Sepsis ProtocolSepsis ProtocolGo Live Go Live

December 1, 2009December 1, 2009Hendricks Regional Health

Phases of SepsisPhases of Sepsis

• Phase I: SIRS (System Inflammatory Response Syndrome) Criteria

• Phase II: Septic• Phase III: Severe Septic• Phase IV: Septic Shock

SIRS – Phase ISIRS – Phase I

• SIRS (Systemic Inflammatory Response Syndrome) Criteria • Temp >38 C (100.4 F) or < 36 C (96.8 F)• HR > 90• RR > 20 or PaCO2 < 32 or mechanical

ventilation• WBC > 12,000 or < 4,000 or > 10% band forms

Sepsis – Phase IISepsis – Phase II

• The patient has Sepsis, if• 2 of 4 SIRS criteria present • suspected or confirmed source of infection

Severe Sepsis – Phase IIISevere Sepsis – Phase III

• A patient with sepsis complicated by:• Tissue hypoperfusion (need fluid)

• Elevated venous lactate (> 2.1 mmol/L)• Oliguria

• Sepsis-induced hypotension• SBP < 90 • MAP < 65 mm Hg• Decrease in SBP of > 40 mm Hg below normal

• Organ dysfunction

Septic Shock – Phase IVSeptic Shock – Phase IV

• Despite adequate fluid therapy, SBP < 90 or MAP < 65

• Sometimes difficult to distinguish between severe sepsis from septic shock

• Carries a mortality rate of 40-60%

HRH Data HRH Data

Audited 44 patient charts in 2008:• Admitted with Sepsis diagnosis - 18

patients (41%)• Admitted to Med/Surg - 28 patients

(63.6%)• FASTeam to ICU - 7 patients (25%)

• Admitted to ICU - 16 patients (36.3%)• Met SIRS Criteria/Septic, different

diagnosis than sepsis– 14 patients (31%)

• Average cost of hospitalization $29,000• Average hospital length of stay 7.3 days• Average hospital length of stay in ICU – 9.4

days• Death 2 patients (4.17%)• Xigris was not administered in 2008

2008 Review of Data2008 Review of Data

Lactate LevelsLactate Levels

• Indication for tissue hypoperfusion and oxygenation

• Elevated Lactates• > 2.1 mmol/L• Identified before the patient is hypotensive (early

indication) • Common with severe septic and septic shock patients• All patients are to be started on the protocol, regardless

of BP• Serial lactate levels are helpful to assess adequacy

of therapies in shock patients • Lactate levels will be drawn q 3 hours x 3

Room for ImprovementRoom for Improvement

• Recognize early signs of Sepsis (41%)• Obtain venous lactate (0%)• Earlier initiation of pressors • Blood cultures obtained

Sepsis Resuscitation Bundle – Sepsis Resuscitation Bundle – First 6 hoursFirst 6 hours

• Measure venous lactate (other labs and tests: ABG, CBC, BMP, CK/Trop, urine cultures, sputum cultures, CXR)

• Blood cultures obtained prior to antibiotic administration

• Administer broad-spectrum antibiotics within 3 hours of ED admission and within one hour of non-ED admission

• Hypotensive/serum lactate >2.1 mmol/L• Deliver 20 ml/kg of NS (adequate amount)• Administer Vasopresors for hypotension not

responding to fluid resuscitation to maintain MAP > 65

Sepsis Resuscitation Bundle – Sepsis Resuscitation Bundle – ED/ICUED/ICU

• If hypotension continues after adequate fluid bolus and/or lactate level > 2.1 mmol/L, insert PreSep Catheter:• Central venous pressure (CVP) 8-12 mm Hg• Central venous saturation (ScvO2) >/= 70%

• Temp-Sensing Foley Catheter:• Urine Output > 0.5ml/kg/hour• Temperature monitoring

• Mechanical Ventilation• PaO2/FiO2 ratio </= 250• Plateau Pressures < 30

• Start Vasopressors (norepinephrine preferred-need central line) • Xigris may be considered

• If no central line, start dopamine and titrate to MAP >/= 65 or SBP >/= 90 mm Hg

ED/ICUED/ICU

Sepsis Management Bundle –Sepsis Management Bundle –(24 Hours)(24 Hours)

• Followed on any Severe Septic patient • Low dose steroids • Maintain glucose control greater then the lower

limit of normal, but less then 150 mg/dl• GI Bleeding Prophylaxis• DVT Prophylaxis• Venous Lactate levels q 3 hours x 3

Enteral nutrition is preferred over parenteral Enteral nutrition is preferred over parenteral because it is associated with improved patient because it is associated with improved patient

outcomes.outcomes.

• Suggest initiate enteral nutrition when:• Patient is malnourished• Patient not expected to resume po within 5 days• Patient is fluid resuscitated and hemodynamically stable• Enteral feeding route can be established• There is no bowel obstruction distal to the site of feeding

Information provided by: Robin Matejcek, Registered Dietitian at HRH

OXEPAOXEPA• Complete, balanced nutrition formula with eicosapentanoic

acid, gamma-linolenic acid, and elevated levels of antioxidants to help modulate the inflammatory response.

• Use in critically ill patients with sepsis, ALI or ARDS clinically shown to:• Reduce markers of pulmonary inflammation

• Improve oxygenation

• Decrease requirements for vent support

• Decrease ICU stay

• Decrease development of new organ failures

• Reduce mortality

Information provided by: Robin Matejcek, Registered Dietitian at HRH

ConclusionsConclusions

• New sepsis orders are intended to smooth processes of care.

• Nursing and other ED and ICU staff have been educated on the early recognition and aggressive resuscitation of sepsis patients.

• For comments, please provide feedback to Adam Andres, David Farman or John Sparzo