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3/4/2018
1
SEPSIS: THE IMMUNE
SYSTEM’S RESPONSE TO INFECTION
Dee Ann Totten, RN, MSN, CNS, APRN, CCRN, CEN
Disclaimer
I do not represent any Special Interest Group, Pharmaceutical Company, or Equipment/Merchandise Sales Group, or have any promotional interest in presenting this lecture. I have not received any payment from anyone other than KCNPNM!!!
Sepsis FactsSepsis is the #1 killer in the United States.
About 600 deaths daily .
50% will die without appropriate treatment.
Early diagnosis & treatment is essential.
Relationship antibiotics & treatment:
Antibiotics in 30 minutes = 82% survival;
3-5 hours = 50% survival
Economics
Sepsis costs $24 billion dollars a year (2014)
Most expensive inpatient cost
5% of U.S. Health Care Budget
Enormous public health burden
(JAMA, Feb., 2017)
DefinitionAccording to the Joint Collaboration Society of Critical Care Medicine & European Society of Intensive Care Medicine:
SEPSIS:
A life-threatening organ dysfunction caused by dysregulatedhost response to infection.
SEPTIC SHOCK:
Sepsis complicated by either hypotension or hyperlactatemia.
Historical PerspectiveSepsis is the oldest, most elusive syndrome in medicine:
Hippocrates – Father of Medicine 460-377 BC
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HistoryGalen – Greatest Physician ancient Rome 130 AD
HistorySemmelweis – Pioneer Asepsis 1818-1865
HistoryPasteur – Germ Theory - 1822-1895
FLOProgressive Insurance – “Name Your Price Tool”
HistoryFlorence Nightingale – Founder of Nursing - 1820-1910
HistoryAdvent of Modern Antibiotics
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History
YOU!!!
____________ (Insert your name here!)
Surviving Sepsis Campaign (SSC)
Established 2002
Goal: To decrease mortality from severe sepsis &
septic shock worldwide.
Established guidelines/protocols for rapid diagnosis &
treatment.
SEPTEMBER IS SEPSIS MONTH!
2015
Centers for Medicare & Medicaid Services established
hospital requirement to report:
1. Sample size of sepsis patients
2. Whether or not meeting SSC guidelines
Initatives
June, 2017 - New England Journal of Medicine
World Health Organization (WHO) made Sepsis a
“global health priority”.
Adopted a resolution to improve sepsis by prevention, diagnosis, & management.
Who Gets Sepsis?80% Sepsis begins outside the hospital
Most sepsis arrives at the hospital’s “front door” (ED)
Ages over 65 & less than 12 months
Weakened immune systems
Chronic medical conditions
Drug –resistant bacteria
Who Gets Sepsis?Males > Females
Blacks > Whites
Hospitalized /Nosocomial
Healthy People
Non-Infectious Causes
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Ground Zero - Screening Suspected or Confirmed Infection:
None
Acute abdominal infection
Bloodstream catheter infection
Bone/joint infection
Endocarditis
Sepsis Front Porch“Ground Zer0”
University of Pittsburgh Medical Center
Dr. Elizabeth Tedestco, Director of Emergency Services conducted a study to evaluate the outcome of SSC protocols in reducing sepsis mortality (2016).
Participants 247: 161 confirmed infections
52% met sepsis protocol
Results were published in Journal of Emergency Nursing, May , 2017.
RESULTS: 28% reduction in mortality though the number of patients identified as infected or septic went up 21.5%!!!
Pediatrics & Sepsis
We’re fighting hard to improve outcomes in pediatric sepsis!!!
Sepsis #1 cause of death pediatrics worldwide.
In the US the CDC ranks sepsis as 7th cause of death
pediatric patient (2014). Mortality = 25%.
SSC Goal: Give broad –spectrum antibiotics within 3 hours of Admission.
Children’s ED WakeMedRaleigh, NC
Hassing & Stone conducted study at their Children’s ED (2016).
Instead of the SSC goal of ABX in 3 hours, they would strive for within 1 hour of arrival . This was termed the “golden hour”.
RESULTS: Reduction in mortality by 10%!!!
Peds “Takes Guts”Signs & symptoms of illness/sepsis may be vague:
1. Poor feeding or not wanting to feed
2. Irritability
3. Inconsolability
4. Typically not hypotensive till too late
5. Prematurity risk
6. Auscultate to confirm VS.
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Suspected Infection & 2 or more SIRS? (10%)
HR > 90
RR > 20
Temp > 101 F or < 96.8 F (38.3 C or 36.0 C)
WBC > 12,000 or < 4,000
Bands > 10%
Altered Mental Status (AMS)
Severe Sepsis (40%)
Mental Status Changes; Decreased LOC
SBP < 90 or MAP < 65
O2 saturation < 90%
Lactic Acid > 2 mmol/L
SEPSIS AWARENESSUL HOSPITAL TIME CLOCK:
UL Employee Name Badge
ALERT
Sepsis – Main ED
Severe Sepsis – Room 9
MAIN ED ALERTWithin 15 minutes:
Sepsis Alert Broadcast
Measure Lactate POC (Repeat in 2 hours if up)
Labs: CBC, CMP, Lactic with Reflex if > 2 mmol/L
Blood Culture #1 on hold
Initiate Cardiac, SpO2, NIBP monitoring
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(continued)Start IV
Notify Attending Lactate POC result
Systemic Inflammatory Response Syndrome
SIRS = Identified by 2 or more: - fever or low temp
- tachycardia
- tachypnea
- change in blood
leukocytes
SIRS
Sepsis = SIRS + Infection
Sepsis is response to infection.
Severe Sepsis = SIRS + Infection + Organ Dysfunction,
Hypoperfusion, or Hypotension.
SOFAOrgan dysfunction is represented by the SOFA Score.
Stands for Sepsis Organ Failure Score
Score of 2 or more points is associated with a
increase in hospital mortality by > 10%.
• Out of hospital bedside SOFA Score: RR > 22, AMS,
SBP 100 or less.
Within 1st Hour:Blood culture #2 (Phlebotomy)
IVF 30 ml/kg if lactate > 4 or hypotension (crystalloids)
Start Antibiotics (Broad Spectrum)
Identify source of infection
(PCXR, UA POC & Culture, Sputum Culture)
If Septic Shock, assess fluid status
Repeat Lactate, reassess volume, vasopressors use (MAP < 65 after IVF’s or initial Lactate > 4mmol/L.
Additional SIRSGlucose (serum) > 140 or < 200 dl (if no DM)
Greater risk poor outcome:
B/P < 100 systolic
AMS
Decreased UO
Decreased platelet count
Decreased Hemoglobin
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Screening Tools Screening Tools
Screening Tools Signs & SymptomsS = Shivering, fever, very cold
E = External pain/discomfort
P = Pale, discolored skin
S = Sleepy, difficult to arouse, confused
I = “ I feel like I might die!”
S = SOA (shortness of air)
Infection
FEVER IS THE FIRST SIGN OF A BACTERIAL INFECTION!
“OH, RATS”
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Culprit MicroorganismsGram + Microorganisms: Staphlococcus
(purple) Streptococcus
Culprit MicroorganismsGram – Microorganisms: E-Coli
(red) Pseudomonas
Klebsiella
Enterobacter
Culprit MicroorganismsCombination m/o both + & -
Fungus
Parasites
Host1. Innate Immunity: “Alarmers”
2. Protease-Activated Receptors (PARS)
* PAR 1 in particular is implicated in sepsis.
3. Mechanism of Organ Failure:
- Low B/P
- Low RBC’s
- Microvascular thrombosis
- Inflammation
- Mitochondial dysfunction
- “Alarms” released
1. Endocarditis
Etiology: The Source Etiology: The Source2. Urinary Tract Infection (UTI)
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Etiology: The Source3. Pneumonia/Emphyema
Etiology: The Source4. Wound Infection
Etiology: The Source5. Acute Abdominal Infection
Etiology: The Source6. Meningitis
Etiology: The Source7. Implantable Device Infection
Etiology: The Source8. Bone/Joint Infection
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Etiology: The Source9. Skin & Soft Tissue Infection
Etiology: The Source10. Bloodstream Catheter Infection
Etiology: The Source11. “Found Down”
Etiology: The Source12. Non-infectious
Complications
*Blood flow to vital organs, brain, lungs, heart, &
kidneys becomes impaired.
* Blood clots form in organs & arms, legs, fingers,
toes …which leads to organ failure & tissue death.
Lab Tests*WBC
*Lactate
*Blood Cultures X 2
UA & Culture
CRP
PT/PTT/D-Dimer
Procalcitonin (PCT)
CMP
Cultures : Sputum/Abdominal/Wound
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Studies“Usefulness of Procalcitonin for the Diagnosis of
Sepsis in the ICU”
Balci, Swagurtekein, et al (August, 2017)
RESULTS: PCT was best predictor of Sepsis in the ICU.
Comparative study of PCT & CRP in early dx.
Better than WBC & temperature.
DiagnosticsPCXR
Abdominal US
Abdominal CT or MRI
ABG
EKG/Cardiac Enzymes
InvasiveThoracentesis
Paracentesis
Swan-Ganz Catheters
Evaluation for Surgery
Confirmatory Tests
Endotoxin
Procalcitonin
Septicyte (genetic component)
“Bundles” (2)SSC organized sepsis protocol into 2 “Bundles”.
Journal Critical Care Medicine – August – 2013
Bundle 1: Initial management within 6 hours of pt.
presentation.
Includes: CPR, IVF’s, Vasopressors, O2 therapy,
Mechanical Ventilation, Probable dx.,
Cultures, ABX, Source Control.
“Bundles”Bundle 2: Management ICU after 6 hours.
Includes:
- Organ Support
- Avoiding Complications
- De-escalating Care (if possible)
- Decreasing Antibiotics
- Immunotherapy Treatment
- Discontinuing Vasopressors
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Antibiotic Rules*Make sure you know patient’s medication
allergies!!!
Give 1 antibiotic at a time!
More than 1 IV line!
Best Antibiotics SepsisCarbapenems:
Meropenum (Merrem)
Imipenem (Pimaxin)
AntibioticsCephalosporins
Cefepime (Maxipime) 4th Generation
Ceftriaxone (Rocephin) 3rd Generation
AntibioticsPenicillins
Piperacillin-Tazobactum (Zosyn)
AntibioticsQuinolones
Levofloxacin (Levaquin) 3rd Generation
AntibioticsOther
Tigecycline (Tygacil)
Metronidazole (Flagyl)
Aztreonam (Azactam)
Vancomycin (Vancocin)
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Antimicrobial TherapyHandout
Depends on adequate coverage resident flora
presumed to be the source of sepsis process &
potential antimicrobial resistance patterns.
(“Bacterial Sepsis” – Emergency Medical Journal )
August, 2017
Studies“Fluid Resuscitation in Sepsis”
Annals of Internal Medicine – September 2015
RESULTS: 14 Studies Canada 2014, 18, 916 pts.
Compared crystalloids, colloids, starches.
* RESULTS: Best IVF replacement sepsis are
crystalloids!
EGDT
Early Goal-Directed Therapy
ICD 10 Code: Sepsis
Minimal 2 codes for severe sepsis:
1. Underlying systemic infection
2. Followed by code for
Severe Sepsis – R 65.2
3. If organ dysfunction other than septic shock
is present, the codes for the specific organ
dysfunction are added.
Post-Sepsis SyndromeAffects 50% of sepsis survivors! (increased risk if in ICU)
Physical and/or psychological long-term effects:
- Insomnia
-Nightmares
-Disability Muscles & Joint Pains
-PTSD
-Hair Loss
-Damage kidneys, lungs, liver
- Other: Amputations, Anxiety, Neurosensory loss, Chronic Pain/Fatigue.
Post-Sepsis Mortality
Mortality : SIRS = 6-7%
Mortality: Septic Shock = 50% (if source of infection was abdominal = 72%)
PROGNOSIS: POOR!!!
* Only 30% alive 1 year after hospital admission.
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Public EducationSepsis Alliance Group (non-profit)
Goal: Save lives & reduce suffering by raising awareness of sepsis as medical emergency.
2016 Survey found 55% of adults had never heard of sepsis, even though it was the 11th leading cause of death in 2014 according to the Center for Disease Control & Prevention.
Sepsis Alliance Newsletter
Question/Answer Format:
What is Sepsis?
Causes?
Population at Risk?
Signs & Symptoms?
Infection
Treatment
Long-term effects?
Prevention
Emergency
Events
Prevention: What About Us?
Wash Your Hands!!!
Clean your equipment!!!
Limit Antibiotic Therapy
Great History & Physical Exam Skills
Listen “to your gut”
Prevention1. Get vaccinated (flu/pneumonia)
2. Prevent infections: Clean wounds
Good handwashing
3. Know the signs & symptoms of sepsis.
4. Smoking Cessation
5. Urge parents unvaccinated kids to limit exposure
seek immediate care fever if < 28 days old.
CASE STUDY #1“New Sepsis Diagnostic Guidelines Shift Focus to Organ Dysfunction”
Julie Jacob, MA (JAMA – February, 2016)
Queens, NY
Male, age 12. Cut arm playing basketball @ school.
Next day, fever & leg pain. Pediatrician – ABX.
Day 2: ED – Diagnosis: “Upset stomach”. Discharged.
Died 3 days later from sepsis – Mortality!
* Parents funded Foundation to increase public awareness of sepsis!
Case Study #2“Management of Septic Shock”
Berger, Rivera, Levy MD’s (NEJM - June, 2017)
65 year old F with 3 day history of dysuria
PMH: HTN on Amlodipine 10 mg PO daily
ED: Chief complaint : “Dizziness”
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Case Study #2VS:
Ht: 65 inches; Wt. 70 kg (154#)
Temp 38.6 (101.4) Lungs: CTA
HR = 125 Warm extremities
B/P: = 85/55 Suprapubic tenderness
RR = 28
O2 Sat = 94% on RA
Case Study #2Labs:
Creatinine = 1.8 Hemoglobin = 9.0
BUN = 76 UA = 3+ leukocytes;
Lactate = 5.0 > 100,000 bacteria
Anion Gap = 25
WBC = 20,000
Case Study #2Started IV & ABX. F/C inserted. – Diagnosis = Probable
UTI
After 2100 ml NS IVF, CVP was 8.0. B/P 80/50 (MAP =60).
UO was 20 ml for the 3 hours she was in the ED.
CVP line placed & Levophed started at 4 mcg/min.
Moved to ICU
Case Study #2ICU: Diagnosis = Septic Shock
HR = 100
MAP = 65-70
CXR: Acute lung injury & good central line placement.
SvO2 < 70; transfused 1 unit packed RBC’s (HCT 30%)
Case Study #2ICU: Diagnosis = Septic Shock
EGDT Protocol Followed:
Continued on Vasopressors Hemodynamics
Intubated/Mechanical Ventilation SvO2 & CVP
Early resuscitation Early CVP line
ABX/IVF’s RBC’s – Hgb 10.0
*SURVIVAL: EGDT improves outcomes in patients sepsis &
septic shock ! (&7% vs. 23%)
Case Study #336 year old , white, F . Ht. = 62 inches. Wt. = 105#.
PMH: Appendecomy age 22. Mild Anemia.
Diagnosed with Crohn’s Disease age 32.
Numerous episodes N/V/D. Multi trips to ED with SBO.
Taking 64 meds a day to control inflammation.
PCP/GI MD/Surgical Consultations
Mao Clinic 3 day evaluation – PE, Labs, Colonoscopy, Consult
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Case Study #3Decides on OR, Small Bowel Resection in 1 week.
Presents day of OR to Pre-Op: N/V/D. Severe RLQ pain.
Fever 104 F. Abdominal distention. Hyperactive high-pitched BS. Guarding & rebound tenderness. Frail, pale, cool & clammy. Thready pulse @ 124/min. B/P 70/palpable. AMS. RR = 26. O2 sat = 95%. Rates pain as 10/10 “twisting pain that takes my breath away”. Vomitus – stool-colored brown & intractable. Family members at bedside.
Case Study #3Labs:
CBC = 22, 000 with 15% bands (left shift)
H & H = 9.0 & 40.
CMP = K+ 1.8
UO = < 20 ml/hr. Normal UA other than elevated BUN
No lactate or PCT (not available @ this time.
Case Study #3CXR = No active pulmonary disease
EKG = Sinus Tachycardia @ 124/min.
CT Abdomin & Pelvis: Free air; Bowel Perforation.
Management: T & C for 2 units PRBC’s
IV/IVF’s F/C to BSD urometer
Morphine/Phenergan Non-invasive monitoring
IV/IVF’s N/G Tube to LWS
ABX: Cephalosporin (Keflex) ; Cimetadine prophylaxis; IV K+ runs
Case Study #3Stabilized & OR 2 hours later: Small Bowel & Colon
Resection; Perforation
Recovery uneventful other than hypoxia RR 2nd to MS.
Hospitalized x 7 days. IVF’s & ABX. Discharged.
Home: 2 weeks later to ED intractable N/V.
TO ED: K+ 1.6. IV, Phenergan, IVF’s, K+ runs, Discharged.
SURVIVED!!! Alive & well; con’t battling Crohn’s.
Case Study #3
SEPSIS CAN HAPPEN TO ANYONE!!! EVEN YOU!!!
“Gloom & Doom”Sepsis…damages critical tissue
Sepsis…leads to failure of vital organs
Sepsis…causes death
The number of deaths from sepsis has increased in the last 20 years because the number of cases of sepsis have increased.
Mortality > 80% 30 years ago; now close to 20-30%.
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What’s In The Future?Failure last 30 years to develop effective strategies in
correcting underlying features of sepsis.
1. Glucocorticoids associated with most benefits.
2. Antibiotics
3. Better pre & clinical research trials.
4. Genetics
Future…5. More targeted drug development.
6. Activated Protein C
7. Interleukins/Interferons
8. Continue protocol revision & evaluation.
9. Education – public & medical personnel
10. *PREVENTION!!!
Studies
“Activated Protein C for Management of Sepsis”
NEJM December, 2009
RESULTS: Benefits controversial.
- Increased bleeding risks
+ Inhibited procoagulation state in sepsis
Future Is Bright!!!
VIDEO
“I’m Bringing Sepsy Back”
Kern Medical Center
Bakersfield, California
CONCLUSIONS = Screening patient for sepsis
E= Early intervention (Antibiotics; IVF’s)
P= Phlebotomy (Labs)
S= Source Identification
I = Interventions (Vasopressors; Hemodynamics)
S= Support Post-Sepsis
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Finally…
Reflections:
REMEMBER WHY?
The End!
Questions???
Thank-You!!!