4/29/2019 1 Sepsis: Identification and Management in an Acute Care Setting SEPSIS LECTURE NPA 2018 Dr. Barbara M. Mills DNP Director Rapid Response Team/ Code Resuscitation Stony Brook University Medical Center OBJECTIVES • To understand and be able to identify the differences between SIRS, Sepsis, Severe Sepsis, and Septic Shock. • To understand the morbidity and mortality of Sepsis in relation to length of stay, current guidelines, cost to health care systems. • To understand modalities of treatment which include management, such as fluid resuscitation and pharmacological interventions.
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Sepsis: Identification and Management in an Acute
Care Setting
SEPSIS LECTURE NPA 2018
Dr. Barbara M. Mills DNPDirector Rapid Response Team/
Code ResuscitationStony Brook University Medical Center
OBJECTIVES
• To understand and be able to identify the differences between SIRS, Sepsis, Severe Sepsis, and Septic Shock.
• To understand the morbidity and mortality of Sepsis in relation to length of stay, current guidelines, cost to health care systems.
• To understand modalities of treatment which include management, such as fluid resuscitation and pharmacological interventions.
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.http://www.cdc.gov/nchs/data/databriefs/db62.pdf accessed August 7, 2015
In‐hospital death 8X higher compared to other diagnoses
Sepsis Bundle Project (SEP)National Hospital Inpatient Quality Measures
SEP-1 Early Management Bundle, Severe Sepsis/Septic Shock
Discharges 10-01-2015 (4Q15) through 06-30-16 (2Q16)
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SEPSIS ECONOMICS
Sepsis is a major and economically significant disease in the ICU,
costing over $20 billion in the United States in 2011 (5.2% of all U.S.
hospital costs) with costs growing to over $23 billion in 2013 (6.2% of all
U.S. hospital costs)
SEPSIS ECONOMICS
Sepsis: major health problem with increasing
prevalence, high costs, and poor
outcomes.
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SEPSIS ECONOMICS
Increased hospitalizations for more than 1 million people in 2008
SEPSIS ECONOMICS
Between 1999 and 2014: 2,470,666 deaths with sepsis
on the death certificate with increase annual sepsis related
deaths by 31%
SEPSIS ECONOMICS
Severe Sepsis and Septic Shock are subsets of sepsis conditions with at least one organ dysfunction, which accounts for 25-50% of in-hospital mortality…
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SEPSIS ECONOMICS
…that can range with a 45%-65% mortality within 6 months
of discharge.
INFECTION
SEPSIS
SEVERE SEPSIS
SEPSIS
INFECTION
INFECTION
Those who survive tend to have increasing complications, morbidity, high costs of care,
and decreasing quality of life.
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HISTORICAL PERSPECTIVE
Source: CHEST 1992
SIRS Criteria ( > 2)• Temperature > 38 C < 36
C• Heart rate > 90 bpm• Respiratory rate > 20 /min
or a PaCO2 < 32 mmHg• White blood cell count >
12,000 / cu mm or < 4,000 / cu mm, or > 10 bands
NEW SEPSIS DEFINITION
• Guidelines were revised in 2008, 2012, and most recently updated in 2015.
• These guidelines have shaped how hospitals must identify and treat patients who are identified as having sepsis, severe sepsis, and septic shock.
NEW SEPSIS DEFINITION
The Surviving Sepsis Campaign (SSC) international guidelines were developed for early detection and treatment
of severe sepsis and septic shock
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NEW SEPSIS DEFINITION
“Sepsis is a life threatening organ dysfunction caused
by a dysregulated host response to an infection.”
The European Society of Intensive Care Medicine/Society of Critical CareMedicine Third International Consensus definitions for Sepsis and SepticShock task force (the Sepsis-3 task force)
NEW SEPSIS DEFINITION
Persistent hypotension requiring vasopressors to keep MAP > 65 mmHg
despite adequate fluid resuscitation
Serum lactate > 2 mmol/L
JAMA 2016
QUICK SOFA / QSOFA
> 22/ min SBP ≤100mmHg
In patients with infection a qSOFAscore > 2 is associated with higher mortality and prolonged ICU stay.
SEPSIS SCORING TOOL
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ProCESS ARISE
Enrollment<2 hours from detection of
shock
2.8 hours (median) from presentation
to ED
Antibiotics75% received
prior to enrollment
70 minutes (median) from
presentation to ED
Fluids>2 liters prior ot
enrollment
2515ml (mean) prior to
enrollment
RESEARCH TRIALS
SEP-1 TWO CLOCKS
3 hour
3 hr.
6 hr.
SEP-1: EARLY MANAGEMENT BUNDLE
Interventions Required: Blood culture before
antibiotics Antibiotics Lactate level
Set Measure ID # SEP-1-8; Early Management Bundle, Severe Sepsis/Septic Shock
Interventions Required: Lactate level repeated
(If elevated)
SevereSepsis
Time Zero
SEP-1 TWO CLOCKS
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2012 NQF: SEPSIS 0500
TO BE COMPLETED WITHIN 3 HOURS OF TIME OF PRESENTATION:
1. Obtain blood cultures prior to administration of antibiotics.
2. Measure lactate level.
3. Administer broad spectrum antibiotics.
4. Administer 30ml/kg crystalloid for hypotension, defined as a “mean arterial pressure” MAP<65 or lactate ≥4mmol/L.
SEP-1 TWO CLOCKS
Focused Exam
SEP-1 TWO CLOCKS
SEP-1 TWO CLOCKS
“Delays in administering all four guidelines recommendations,
even when they did not exceed 3 hours, were associated with
a significant increase in in-hospital mortality.”
SCCM journal April 2018. Volume 46. Number 4
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3 hr.
6 hr.
SevereSepsis
Time Zero
Interventions Required:ALL of Severe Sepsis + Fluid 30 ml/kg(NO exclusionary
criteria)
Physical Exam (ALL)• Vital Signs (T, HR, RR, BP)• Cardiopulmonary exam• Capillary refill evaluation• Peripheral Pulse evaluation• Skin evaluation
Hemodynamics (2 of 4)• CVP• SVO2• Bedside cardiovascular ultrasound• Passive leg raise / fluid challenge
Shock Assessment
Interventions Required:Persistent Hypotension
Within 1 hour of fluid add VASOPRESSORPersistent Hypotension
OR Lactate > 4 Shock Assessment (1 of 2)
SEPTIC SHOCK ONLY
2012 NQF: SEPSIS 0500
1. Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure (MAP) ≥65mmHg)
SEP-1 TWO CLOCKS
TO BE COMPLETED WITHIN 6 HOURS OF TIME OF PRESENTATION:
MEAN ARTERIAL PRESSURE
Urinary output (mL) 49 +18 56 + 21 43 +13 .60/.71
Capillary blood flow (mL/min/100 g) 6.0 + 1.6 5.8 + 11 5.3 + 0.9 .59/.55
Red Cell Velocity (au) 0.42 + 0.06 0.44 +016 0.42 + 0.06 .74/.97
Pico2 (mm Hg) 41 + 2 47 + 2 46 + 2 .11/.12
Pa‐Pico2 (mm Hg) 13 + 3 17 + 3 16 + 3 .27/.40
75 mm Hg65 mm Hg 85 mm Hg F/LT
Adapted from Table 4, page 2731, from LeDoux, Astiz ME, Carpati CM, Rackow ED. Effects of perfusion pressure on tissue perfusion in septic shock. Crit Care Med 2000; 28:2729-2732
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2012 NQF: SEPSIS 0500
TO BE COMPLETED WITHIN 6 HOURS OF TIME OF PRESENTATION:
2. In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate ≥4 mmol/L (36mg/dl):
Measure central venous pressure (CVP)
Measure central venous oxygen saturation (ScvO2)
3. Remeasure lactate if elevated
SEP-1 TWO CLOCKS
FLUID RESUSCITATION
RESEARCH SUPPORTING FLUID RESUSCITATION BUNDLE
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CHOICE OF FLUIDS
Crystalloids Colloids
Ringers Lactate
Normal Saline
AlbuminGelatinsHetastarch
IV FLUID COMPOSITIONS
FLUID REPLACEMENT CHALLENGES
End Stage Renal Disease on Dialysis
Compensated Congestive
Heart Failure
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HEMODYNAMIC CHANGES IN SEPTIC SHOCK
Interstitial Edema in Septic Shock
Lungs Brain Kidney
Dellinger RP. Cardiovascular management of septic shock. Crit Care Med 2003;31:946-955.
During Septic Shock
10 Days Post Shock
EndDiastole
EndSystole
EndDiastole
EndSystole
Courtesy of Joe Parrillo Hackensack NJ
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RESEARCH RECOMMENDATION
SCCM recommends that, in the resuscitation of sepsis-induced
hypoperfusion, at least 30 ml/kg of IV crystalloid fluid be given within the first 3 hours (strong recommendation,
low quality of evidence).
ANTIBIOTIC THERAPY
• Started within 3 hrsafter severe sepsis presentation
• Monotherapy vs. Combination Therapy
• Choose Aminoglycosides or Aztreonam or Ciprofloxacin
• Cephalosporins, (1st and 2nd Generation)- or – Clindamycin - or - Daptomycin - or -
Glycopeptides - or - Linezolid - or -
Macrolides - or - Penicillins
COMBINATION THERAPY
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CHOICE OF VASOPRESSERS
First Line
Second Line
Niche Drugs
Norepinephrine
Epinephrine Low Dose Vasopressin(.01-.03 units/min)
Dopamine (sinus
bradycardia)
Phenylephrine (high cardiac output
or serious tachyarrhythmias
and salvage)
•We suggest against using IV hydrocortisone to treat septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability. If this is not achievable, we suggest IV hydrocortisone at a dose of 200 mg per day
SURVIVING SEPSIS CAMPAIGN 2016
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•No ACTH stimulation tests or serum cortisol testing
•No additional mineralocorticoid
•7 days
•Taper
SURVIVING SEPSIS CAMPAIGN 2016
• Hydrocortisone provides adequate glucocorticoid and mineralocorticoid effects so fludrocortisone is not needed.
• Tapering of steroids is recommended.
• Although the current hypothesis for the use of steroids in septic shock is to treat relative adrenal insufficiency, current evidence suggests no value in measuring this with a corticotropin response test.
WHAT DO WE KNOW?
• Steroids are of no benefit in the treatment of severe sepsis in the absence of shock.
• Low dose steroid therapy reduces time to reversal of septic shock
• Still controversial as to whether or not there is a meaningful reduction in mortality.
• The more severely ill and hemodynamically unstable the patient is the more likely to benefit from stress-dose steroids.
WHAT DO WE KNOW?
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TO SAVE LIVES.....
Early fluid resuscitation
Early identification
Early antibiotics
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