice
Administer fluids to maintain:Mean arterial pressure at >65 mmHgCentral venous pressure (CVP)
8-12 mmHgCentral venous or mixed venous oxygen
saturation > 70%.
Severe Sepsis: Initial recognition and resuscitation 10
Expected Practice
Administer vasopressors if necessary to achieve a mean arterial pressure of 65 mmHg
If Venous Oxygen saturation goal not attained consider;
Additional fluidsBlood transfusion Dobutamine infusion
Severe Sepsis: Initial recognition and resuscitation 11
Expected Practice
Maintain blood glucose levels at < 150 mg/dL.
Consider administration of human recombinant activated protein C
Note: Administration of human recombinant activated protein C (drotrecogin alfa activated) is no longer recommended. The FDA sent out notification on October 25, 2011 that Eli Lilly has withdrawn this drug from the market.
Severe Sepsis: Initial recognition and resuscitation 12
Scope and Impact of the Problem
Severe sepsis is a major healthcare problem that affects millions of people around the world each year with an extremely high mortality rate of 30-60%.
Severe Sepsis: Initial recognition and resuscitation 13
Scope and Impact of the Problem
Mortality from sepsis is greater than that of breast cancer, lung cancer, and colon cancer combined and is the number one cause of death in the non-coronary ICU. The incidence of severe sepsis is expected to double over the next 25-30 years.
Severe Sepsis: Initial recognition and resuscitation 14
Supporting Evidence
More than 750,000 cases of severe sepsis occurred annually
Sepsis can rapidly progress to severe sepsis to septic shock within 24 hours
Severe Sepsis: Initial recognition and resuscitation 15
Supporting evidence
Treatment should be initiated regardless of where the patient is located within the hospital.
Patients treated aggressively within the first 6 hours of presentation have lower mortality
Severe Sepsis: Initial recognition and resuscitation 16
Supporting evidence
Serum lactate levels can be elevated in the setting of a normal or increased cardiac output.
The measurement of serum lactate can reflect occult decreases in global tissue perfusion and may be an indicator of organ dysfunction.
The presence and the clearance rate of lactate are associated with increases in patient morbidity and mortality.
Severe Sepsis: Initial recognition and resuscitation 17
Supporting evidence
Early administration of appropriate antibiotics decreases mortality in patients with Gram- positive and negative bacteremias.
Empiric broad spectrum antibiotics should be initiated prior to identification of the infecting organism
Reassess after 48-72 hours based on culture results and clinical data.
Severe Sepsis: Initial recognition and resuscitation 18
Supporting evidence
Surviving Sepsis Campaign guidelines state that the goal of the first 6 hours of treatment
Achieve and maintain a CVP of 8-12 mm Hg or 12-15 mm Hg for patients receiving mechanical ventilation and a MAP of at least 65 mm Hg with fluid resuscitation.
Dobutamine is identified as the medication of choice to increase cardiac output to normal levels or to improve lactate clearance
Severe Sepsis: Initial recognition and resuscitation 19
Supporting evidence
No benefit has been shown for increasing cardiac output above physiologic normal levels.
Available data do not support the use of low dose dopamine for renal protection
Severe Sepsis: Initial recognition and resuscitation 20
Supporting evidence
Colloids have not been shown to be of more benefit than crystalloid for fluid resuscitation.
Severe Sepsis: Initial recognition and resuscitation 21
Supporting evidence
Fluid replacement should be optimized before vasopressors are started.
Norepinephrine or dopamine are identified as the initial vasopressors to increase vascular tone and blood pressure.
Severe Sepsis: Initial recognition and resuscitation 22
Supporting evidence
Meta analyses concluded that administration of high dose corticosteroids are of no benefit or may be detrimental to patients with septic shock.
In vasopressor dependent shock, low-dose exogenous cortisol may improve the uptake of the patient’s own and the exogenously administered sympathetic stimulants when serum cortisol levels are low.
Severe Sepsis: Initial recognition and resuscitation 23
Supporting evidence
Glucose levels within 80-110 mg/dL may decrease morbidity and morality in a surgical population.
Glucose levels < 150mg/dL showed reduced morbidity in critically ill medical patients.
Severe Sepsis: Initial recognition and resuscitation 24
Supporting evidence
Administration of human recombinant activated protein C (drotrecogin alfa activated) is no longer recommended. The FDA sent out notification on October 25, 2011 that Eli Lilly has withdrawn this drug from the market. In a recently completed clinical trial (PROWESS-SHOCK trial), the drug failed to show a survival benefit for patients with severe sepsis and septic shock.
Severe Sepsis: Initial recognition and resuscitation 25
Actions for Nursing Practice
Educate all nursing staff on the risk factors and clinical signs of sepsis.
Severe Sepsis: Initial recognition and resuscitation 26
Actions for Nursing Practice
Create an interdisciplinary team to develop protocols or guidelines.
Severe Sepsis: Initial recognition and resuscitation 27
Actions for Nursing Practice
Consider development of a rapid response team to facilitate prompt identification of patients with sepsis.
Severe Sepsis: Initial recognition and resuscitation 28
Need More Information or Help?
For additional information/assistance go to www.aacn.org then select PRN.