Early Detection & Treatment of Sepsis in the Adult

Kelly Nguyen, MSN, RNSepsis Coordinator

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Learning Objectives• Verbalize an understanding of Systemic Inflammatory

Response Syndrome (SIRS), sepsis/severe sepsis & septic shock.

• Verbalize understanding of the importance of early recognition & treatment for patients with sepsis/severe sepsis & septic shock.

• Identify actions required by the RN to facilitate appropriate care for patients with sepsis/severe sepsis & septic shock.

• Verbalize understanding of elements of the new sepsis core measure.

• Identify key symptoms of sepsis to teach others.

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Sepsis is• Greek. Means “decay” or “to putrefy.”• The body’s overwhelming and life-threatening response to infection which can lead to tissue damage, organ failure and death.1

21 Sepsis.org

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Public Interest Over Time

• A person is hospitalized every 20 seconds for sepsis.1

• One person dies every 2 minutes from sepsis.2

• Sepsis is the leading cause of death in U.S hospitals.3

• Deaths from sepsis outnumber those from breast cancer, prostate cancer and AIDS combined.4

• Each year more than $24 billion is spent on acute care in-hospital costs; making sepsis the most expensive condition in the US to treat.5

People Need to Know:

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1 http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/infectious-disease/sepsis//2,4 http://www.cdc.gov/nchs/fastats/lcod.htm3 http://www.centerfortransforminghealthcare.org

http://www.sepsis.org5 http://www.hcup-us.ahrq.gov/reports/statbriefs/sb122.jsp

Sepsis Can Happen to Anyone, Anytime

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Who is at Greater Risk?• People with

• Weakened immune systems• Pre-existing infections• Pre-existing co-morbidities (like diabetes or alcoholism)• Severe injuries (such as large wounds)• Invasive lines, drains and/or tubes

• The very old or very young• Patients who have had surgery or invasive procedures• Hospitalized patients

cfotips.com6

www.sepsis.org

Just Like Heart Attack and Stroke:

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Allcentexsepticaustin.com

So… What Exactly IS Sepsis?

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Sepsis Progression: The Basics

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www.nysut.org

Schematic of Sepsis“… this schematic illustration somewhat oversimplifies the pathophysiologic process…”

“… provides a framework for understanding a complex chain of events.”

“The pathways are not distinct, and the effects of any one mediator may vary with physiologic conditions.”

“If the body cannot restore homeostasis… the general inflammatory response will produce clinical evidence of sepsis.” Bone, R.C. (1991). The Pathogenesis of Sepsis. Annals of Internal

Medicine, 115:457-469. 10

“Except on few occasions, the patient appears to die from the body's response to infection rather than from it."

Sir William Osler – 1904The Evolution of Modern Medicine

Sepsis is Not a New Concept

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How Did We Get Here?

Adapted from:Slesinger, T.L. & Dubensky, L. (2017). Sepsis-3, a new definition. Solutions or new problems? Retrieved February 14, 2017 from www.acep.org

Barcelona Declaration est.

SSC

SSC CCM Guidelines

revised

SCC Revised to include 3 &

6h bundles, RN screening

SEP-1

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2015: Sepsis Became a Core Measure• Called “SEP-1”• Focused on patients (18yrs & older) with severe sepsis or

septic shock.• Requires completion of time sensitive interventions.• Composite measure. If one element of SEP-1 is missed

the entire case fails.

• Pertinent Clinical Exclusions:• Advanced directives for comfort/palliative care• Patient or designee refuses treatment

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2016: Then This Happened

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2017: And Now Here We Are…

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So Now People are Feeling Like this:

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Adapted from the ACCP/SCCM Consensus Conference Committee. Chest. 1992;101:1644-1655.

Bacteria

Fungus

Parasite

Virus

Other

Infection

SEP-1 Sepsis Definitions

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Systemic Response

Pancreatitis

Trauma

LargeBurns

Other

SepsisSepsis

Severe Sepsis

Septic Shock

Systemic Inflammatory Response Syndrome (SIRS)

• Patients may have SIRS for a variety of clinical conditions• Characterized by the presence of two or more of the

following:• Core temp > 38.3°C (100.9°F) or < 36° C (96.8°F)• Heart rate > 90 bpm• Respiratory rate > 20 bpm• WBC count > 12,000µL or < 4,000µL• Normal WBC with 10% bands

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Don’t Let This Be You, Too!

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Sepsis Progression in Detail

SIRS

• Systemic Inflammatory Response Syndrome (SIRS). A group of clinical criteria that indicate a systemic reaction to an insult.

Sepsis• Two or more SIRS with a known or suspected infection.

Severe Severe Sepsis

• Sepsis with acute sepsis-induced hypoperfusion or organ dysfunction.

Septic Septic Shock

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Identifying Acute Organ Dysfunction as a Marker of Severe Sepsis

• Tachycardia• SBP< 90 or > 40 below

baseline• MAP < 65 • capillary refill• Need for vasopressors

• Unexplained metabolic acidosis

• Lactate > 2• Blood glucose > 140 in

non diabetic

• Acute hypoxemia PaO2/FiO2 < 250 without pneumonia as infection source or < 200 with pneumonia as source

• RR > 20• Acute respiratory failure

• SpO2 < 90% on room air• Increasing need for O2

• UO < 0.5 ml/kg/hr(despite fluid)

• Creatinine > 0.2• Has not voided or does

not feel the need

• Platelets < 100,000• aPTT > 60 sec

Respiratory

Metabolic

Cardiovascular

Renal

Hematologic

CNS• Acute change in

mental status

Liver/GI• New ileus• INR > 1.5• Bilirubin > 2.0• AST, ALT, Alk Phos

Image reproduced with permission from Martie Mattson, CNS

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Mortality Increases with the Number of Organs Affected

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Sepsis Progression in Detail

SIRS

• Systemic Inflammatory Response Syndrome (SIRS). A group of clinical criteria that indicate a systemic reaction to an insult.

Sepsis• Two or more SIRS with a known or suspected infection.

Severe Severe Sepsis

• Sepsis with acute sepsis-induced hypoperfusion or organ dysfunction.

Septic Septic Shock

• Severe sepsis with sepsis-induced hypotension persisting despite adequate fluid resuscitation &requiring vasopressors.

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Beware of False Perceptions • Some patients may not have 2 SIRS and are still septic• Many patients always have SIRS/Organ Dysfunction• You can be normothermic and be septic• Patients can’t be septic if they are normotensive and “look

good.”

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February 2016 (Sepsis-3)Eliminated term “Severe Sepsis,” replaced with “sepsis”

• Sepsis: “Life-threatening organ dysfuntion caused by a dysregulated host response to infection1”

• Septic Shock: “… profound circulatory, cellular, & metabolic abnormalities are associated with a greater risk of mortality1”• Septic Shock: Clinical definition

• Vasopressor therapy needed to elevate MAP to ≥ 65• Lactate > 2.0 in the absence of hypovolemia

https://emcrit.org/pulmcrit/problems-sepsis-3-definition/

1 Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3), JAMA, February 23, 20162 Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016, CCM, 2017

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Operationalization of Clinical Criteria

The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3), JAMA, 2016; 315(8): 801-810

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a. PaO2/FIO2 ratio was used preferentially. If not available, the SaO2/FIO2 ratio was used b. Vasoactive mediations administered for at least 1 hr (dopamine & norepinephrine μmg/kg/min)

SOFA Score > 2 Above Baseline

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QSOFA• Prompt to consider possible sepsis• Three parameters, each worth 1 point

• Alteration in mental status• RR > 22• Systolic BP ≤ 100

• Two or more, predictive of increased mortality & ICU stay

• Follow up with SOFA

29Qsofa.org

Challenges with QSOFA• Altered mental status can be subjective and difficult to identify if baseline not known

• A percentage of patients may normally have a SBP < 100

• If any questions, do the SOFA

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Bottom Line is: Early Recognition is Prevention

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Sepsis Screening Practice #180 YOM recently admitted from ED for cholangitis. Now presenting with ABD pain, weakness, watery diarrhea, fever, chills

Labs: WBC 15.2, Lactate 2.6

Sepsis/Severe Sepsis or Septic Shock?

VS: 38.8, 107, 24, 220/95, 94% RA

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Sepsis Screening Practice #232 YOM arrives in ED, c/o pain in foot. Says he stumbled off curb the evening before and has had trouble walking since. Foot painful, red, swollen and warm.

Labs: WBC 17.1, Lactate 4.0

Sepsis/Severe Sepsis or Septic Shock?

VS: 38.5, 98, 18, 125/70, 99% RA

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Time of Presentation• The time in which the patient meets all of the following

criteria (within a 6 hour window):• Suspected or confirmed infection• Two or more SIRS present• One or more organ dysfunction criteria present

Slideshare.net34

TOP Practice• 87 YOF with hx: Dementia, DM, a-fib, currently being

treated for LLL PNA

• 08:24: WBC 13,000, platelet count 98,000

• 11:07: T 101.2, P 67, RR 22, BP 112/67 (82)

What’s the TOP?

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Sepsis/Severe Sepsis or Septic Shock?

TOP Practice• 24 YOF with hx: CP, recurrent UTI’s. Currently being

treated for cellulitis around GT.

• 02:24: T 38.1, P 112, RR 24, BP 101/52 (68)

• 04:41: T 38.4, P 108, RR 22, BP 98/48 (64)

• 07:01: T 38.3, P 110, RR 24, BP 102/54 (70)

What’s the TOP?

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SEP-1 Requirements for Severe Sepsis & Septic Shock:• Anticipate orders for the following:

• Within 3 HOURS from TOP:• Measure serum lactate • Obtain two sets of blood cultures (& source cultures as indicated)• Administer appropriate antibiotics • Administer crystalloid fluid bolus(es) for hypotension and/or

lactate > 3 mmol/L

• Within 6 HOURS from TOP:• Re-measure elevated lactates every 2h until < 2.0 mmol/L• Administer vasopressors for hypotension not responding to fluid

resuscitation • Volume status and tissue profusion assessment (invasive/non-invasive)

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Lactate and Sepsis• Ranges:

• Normal ≤ 1.0• > 2.0 is an indication of severe sepsis*• ≥ 4 is an indication septic shock*

• Serial lactates more important1• Must re-measure within 6 hours if initial lactate >2 mmol/L

• “Lactime” (duration lactate > 2mmol/L) is predictive of organ failure and mortality2

1 Mikkelsen, M., et. al. (2009, May). Serum lactate is associated with mortality in severe sepsis independent of organ failure and shock, Crit Care Med, Vol 37, No 5, 1670-1677.

2 Nguyen, H.B., et. al, Early lactate clearance is associated with improved outcome in severe sepsis and septic shock. Crit Care Med, 2004, 32(8).

Medtoworld.com

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Two Types of Lactic Acidosis

FACT: Elevated lactate levels are predictive of increased mortality no matter what the cause Husain et al, Am Jrnl Surg, 2003

TYPE A TYPE BDue to poor tissue perfusion or oxygenation (hypoxic)

No apparent hypoperfusion(non-hypoxic)

- Ischemia- Hypovolemia- Cardiac failure/arrest- Severe asthma, COPD- Respiratory failure- Sepsis

- Delayed clearance- Renal or hepatic failure- DM- Malignancy- Medications- Seizures

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Who Remembers This?

En.wikipedia.org

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Citric Acid Cycle in a Nutshell

• Normal process in aerobic organisms• Middle of three major steps in cellular respiration• Series of chemical reactions which harvest energy for

cells to use• When there isn’t enough cellular oxygen delivery cardiac

output is redistributed so more oxygen can be extracted from capillary blood.

• Enough oxygen can’t be extracted from capillaries to support aerobic metabolism so cells begin using anaerobic sources of energy

• Results in lactate production which is why lactate is considered a surrogate marker for tissue hypoxia

Bridges, EJ & Dukes, MS. Cardiovascular aspects of septic shock. Critical Care Nurse. April 2005Schwarts, Steve (2016, March 5). Krebs Cycle, Layman’s Explanation. www.quora.com

Gunnerson and Pinksy, (2016, April 25). Lactic Acidosis. Retrieved November 16, 2016 from emedicine.medscape.com41

Diagnosis

• At least 2 sets of blood cultures (aerobic & anaerobic); at least one set percutaneously, & at least one set through each previously inserted vascular access device

• Cultures as clinically appropriate before antibiotics if no significant delay (>45 min)

• Imaging studies performed promptly to identify source

www.flicker.com

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Antibiotics• Effective broad spectrum antibiotic with the goal of

administering within the first hour after recognition of severe sepsis and septic shock

• Every hour of delay in antibiotic in septic shock patients survival by 7.6% Kumar et al, Crit Care Med, 2006, 34,(6)

• Use of procalcitonin or other biomarkers to discontinue antibiotics if no evidence of infection

• Antiviral therapy initiated early• Not to be used if inflammatory

state noninfectious

Ivleagueinc.com43

Fluid Resuscitation

• Give 30 ml/Kg crystalloid as a fluid challenge

• Look for hemodynamic improvement

• Albumin when patients require substantial amounts of crystalloids

Athicketofmusings.com

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Post-Bolus Assessment

• In the event of persistent hypotension (MAP < 65) after initial fluid administration or initial lactate ≥ 4 reassess & document volume status & tissue perfusion by EITHER

• Repeat focused exam including:• VS• Cardio/pulmonary status• Cap refill• Peripheral pulse evaluation• Skin exam

• Two of the following:• Measure central venous pressure (CVP)• Measure central venous oxygen saturation (ScvO2)• Bedside cardiovascular ultrasound• Assess fluid responsiveness with passive leg raise or fluid challenge

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Supportive Therapies• Corticosteroids• Blood Administration• Glucose Management• ARDSNET Protocol• VTE Prophylaxis• Stress Ulcer Prophylaxis• Renal Replacement Therapy• Nutrition• Advanced Care Planning

Drkaplan.co.uk

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Case StudyAdmission Day 1

• 84 YOM BIBA from SNF. • Alert to self, place, event (baseline) • Admitted on PMs to M/S. Dx PNA . • ED Course:

• Orders: PIV, 500ml NS bolus, tylenol PO, levofloxacin 750mg IV

• Pertinent Labs: WBC 17,000, lactate 1.6, Chem WNL. BC pending

• VS: 38.6, 96, 28, BP 156/82, 93% on 2L NC

How would you screen this patient?

Mercola.com

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• Admission Day 3: • AM VS: 38.0, 92, 30, 102/70, 92% 3L NC• Appears more confused. Repeatedly asking staff why he is at the hotel

How would you screen this patient?

Case StudyAdmission Days 2 & 3

• Admission Day 2: Uneventful. • AM VS: 38.3, 90, 24, 136/82, 94% 3L NC

How would you screen this patient?

• Lactate 3.4, UA cloudy and positive for WBCWhat should the next step(s) be?

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Role of the RN• Know the stages of sepsis; identify at-risk patients early. • Don’t hesitate to ask: “Could this be sepsis?”• Treat sepsis as a medical emergency! • Assist providers in meeting the 3 & 6 hour requirements.• Know your facilities policies/procedures• Follow infection control measures • Wash your hands!

Villanovau.comTelegraph.co.uk49

Teach Everyone, Any Chance You Get!

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The Unfortunate Reality

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Want to Know More?

• Check out these websites:• www.sepsis.org• www.survivingsepsis.org

• Play Septris!• Septris at Stanford Med

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Additional References Hall, M.J., Williams, S.N., DeFrances, C.J., & Golosinkiy, A. (2011). Inpaient Care for Septicemia or Sepsis: A

challenge for patients and hospitals. NCHS Data Brief, 62.

Castellanos-Ortega, A., Suberviola, B., Garcia-Astudillo, L. A., Holanda, M. S., Ortiz,F., Llorca, J., et al. (2010). Impact of the Surviving Sepsis Campaign protocol on hospital length of stay and mortality in septic shock patients: Results of a three-year follow-up quasi-experimental study. Crit Care Med, 38(4)

LaRosa, S.P. (2016). Sepsis. Cleveland Clinic. Retrieved January 2, 2016 from https://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/infectious-disease/sepsis/

Dellinger, R.P., Mitchell, M.M., Rhodes, A., Annane, D., Gerlach, H., Opal, S.M., el. Al. (2012). Surviving Sepsis Campaign: international guidelines for management for severe sepsis and septic shock: 2012. Crit Care Med, 41(2), 580-637.

Levy, M. M., Dellinger, R. P., Townsend, S. R., Linde-Zwirble, W. T., Marshall, J. C.,Bion, J., et al. (2010). The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Intensive Care Med, 36(2), 222-231.

Mikkelsen, M. E., Miltiades, A. N., Gaieski, D. F., Goyal, M., Fuchs, B. D., Shah, C. V.,et al. (2009). Serum lactate is associated with mortality in severe sepsis independent of organ failure and shock. Crit Care Med, 37(5), 1670-1677.

Rivers, E. P., Coba, V., Visbal, A., Whitmill, M., & Amponsah, D. (2008). Management of sepsis: early resuscitation. Clin Chest Med, 29(4), 689-704.

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