PHYSIOLOGY AND MANAGEMENT OF THE SEPTIC PATIENT Melanie Sanchez, RN, MSNE, OCN, CCRN Clinical Nurse III City of Hope National Medical Center

HOW THE EXPERTS TREAT HEMATOLOGIC MALIGNANCIES LAS VEGAS, NV MARCH 14, 2018

DISCLOSURES

I do not have anything to disclose.

“WHEN NURSES KNOW BETTER THEY DO BETTER”

GOAL is to Increase Nurse’s – Knowledge

– Skills – Confidence

….. to better care of Oncology patients

REVIEW

Sepsis incidence Visual of sepsis pathophysiology Sepsis recognition Early goal directed therapy – one hour sepsis bundle Sepsis recognition and treatment

Incidence and Prevalence of Severe Sepsis and Septic Shock

• 19 million cases worldwide • 750,000 cases in United States annually

– 2% of all hospital admissions – 10% of all ICU admissions

• Historic mortality in 1980’s up to 80% • Current mortality rates range from 20-30%

Risk Factors for Severe Sepsis and Septic Shock

• Cancer • Transplant-related immunosuppression • Graft-versus-host disease • Neutropenia • Loss/compromise of mucosal barriers • In-dwelling venous access devices • Acquired immunodeficiency syndrome • Chronic obstructive pulmonary disease • Age (infants, elderly)

Sites of Infection

• Most common sites of infection – Pneumonia – Intraabdominal sites – Urinary tract

• Blood cultures positive in 1/3 of patients • 1/3 of patients have no positive cultures from any site

Microbiological Causes of Sepsis

• In survey of 14,000 septic patients: – 62% gram negative organisms – 47% gram positive organisms – 19% fungal organisms

• Most common pathogens – Staphylococcus aureus – Streptococcus pneumoniae – Escherichia coli – Klebsiella species – Pseudomonas aeruginosa

UNDERSTANDING THE IMPORTANCE Sepsis is the LEADING cause of non‐relapse MORTALITY in oncology patients

https://learn.premierinc.com/ebooks/sepsis-infographic

1. 2. 3.

2012 Sepsis Definition was too complicated

Definition Sepsis: Life-threatening Organ Dysfunction caused by a dysregulated host Response to infection Septic Shock: Subset of sepsis with circulatory and cellular dysfunction associated with increased mortality

SEPSIS + REFRACTORY HYPOTENSION &/or Lactate >= 4mmol/L

(JAMA Network, 2016)

(Surviving Sepsis Campaign, 2016)

INFECTION LEADS TO SIRS

SIRS (Systemic Inflammatory Response Syndrome) activated by Infection

Positive Criteria for SIRS >=2: – Temperature ≥ 38 C or ≤ 36 C – HR ≥ 90 beats per minute – RR ≥ 20 breaths per minute or PaCO2 < 32 mmHg – WBC ≥ 12,000/mm3, ≤ 4,000/mm3, or > 10% bands

SITE OF INJURY PATHOPHYSIOLOGY

Capillary Leak ALL VESSELS ARE INJURED

Guideline: Meet Criteria 1, 2, &3 for Severe Sepsis Order Set 1. Known or Suspected Infection - Pneumonia, UTI, Cold/Flu, Diarrhea, Vomiting, CMV, VRE, CDIFF, MRSA,

Wound, Recent Surgery, Rigors, Chills

2. Meet 2 Criteria:

1. Temp > 38.3* or < 36* -Fever or Hypothermia

2. WBC < 4.0 -Immunosuppression WBC > 12.0 -Infection Response or Bad Disease Blasts > 10% -Bad Marrow

3. HR > 90 -Tachycardia

4. RR >20 -Tachypnea

5. Altered LOC -Somnolence or Confusion /etc.

SBP < 90 SBP Decrease > 40 (from Baseline) Lactate > 4 Acute Organ Dysfunction-Low Urine Output or ↑ serum creatinine or acute lung injury

ORGAN DYSFUNCTION & QSOFA

qSOFA Score >= 2 : Predictor of ↑ Mortality

(JAMA Network, 2016)

Hypothermia/

Low WBC or High WBC ↑ Heart Rate

Extremely Tired or Sleepy

Acute Rise in serum creatinine or bilirubin

FLUID RESUSCITATION

30ml/kg • Average 2 Liters NS over 1 Hour

(each 1LNS over 30min)

• Rate: @ 999ml/hr for each1L NS Bag

• Albumin 5% 500ml?

FILL MY EMPTY TANK

of Blood Vessels

Within 1 Hour

*ANTIBIOTICS* TREAT PRIMARY CAUSE OF SEPSIS

• Every Hour Antibiotics are delayed Mortality ↑ almost 8%!

• 6 Hours = 48% Mortality Rate

Within 1 Hour

STAT LABS Within 1 Hour

Might as Well Draw Labs All at Once

Blood cultures x 2 Arterial blood gas, lactate, and ionized calcium

CBC, platelets and differential PT / PTT / INR / fibrinogen Comprehensive metabolic profile ScvO2 (mixed venous saturation of oxygen) Q 30 minutes Urinalysis, culture & sensitivity

Lactate <=1.6

ScvO2 = 70%

SBP >100 OR MAP >=65

CVP (8-12) non-intubated

CVP (12-15) intubated

Goals & Monitoring

LACTATE GOAL < 1.6

• When the body experiences inadequate tissue perfusion Lactate Increases

• Lactate gives you a baseline for how bad the patient’s oxygen demand is & allows you to monitor trends to guide treatment

• Does pt need more Fluids? RBC’s? FIO2? Immediate ICU transfer?

• Ionized Ca+: drops in Sepsis and can lead to Cardiac Dysfunction

– <0.75 possible treat <0.5 Critical, needs Replacement

What is ScvO2, & why a Goal of >70% Definition ScvO2: Oxygen saturation of blood being dumped back into the right atrium by the SVC after

it has circulated through your tissues, reflecting the balance between oxygen delivery and oxygen consumption

Normal Oxygen Tissue Extraction ~25-30%

Why is it so Important to Monitor?

Normal values of: BP, MAP, CVP, HR DO NOT RULE OUT TISSUE HYPOXIA

Values can look alright, but patient might still be hypoperfused and need fluids, red blood cells, dobutamine

Want to make sure patient is being well perfused/hydrated to decrease damage to organs by tissue hypoxia

ScvO2 Goal >70% ScvO2 Status

70-80% Normal

50-69% Compensatory

30-49% Exhaustion

25-29% Severe Lactic Acidosis

<25% Cell DEATH

Draw line Proximal to Heart

ScvO2 Goal >70%: amount of O2 in blood serum

• Versus intravascular volume & CHF in sepsis Cardiac Output

• FIO2 amount of inspired oxygen • PEEP open up alveoli allowing O2 exchange Oxygen supply

• Pt can be hemodiluted/bleeding in sepsis

Increased oxygen consumption

Hemoglobin / Hematocrit

What Effects ScvO2%————> O2 Delivery & O2 Consumption

• Fever, chills, pain, injury

Reduce oxygen demand

EARLY GOAL DIRECTED THERAPY Within 1Hour

ABG with LACTATE Ca+

Blood Cultures (ScvO2 c Labs can be drawn same

time as cultures)

*Antibiotics* Source Control

Fluids 30ML/KG 2Liters avg for 150lb pt

*TEAMWORK*

GOAL MEDS -LEVOPHED -HYDROCORTISONE -VASOPRESSIN -EPINEPHRINE ? DOBUTAMINE ?

GLUCOSE <180

TIDAL VOLUME 6ml/kg

Stress Ulcer Prophylaxis

DVT Prophylaxis

Monitoring CVP MAP ScvO2 Lactate

Monitor ScvO2

After Monitor Goals

Hgb<8.5 or Hct<28 Transfuse RBC

Monitor Lactate ScvO2

SBP or MAP CVP

LOOK AT BIG PICTURE - SBP - SCVO2 - LACTATE TREND

• Fill the tank – For SBP < 90 – fluid resuscitation at 30 mL / kg

• Squeeze the vessels – If SBP < 90 after bolus

• Start vasopressor (Dopamine non-ICU; Levophed ICU) • Increase oxygen perfusion

– If SBP > 90 and ScvO2 < =70% • ? Fluids ? RBC ? Dobutamine • ? FiO2 ? Intubation • ? Pain meds ? Ice packs

• ? Pressors too high • ? All antibiotics on board

SEPSIS SCENARIOS • But first……

• https://www.youtube.com/watch?v=FcNa7S4U0ok

CASE STUDY Jane Doe 62F AML s/p Chemo & Allogenic Transplant Day +8

History of VRE, CDIFF, AFIB, DM2 Problems:

Nausea, Vomiting, Diarrhea for the last week Dry Cough & Runny Nose

CASE 1 • You are a Nurse precepting a new grad, the new grad asks you:

Why does the patient’s blood pressure drop so much with

Sepsis?

CASE 2 • Your septic patient is in DIC (Disseminated Intravascular Coagulation)

and the new grad nurse asks you

– What is DIC and what caused it in your Septic Patient?

CASE 3 NON-ICU FLOOR • Your patient starts showing signs of worsening sepsis. Dr Parker

orders the NON-ICU Sepsis Order Set

• Can you draw a ScvO2 from a PICC line?

• The new grad asks you the precepting nurse why we have to draw ScvO2 every 30minutes until at goal on your septic patient?

What do we want to make sure we get done within an hour?

THANK YOU!