4/25/17. Critical Care Transport Management of Sepsis Patients TYPES OF SHOCK- REVIEW

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1 Critical Care Transport Management of Sepsis Patients By: Bradley Mullinax, BSN, RN, CFRN, CEN, AEMT TYPES OF SHOCK- REVIEW -HYPOVOLEMIC SHOCK- NO WATER IN PUMP -CARDIOGENIC SHOCK- FAILURE OF THE PUMP -DISTRIBUTIVE SHOCK- FAILURE OF THE PIPE (SEPTIC, ANAPHYLACTIC, NEUROGENIC) -OBSTRUCTIVE SHOCK- TAMPONADE, TENSION PNEUMOTHORAX 1

2 Pathophysiology of Sepsis Sepsis is a systemic inflammatory response to an infectious process that causes the release of cytokines, such as interleukins and prostaglandins. Once released the body responds with an inflammatory response such as fever or hypothermia, tachycardia, and leukocytosis or leukopenia. The body also starts producing microvascular thrombosis, which consume the body s clotting mechanism. We often see this manifest as DIC As the condition progresses, the body releases antiinflammatory mediators to offset the inflammatory process. This is similar to a histamine release in anaphylaxis, which results in hypotension. Distributive Shock State THE STATISTICS Sepsis is a leading cause of death and harm. Patients with severe sepsis or septic shock have a mortality rate of about 40%-60%, with the elderly having the highest death rates. As providers, we are in the position to spot patients who are ill or deteriorating, and initiate life-saving treatments. (McClelland & Moxon, 2014) WHY SHOULD WE BE WORRIED ABOUT SEPSIS PRE-HOSPITAL? OVER 26 MILLION PEOPLE AFFECTED BY SEPSIS OCCUR EACH YEAR. #3 CAUSE OF DEATH IN THE U.S. LARGEST KILLER OF CHILDREN AND NEWBORN INFANTS IN THE WORLD. 10% MORTALITY RATE FOR EVERY HOUR THAT TREATMENT IS DELAYED LIFE FORCE ENCOUNTERS THESE PATIENTS PRE-HOSPITAL AND ON INTER-FACILITY TRANSPORTS WHERE TREATMENT HAS NOT BEEN STARTED OR TREATED INAPPROPRIATELY. THE RECOMMENDATION IS THAT ANTI-MICROBIAL THERAPY BE INITIATED WITHIN THE 1 ST HOUR OF PRESENTATION #1 IN HOSPITAL RELATED COSTS. $20 BILLION PER YEAR 2

3 THE SOURCES OF INFECTION Diagnosed or Suspect Pneumonia- HAI? Diagnosed or Suspect Urinary Tract Infection- HAI? Infected Wound- HAI? Abdominal Pain with unknown etiology Immuno-Compromised Patient- HAI? Recent Surgery or Hospitalization- HAI? Central Line Access in place- HAI? Chronic Dialysis Patient- HAI? Recent Home Infusion Therapy- HAI? Recent intubation/ventilated- HAI? HAI? CAI? VAP? WTH? WTF? HAI- HOSPITAL ACQUIRED INFECTION CAI- COMMUNITY ACQUIRED INFECTION VAP-VENTILATOR ASSOCIATED PNEUMONIA CLABSI-CENTRAL LINE ASSOCIATED BLOOD STREAM INFECTION CAUTI-CATHETER ASSOCIATED URINARY TRACT INFECTION As critical care providers, we need to think critically about what is going on with our patients. Is this a big pneumonia? Is it (VAP) or aspiration? Is this a nursing home patient with a huge UTI? Has this patient been admitted to small community hospital ICU with a central line placed (CLABSI). Is this a chronic diabetes patient with an open and infected wound? We need to be able to pickup on these clinical cues to help guide the treatment process in the aircraft as well as at the receiving facility. CAI vs. HAI changes the anti-biotic therapy! Assessment and Screening Initiate a Screening Tool 3

4 THE STEPS OF SEPSIS Assessment and Screening Screen All Patients SIRS Criteria SIGNS/SYMPTOMS TEMP >38.0 C or <36 C (>100.4 OR <96.8) HR >90 RR >20 WBC >12,000 OR <4000 NEW ONSET AMS 2 OR MORE +(PLUS A KNOWN OR SUSPECTED INFECTION)= START SEPSIS BUNDLE (Birriel, 2013) QSOFA- QUICK SEPSIS ORGAN DYSFUNCTION ASSESSMENT RELATIVELY NEW SCREENING CRITERIA TO HELP SCREEN SEPSIS PATIENTS. Some very recent data from some sources suggests that QSOFA has failed validation and has no future in diagnosing Sepsis. 24% of infected patients with 2 or 3 qsofa points accounted for 70% of deaths times for likely for in-hospital mortality with a score of 2 or more. QSOFA CRITERIA (2 OR MORE) 1. ALTERED MENTAL STATUS 2. RESPIRATORY RATE 22 OR GREATER 3. SYSTOLIC BLOOD PRESSURE LESS THAN 100 (QSOFA GUIDELINES, 2016) 4

5 LAB VALUES -WBC: 5-10 K NORMAL- MAY BE HIGH OR LOW -PH: PROBABLY LOW- ACIDOSIS IN A HYPOPERFUSED SEPTIC STATE -K: MAY BE HIGH OR LOW, RENAL COMPROMISE MAY CAUSE INCREASE IN POTASSIUM LEVEL -LACTATE: >2 IS CAUSE FOR CONCERN -PLATLETS: MAY BE LOW-DIC, LIVER FUNCTION- MAY BE ELEVATED, INDICATIVE OF HEPATIC COMPROMISE -PT/PTT/INR: ELEVATED WHEN CLOTTING CASCADE COMPROMISED -CREATNINE: MAY BE ELEVATED, INDICATIVE OF RENAL COMPROMISE -URINE: BACTERIA? CONCENTRATED? NITRITE POSITIVE? -CRP: ELEVATED- INDICATIVE OF INFLAMMATION -CHEST XRAY: ARDS, PNEUMONIA IMAGING RML Pneumonia ARDS ETCo2- Capnography and Sepsis Capnography provides valuable information not only about ventilation but perfusion as well. As perfusion decreases, so does the EtCO2. This results in elevation of the metabolic waste, which is comprised mainly of lactic acid. Therefore, EtCO2 level is inversely proportional to lactate levels. As we see lactate levels rise in septic patients, we see EtCO2 levels drop. EtCO2 readings of less than 25 mmhg in the clinical setting of shock are associated with significant increase in mortality. Patients with EtCO2 of 25 mmhg may have lactate levels as high as 6.1 mmol/l. Capnography can be monitored and helpful in assessing the impact of therapies designed to improve perfusion. Recommend to correlate with at least 1 ABG draw to establish a baseline. 5

6 Criteria for organ dysfunction Systolic blood pressure <90 mm Hg or decrease >40 mm Hg from baseline, mean arterial pressure <65 mm Hg Bilateral pulmonary infiltrates with increasing oxygen requirements to maintain SpO2 >90%, Creatinine >2.0 mg/dl Bilirubin >2 mg/dl, platelet count <100,000/µL (or 100 K/ µl), coagulopathy (DIC) Lactate >4 (Birriel, 2013) Immediate Interventions Protocols are Preferred 1. Large Bore IV x2 (18 gauge if possible) or Central Line if Possible 2. Labs (ISTAT-CHEM 8, LACTATE, ABG, BLOOD CULTURES X2 SETS). USE THE CULTURE BOTTLES- Only if blood cultures are not going to delay patient ATB therapy 3. High Flow Oxygen Administration (Consider Chronic Lung Patients) 4. Initiate Accurate Urine Outputs (Foley Insertion with Temp Probe). The goal is 0.5 ml/kg/hr. Obtain urine sample upon insertion. If possible and appropriate spend the extra time at the facility to perform this procedure. 5. Fluid resuscitation is essential to prevent hypotension and improve cardiac output and therefore tissue perfusion. Consider early use of pressors if patient is not responding to fluid therapy. (McClelland & Moxon, 2014) Sepsis Bundle Completed within 3 hours of Presentation 1. Measure lactate level- Goal is to normalize the lactate 2. Obtain blood cultures prior to administration of antibiotics. Do not with-hold antibiotic administration based solely on the inability to obtain a culture. Document why cultures can t be drawn and move on! 3. Administer broad spectrum antibiotics within the 1 st hour if possible. The choice of antibiotics should be guided by the susceptibility of likely pathogens in the community and the hospital, as well as any specific knowledge about the patient. We are currently reviewing our formulary, but we are likely staying with Rocephin changing the dose to 2 Grams. 10 PERCENT INCREASE IN MORTALITY FOR EVERY 1 HOUR DELAY IN RECEIVING ANTIBIOTIC THERAPY FOR A SEPTIC PATIENT **Rocephin 2 Grams in 50 ml of NS over 30 minutes CAI** 4. Administer 30ml/kg crystalloid for hypotension or lactate 2mmol/L. The targets for quantitative resuscitation are CVP of 8 mm Hg, ScvO2 of 70 percent, and normalization of lactate. If CHF is a concern for the clinician, contact medical control. NOT RECOMMENDED TO WITH-HOLD FLUID PROTOCOL BASED ON HEART FAILURE HISTORY. (Surviving Sepsis Campaign) 6

7 Sepsis Bundle Completed within 6 hours of initial Presentation 1. Monitoring: Because hypotension is a primary feature of septic shock and improving blood pressure is a therapeutic goal, accurate and continuous measurement of blood pressure is essential. ART Lines are preferred ASAP to enable continuous invasive blood pressure monitoring. 2. Administer vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) 65mmHg. Aggressive vasopressor use to maintain MAP. Primary drug is Levophed, Secondary is Vasopressor (Preferred) or Epinephrine. Higher MAP does not improve outcomes 3. Consider blood products if HCT less than 30 or HgB <7. 4. Maintain ScvO2: >70%, along with blood products and fluids consider the use of inotropes such as Dobutamine (20 mcg/kg/min). You may need to add Norepinephrine if not in use to counteract dilation caused by the Dobutamine. 5. Re-measure lactate if initial lactate elevated. Every 2 hours Lactates are recommended to guide treatment process. We need to determine the initial draw and time our repeat lactates in-flight. Document these findings and communicate them to the receiving facility. If patient is responding, we should see a 20% decrease after 2 hours of treatment. Significant decrease in mortality when lactate level is used to drive therapy. CVP is no longer necessary (Surviving Sepsis Campaign) WHICH VASOPRESSOR? Norepinephrine (through a central venous catheter as soon as placement if possible) is the first choice vasopressor agent to correct hypotension in septic shock. Levophed- 4mg in 250 ml in approved diluent (usually D5, NS can be used in emergencies) range: 1-30 mcg/min. Drip (1 mcg=3.8 ml/hr ). Max dose 30 mcg/min Vasopressin use may be considered in patients with refractory shock despite adequate fluid resuscitation and high-dose conventional vasopressors. It is not recommended as a replacement for norepinephrine as a first-line agent. Vaspopressin- 20 units in 100 ml NS range: 0.04 units/min. Drip (0.01 unit=3ml/hr) Epinephrine (added to and potentially substituted for norepinephrine) may be used when an additional agent is needed to maintain adequate blood pressure. Works on the same receptors as Levophed. Epinephrine- 1mg in 100 ml NS (10 mcg per ml) range: 1-20 mcg/min. Drip (1 mcg=6 ml/hr) Phenylephrine should not be used as a first-line vasopressor as part of the treatment of septic shock. Phenylephrine was reported to reduce splanchnic blood flow and oxygen delivery in septic shock patients. Phenylephrine: 10mg in 100 ml NS. 100mcg/mL. Range: mcg/min. Drip (10 mcg=6 ml/hr) Dopamine may be used as an alternative vasopressor agent to norepinephrine only in highly selected patients (e.g., a patient with low risk of tachyarrhythmias and absolute or relative bradycardia). Dobutamine may be added for refractory hypoperfusion to fluids and vasopressors mcg/kg/min Don t forget the push dose pressors: Epi and Neo (Refer to above dosing) (Surviving Sepsis Campaign) 7

8 OTHER CONSIDERATIONS Hydrocortisone 200 mg per day or alternative Dexamethasone 4mg IVP REPORT SEPSIS NOTIFICATION to receiving facility during radio report, some have protocols for direct ICU admission for Septic Shock Warm fluids for hypo-thermic patients Repeat Lactate every 2 hours as mentioned, guides therapy. Direct indication of tissue perfusion. Bleeding-DIC: Plasma, Platelets, Heparin Life Force Vent Management Guidelines: Ventilatory Support- 6mL/kg Tidal Volume, (>5 PEEP), FIO2 to support patient. Higher levels of PEEP and less dependence on FIO2. Renal Failure: Dialysis- continuous or intermittent Glucose Control: Target , refer to Life Force guidelines for glucose control Nutrition within 48 hours of diagnosis approximate 500 cal/day Analgesia/Sedation: Minimized continuous or intermittent sedation is recommended unless intubated. Cautious use of Etomidate for RSI??? Avoid the use of Sodium Bicarbonate. No evidence to support the use of bicarb actually improves patient outcomes (Dellinger, 2013) CASE STUDY #1 42 year old female presents to the ED at 1700 hrs. Chief Complaint: Fever, Abdominal Pain. Hx of present illness: She states that two days ago she had some burning with urination. She states that she has only urinated one time in the last 24 hours. She also states that she has bilateral flank pain that's 8/10. Vitals: BP 92/68, HR 116, RR-20, O2 Sats 95% RA, Temp 101.6, Weight: 100kg What do we do? Suspected infection? HAI or CAI?, SIRS? Organ Dysfunction? Start the Bundle? Plan of Care 8

9 CASE STUDY #2 80 year old female scene call from Marion County. Chief Complaint: Fever, Cough, Decreased Oxygen Sats. Hx of present illness: Family state that she has become increasingly weak and less responsive over the last 24 hours. Her daughter says that she has been coughing up green junk for about a week since she released from the hospital, when she had hip replacement. She also states that she had complications during surgery and had to be on one of those breathing machines for a few days. She thinks that dang hospital has done this to her mom. EMS has already given 1L of NS, 22 gauge IV in L Thumb Current Vitals: BP 80/40, HR 140 Afib, RR-30, O2 Sats 89% NRB 15L, Temp 96.4 rectal, Weight: 60 kg GCS 8 What do we do? Suspected infection? HAI or CAI?, SIRS? Organ Dysfunction? Start the Bundle? Plan of Care CASE STUDY #3 26 year old male patient scene call in White County, TN. History of Present illness, patient is a end stage Cancer patient that has been treated at Vanderbilt Children s Hospital since his youth. Recently diagnosed with some type of fungal pneumonia. Pt was on vacation and started feeling anxious. Family gives him a prescribed anxiolytic for anxiety, but he continues to get worse. EMS is called. EMS arrives, patient is tachycardic, hypotensive, anxious with decreased LOC. IV access is very poor, after several attempts, a 22 gauge IV is successful in the left foot. Pt is on NRB mask at 15L. BGL by EMS is 32. Vitals: BP 70 palp, HR 153 sinus tach, RR 30, SPo2 96% on NRB, temp is 96.4 What do we do? Suspected infection? HAI or CAI?, SIRS? Organ Dysfunction? Start the Bundle? Plan of Care Life Force is contacted for rapid transport of this patient to Vandy Peds. Upon arrival, D-50 has been given through 22 gauge in foot. IV fluids started NS at bolus rate. Pulse is still thready with no improvement in mental status. BP is not obtainable by monitor. Right EJ is started, fluids moved to EJ and placed on pressure bag BGL is reassessed and now 150 I-STAT labs performed by ABG. Metabolic acidosis ph 6.9, HCO3 6, PO2-156, PCO2-30 Fluids at 30 ml/kg, BP improves to 116/58, HR is now 120 Rocephin 2 grams given per protocol Lactic acid is >16, Creatnine 4.5 Report called to Vandy Peds, they are waiting on helipad with rapid response team. Pt is now following some commands, still able to maintain his own airway. Intubation is delayed in the ED until neuro exam can be performed, but subsequently intubated later Vitals: BP 120/60, HR 120 sinus, RR 28, SPo2 97% NRB at 10L. Total fluid infused before and during transport 3L, pt weight is 100 kg 9

10 4/25/17 REFERENCES Birriel, B. (2013, April 2). Rapid Identification of Sepsis - The Value of Screening Tools. Retrieved November 10, 2015, from Society of Critical Care Medicine: Dellinger, R. P. (2013). Surviving Sepsis Campaign: International Guidelines for Managment of Sepsis and Septic Shock. CCM Journal, McClelland, H., & Moxon, A. (2014). Early Identification and Treatment of Sepsis. Nursing Times, Surviving Sepsis Campaign. (n.d.). Sepsis Six Hour Bundle. Retrieved November 10, 2015, from Surviving Sepsis Campaign: Surviving Sepsis Campaign. (n.d.). Sepsis Three Hour Bundle. Retrieved November 10, 2015, from Surviving Sepsis Campaign: QSOFA Guidelines: University of Pittsburgh Critical Care Medicine. February Vasopressors for Septic Shock: Pulmonary Critical Care Central. September RXLIST.com The Internet Drug Resource: Dosages and Indications for Zosyn. Surviving Sepsis, 3 Hour Bundle Blood Culture Procedures: Society of Critical Care Medicine Surviving Sepsis Campaign Glucose Control: Society of Critical Care Medicine Presentation available upon request Drugs.com: Vancomycin Dosages and Indications. Sepsis Definitions and New Recommendations: Society of Critical Care Medicine. February Third International Consensus Definitions for Sepsis and Septic Shock: JAMA, Vol. 315, No. 8. February Diagnosing and Treating Severe Sepsis in Critical Care Transport: Kevin Collopy, Clinical Educator Air Link New Hanover Regional Medical Center. June Presentation available upon request. Erlanger Medical Center Shock/Trauma Survival Guide Sepsis Alliance: Sepsis Fact Sheet (2014). JEMS: Assessing and managing Sepsis in the prehospital setting (October 2015). Intensive Care Medicine: Surviving Sepsis Guidelines: International Guidelines for Management of Sepsis and Sepsic Shock (2016) /s