IMPROVED SURVIVAL EARLY RECOGNITION EARLY INTERVENTION

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1 Mortality Escalates along the Sepsis Continuum: A Clear Trend Exists Sepsis Mortality Continuum Texas Texas Gulf Gulf Coast Sepsis (%) Mortality Perhaps The Best Opportunity for Safe and Effective Intervention is Here! Sepsis Category 40 EARLY RECOGNITION EARLY INTERVENTION IMPROVED SURVIVAL 35 Recognize the Signs of Sepsis Texas Texas Gulf Gulf Coast Sepsis Elevated Heart Rate Hyperthermia/Hypothermia Elevated/Low WBC Count Elevated Respiratory Rate Acute Change in Mental Status These vital signs may seem easy to spot but are often overlooked! 42 1

2 Mild Tachypnea is an *Early* Sign Total Observations: 1,883,135 (%) %RR = 18: %RR = 19: 7.21 %RR = 20: %RR 18 or %RR Remainder: Sepsis on a Continuum Tachycardia Tachypnea Confusion Fever CLINICAL SIGNS Decreased UOP Hypotension Elevated lactate Organ dysfunction Refractory hypotension On vasopressors On inotropes Mechanical ventilation SEPSIS SEVERE SEPSIS SEPTIC SHOCK DEATH Recognition/Assessment Call Response Team! Oxygen Fluid bolus Obtain cultures Obtain other labs Antibiotic administration VS Monitoring I&O Monitoring NURSES ROLE 44 SIRS Systemic Inflammatory Response Syndrome Temperature >100.9 F (38.3 C) (hyperthermia) or <96.8 F (36 C) (hypothermia) Heart Rate - >90 bpm (tachycardia) Respiratory Rate - > 20 (tachypnea) WBC > 12,000 µ/l (leukocytosis) or < 4,000 µ/l (leukopenia) 45 2

3 Sepsis 2 or more SIRS + a suspected or confirmed source of infection = SEPSIS 46 Pathophysiology of Sepsis 16 Intravascular inflammation: Is uncontrolled, unregulated, and self-sustaining Causes blood to spread mediators usually confined to the interstitial space 47 Severe Sepsis Sepsis + organ dysfunction, hypoperfusion or hypotension = Severe Sepsis 48 3

4 Signs of Severe Sepsis Organ Dysfunction Variables 15 Arterial hypoxemia Acute lung injury Acute oliguria UOP < 0.5 ml/kg/hr for at least 2 hours despite fluid resuscitation Coagulation abnormalities Thrombocytopenia Hyperbilirubinemia Ileus/hypoactive bowel sounds 49 Signs of Severe Sepsis (con t) Hemodynamic Variables 15 Sepsis-induced hypotension Mixed venous oxygen saturation < 70% Cardiac index < 3.5 L/min Tissue Perfusion Variables 15 Mottled skin or decreased capillary refill Elevated lactate > 4 mmol/l (you can have severe sepsis without elevated lactate) 50 Signs of Severe Sepsis (con t) Tachypnea, tachycardia and changes in mental status are early signs of severe sepsis AND often precede both fever and hypotension Skin remains warm (in early shock stage) unless severely volume depleted, then skin can be cool and mottled (in late shock stage) Early recognition is the key to successful treatment and outcomes! 51 4

5 Septic Shock Sepsis + BP after fluid resuscitation (refractory hypotension) & perfusion abnormalities = Septic Shock 52 Early Goal Directed Therapy Fluid resuscitation NS or LR Blood products if Hgb 7 (goal is 7-9) Labs & Diagnostic Tests Pan Culture Blood cultures (X2), urine, sputum, wounds, etc. as indicated Antibiotics Initiate within 1 hour of recognition of sepsis 53 Lactic Acid levels common in patients with severe sepsis or septic shock levels may be either/or both metabolic failure or tissue hypoperfusion In sepsis, early lactate clearance is associated with preserved organ function and improved survival prolonged lactate clearance is associated with worsened multi-organ dysfunction 54 5

6 Hemodynamic Support & Antibiotics are *KEY* Volume resuscitation and immediate antibiotic administration are the most important therapies: Fluid volume significantly increases cardiac output and systemic oxygen delivery Fluids alone may be sufficient to reverse hypotension and restore hemodynamic stability Fluid requirements may be as much as 3-5 liters Fluid challenge should be titrated to BP, HR and CO 55 Source Control Antimicrobials Source - bacterial, viral, fungal, or parasitic Surgery Source control is imperative when possible. Other Infected lines, catheters, & implants 53 Noninfectious Mimics of Sepsis Acute myocardial infarction Acute pulmonary embolism Acute pancreatitis Acute GI bleed Adverse drug reactions Trauma Burns 57 6

7 Goals HR < 100 bpm SBP > 90 mmhg or MAP > 70 mmhg RR < 20 Temperature normalized Lactic acid < 1.5 mmol/l Urine output 0.5 ml/hr/kg Source control Return to baseline mentation 55 Disclaimer The project described is supported by Funding Opportunity Number 1C1CMS from the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services. The contents of these slides are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. The research presented here was conducted by Houston Methodist. Findings might or might not be consistent with or confirmed by the independent evaluation contractor

8 References 1. Sands KE, Bates DW, Lanken PN et al. Epidemiology of sepsis syndrome in 8 academic medical centers. Academic Medical Center Consortium Sepsis Project Working Group. JAMA 1997; 278: Angus DC et al. Epidemiology of Severe Sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med. 2001; 29: CDC FastStats: Leading Causes of Death: 4. Halpern NA, Pastores SM, Greenstein RJ. Critical care medicine in the United States : an analysis of bed numbers, use, and costs. Crit Care Med Jun ;32(6): Elixhauser A, Friedman B, Stranges E. Septicemia in U.S. Hospitals, HCUP Statistical Brief #118 [Internet] Jul [cited 2011 Jul 20]; Available from: 6. Hall M, Williams S, DeFrances C, Golosinsky A. Inpatient care for septicemia or sepsis: A challenge for patients and hospitals [Internet] Jun [cited 2011 Jun 30];Available from: 7. Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest Jun;101(6): Rivers E, et. al. EARLY GOAL-DIRECTED THERAPY IN THE TREATMENT OF SEVERE SEPSIS AND SEPTIC SHOCK, N Engl J Med, Vol. 345, No. 19, pgs Halpern NA, Pastores SM, Greenstein RJ. Critical care medicine in the United States : an analysis of bed numbers, use, and costs. Crit.Care.Med 2004;32: PMID Critical Care Workforce Partnership Position Statement: The Aging of the U.S. Population and Increased Need for Critical Care Services, Amer.Assoc.Critical.Care.Nurses, et. al., November Donchin Y, Gopher D, et. al. A look into the nature and causes of human errors in the intensive care unit. Crit.Care.Med 1995; 23: Dellinger RP, et. al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 2004 Vol. 32, No. 3, pgs Surviving Sepsis Campaign website: ( 14. Neviere, R. Sepsis and the systemic inflammatory response syndrome: Definitions, epidemiology, and prognosis. In: P. E. Parsons & G. Finlay (Eds), UpToDate. Retrieved from: Levy MM, Fink MP, Marshall JC, et al: 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. (2003). Intensive Care Medicine, 29: McCance, K.L. & Huether, S.E. (2006). Pathophysiology: The Biologic Basis for Disease in Adults and Children (5th ed.). St. Louis, MO. Elsevier Mosby. 17. Sarnak MJ, Jaber BL. Mortality caused by sepsis in patients with end-stage renal disease compared with the general population. Kidney Int. 2000;58(4): doi: /j x. 18. Powe NR, Jaar B, Furth SL, Hermann J, Briggs W. Septicemia in dialysis patients: Incidence, risk factors, and prognosis. Kidney Int. 1999;55(3): doi: /j x. 19. Abou Dagher G, Harmouche E, Jabbour E, Bachir R, Zebian D, Bou Chebl R. Sepsis in hemodialysis patients. BMC Emerg Med. 2015;15. doi: /s y. 20. Vanholder R, Ringoir S. Polymorphonuclear cell function and infection in dialysis. Kidney Int Suppl. 1992;38:S91-S Rao M, Guo D, Jaber BL, et al. Dialyzer membrane type and reuse practice influence polymorphonuclear leukocyte function in hemodialysis patients. Kidney Int. 2004;65(2): doi: /j x. Acknowledgements: Sepsis Nurse Practitioner Team at Houston Methodist Hospital Supported in part by a training fellowship from the Keck Center for Interdisciplinary Bioscience Training of the Gulf Coast Consortia (NLM Grant No. 5T15LM007093). 61 AQKC HAI LAN Webinar Sepsis Levi Njord, Director, Infection Prevention & Epidemiology Summary ESRD surveillance in the United States National incidence of sepsis Surveillance & treatment obstacles Strategies to improve surveillance & treatment Opportunities ahead 8

9 The Dialysis Event Positive blood culture IV abx start PRS at vascular access Fever Chills Hypotension Other Patient-Months Number of: Unique patients Treating on the first two treatment days of the month Grouped by vascular access Methods of surveillance Method Strengths Limitations Centrally identified / Centrally reported Centrally identified / Facility reported Facility identified / Facility Reported Standardized application of rules Limited burden on facilities Highly auditable Standardized application of rules Highly auditable Easiest to implement Most like CDC-defined process Lessfacility engagement with surveillance data Requires advanced technical support Clerical burden on facilities Opportunity for data entry error Requires moderate technical support Highly burdensome for facilities Large variance in rule application Difficult to audit Ideally surveillance would be standardized, accurate, fair, useful and not burdensome to facilities 9

10 Bloodstream Infection Rate Σ Σ 100 BSI rates can be calculated monthly, quarterly, or annually BSI rates can be grouped by vascular access type Requires that blood cultures were drawn and/or recorded IV abx& PRS have no bearing on current BSI rates Blood cultures are grouped by the NHSN 21 day rule Standardized Infection Ratio Steps to calculate SIR 1) Obtain the national reference stratified BSI rates 2) Divide the rates by 100 to get the rate per 1 patient month (basic rate) 1 National Rate Rate 2 CVC 2.16 AVF 0.26 # / 100 AVG 0.39 Other 0.67 National Rate Rate CVC AVF AVG Other ) Multiply the basic rate by facility s census stratified by access type to obtain the expected number of infections 4) Obtain the facility s observed infections for the year stratified by access type 5) Sum the expected number of infections 6) Sum the observed number of infections 7) Divide the sum of observed infections by the sum of expected infections to obtain the SIR National Rate Rate Annu al Censu s Expecte d BSI X CVC = AVF X = X = AVG Other National Rate X Observe d BSI = Expected BSI CVC AVF AVG Other TOTAL National Rate Observe d BSI CVC 3 AVF 2 AVG 1 Other 0 7 Observed 6 Expected SIR 0.73 How are we doing? 10

11 Obstacles Early and standard identification of sepsis Sign-based identification Cases identified outside the clinic Obtaining blood culture results Drawing blood cultures when indicated Obtaining externally resulted results Antibiotic stewardship Strategies to improve identification Standardized and clear sign definitions Fever, Chills, Hypotension Altered mental status, pain, etc. Consider the vascular access Clinical algorithms Strategies to obtain results Blood Culture Rate Σ Σ 1. Blood culture results can be negative or positive 2. Signs of sepsis include fever, chills, hypotension Structured follow-up with each hospitalization or missed treatment Health Information Exchanges 11

12 Opportunities ahead Promising new technologies Surveillance Prevention Collaboration between stakeholders Dialysis providers, regulators, public health, ESRD networks/qios, academia, etc. AQKC Contact Information and Sepsis Resources How to get help Sepsis Resources AQKC website ( Network contacts ESRD Network 8 - SMcMaster@nw8.esrd.net (Alabama, Mississippi, Tennessee) ESRD Network 14 - danchia@nw14.esrd.net (Texas) Please take a moment to complete the poll questions at the end of the webinar DO NOT patient-specific information (name, DOB, SSN, etc.) to the Network office! 12