Understand the scope of sepsis morbidity and mortality Identify risk factors that predispose a patient to development of sepsis Define and know the

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2 Understand the scope of sepsis morbidity and mortality Identify risk factors that predispose a patient to development of sepsis Define and know the differences between sepsis, severe sepsis and septic shock Understand the pathophysiology behind sepsis Identify the elements of the sepsis core measure (sepsis treatment) Discuss the RN s role in the treatment of the septic patient

3 Oldest known disease Hippocrates Mortality ranges from 28 percent to 50 percent More than prostate cancer, breast cancer and AIDS combined No. 1 cause of death in non-cardiac ICUs Recognition and early treatment will improve mortality Expected mortality is percent upon identification

4 More than 1 million cases of sepsis a year Major cause of morbidity and mortality worldwide In the U.S., 500 patients die of severe sepsis daily Equivalent to two planes crashes a day Identifying sepsis the real challenge Stems from another condition, i.e. pneumonia, urinary tract infection, invasive medical procedure Bacteria is the most common cause Symptoms may be mistaken as other causes

5 More common in elderly and children Post-op patients 10x more likely to die from sepsis than an MI or stroke Chronic illnesses Diabetes Cardiovascular Immunosuppressive diseases Poor nutrition Debilitation Long hospital stays

6 SEVERE SEPSIS SIRS: any 2 of the following T: > 100.4F < 96.8 F RR: > 20 HR: > 90 WBC: >12,000 < 4,000 > 10% bands SEPSIS 2 SIRS + infection Sepsis + Acute organ damage Respiratory: (acute) Ventilator/BiPAP/ worsening O2 sat Cardiovascular: SBP < 90/MAP < 65 Renal: Creatinine >2.0 or U/O <0.5ml/kg/h Hepatic: Total Bilirubin > 2mg/dl Hematologic: Platelet < 100,000, INR > 1.5 or aptt > 60 sec Metabolic: Lactate > 2mmol/L CNS: Altered consciousness or sudden change from baseline SEPTIC SHOCK Severe sepsis with persistent: Hypotension or lactate >/= 4mmol/L *Do not include organ dysfunction related to chronic condition

7 Infection Inflammatory response Break down of the systems Organ failure, shock and death

8 Septic shock a component of distributive shock defined as abnormal distribution of blood flow in the smallest blood vessels results in inadequate supply of blood to the body s tissues and organs. Identifying patients with sepsis early can prevent them from developing severe sepsis or septic shock Patient s expected mortality at timing of identification is percent (Gaieski, 2010) To screen effectively, it must be part of the nurses daily routine If you identify patients early, then you can intervene and prevent further tissue damage

9 Oxygenation Increase respiratory rate Decrease in pulse oximetry Change in mental status Decrease tissue perfusion Blood pressure Tissue perfusion Urine output Renal hypo-perfusion

10 Adapted from Kumar A, et al. Crit Care Med. 2006; 34: (as cited in Uslan D, 2014) Sepsis is a race, and the timing of interventions is crucial for patient s survival. It is, you, the RN, who will identify the symptoms before the LIP.

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12 The Golden Hour Early identification and treatment have proven to decrease mortality in AMI, stroke and traumas. AMI Stroke Trauma <10% <8% <5% Why not sepsis?

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15 To be completed in three hours To be completed in six hours Assess and identify the septic patient Initiate orders for sepsis bundle Lactate Blood culture Antibiotics Fluid bolus 30ml/kg If lactate is greater than 4mmol/L If systolic blood pressure is less than 90 Repeat lactate if initial measurement is greater than 2mmol/L LIP placed an Edwards line? Measure CVP Measure ScvO2 Edwards line not placed? LIP needs to document reassessment including: (Sorry can t use nursing documentation; this one is for the doctors) Cardiopulmonary function Cap refill Skin assessment Peripheral pulse assessment Most recent vital signs (There is a template for physician to use to ensure all measurements are captured)

16 Dellinger, R. P., Levy, M. M., Rhodes, A., Annane, D., Gerlach, H., Opal, S. M.,... Moreno, R. (2013, February). Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock [Journal]. Journal of Critical Care Medicine, 41(2), Gaieski, D., Pines, J., Band, R., Mikkelsen, M., Massone, R., Furia, F.,... Goyal, M. (2010). Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department. Society of Critical Care Medicine, 38(3), 1-9. doi: /ccm.0b013e3181cc4824 Kumar, A., Roberts, D., Wood, K., Light, B., Parrillo, J., Sharma, S.,... Cheang, M. (2006). Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock*. Critical Care Medicine, 34(6), doi: /01.ccm e9 Septimus, E., Surviving Sepsis 2015 Making Best Practice Common Practice (2015).

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18 80-year-old male transfer from acute care facility following hip repair surgery two days prior. HX of CAD, TIA and AFib. During acute hospital stay developed PN due to dysphagia and aspiration requiring PEG placement. Patient with oral intake only and antibiotics were discontinued day after arrival to facility. 12:00 BP 124/76, P 100, RR 20, temp 99 and alert to person, place and time 14:00 BP 110/68, P 110, RR 22, temp 100 and patient more lethargic 16:00 Patient with AMS BP 100/60, P 112, RR 24 and temp 100.7; decreased breath sounds and crackles on right side. Does patient have severe sepsis/septic shock and how would you have treated this patient in the first three to six hours?

19 Special thanks to the following for the development of this education module: