Patient Safety Safe Table Webcast: Sepsis (Part III and IV) December 17, 2014

Patient Safety Safe Table Webcast: Sepsis (Part III and IV) December 17, 2014

Presenters Mark Blaney, RN Regional Nurse Educator CHI Franciscan Health Karen Lautermilch Director, Quality & Performance Improvement Washington State Hospital Association

35.2% decrease in mortality rate. 13 fewer deaths per week due to severe sepsis or septic shock, saving $96.8 million.

Friday, December 5 th (Sessions 1 & 2) Session 1: Recognition & Pathophysiology Describe the importance of the early identification of Sepsis. Differentiate between SIRS, Sepsis, Severe Sepsis, and Septic Shock. Recognize the progression of the inflammatory response in Sepsis. Identify three signs and symptoms that can help with the early identification of Sepsis. Session 2: Initial Treatment Define your role in the care of the Septic patient. Explain the rationale for each element in the Surviving Sepsis Campaign 3 hour bundle. Apply the steps of Sepsis care into your practice.

Friday, December 17th 10:00 a.m. 11:30 a.m. (Sessions 3& 4) Session 2: Initial Treatment Session 3: Septic shock Treatment Define your role in the care of the Septic patient. Explain the rationale for each element in the Surviving Sepsis bundle. Apply the steps of Septic Shock care into your practice. Session 4: Sepsis Recognition for Nursing Assistants and ER Techs Recognize the importance of the early identification of Sepsis. Define your role as a member of the Sepsis care team. Identify three signs and symptoms that patients could display during the progression of Sepsis.

SEPSIS What is it? How do we find it? How do we fix it? P Mark Blaney RN, BSN, CEN WSHA Training - 2014

SEPSIS Session 3: 6-Hour Bundle Mark Blaney RN, BSN, CEN WSHA Training - 2014

Session 3 Objectives Define your role in the care of the Septic patient Explain the rationale for each element in the Surviving Sepsis Campaign 6-hour bundle Apply the steps of Septic Shock care into your practice

CARE OF THE SEPTIC PATIENT

Role in Sepsis Care Prevention Assessment and recognition Advocating for your patient Team work Consider calling a Code Rapid Response early

Role in Sepsis Care RNs must be severe sepsis experts: Have knowledge of risk factors Recognize classic & atypical signs and symptoms Understand potential diagnostic tests and their use Know potential differential diagnoses and include sepsis as one of them Understand evidence-based standards of care for sepsis

3-Hour Bundle Review Measure lactate level Obtain blood cultures prior to antibiotic Administer broad-spectrum antibiotic Administer 30ml/kg crystalloid for hypotension or lactate 4 mmol/l Surviving Sepsis Campaign, 2012

Sepsis Care Overview Step 1: SIRS + Infection (Sepsis) Notify Provider now Request labs: lactate, CBC, blood cultures x2, etc. Ask: Do you want to start an antibiotic now? Step 2: MAP <65, SBP <90, lactate > 2? Ask: Do you want a 30ml/kg fluid challenge? Step 3: Fluid challenge ineffective? (MAP <65, lactate 4) Request transfer to ICU if not done already (6-Hour Bundle)

6-Hour Bundle If hypotension persists despite volume Utilize vasopressors to maintain MAP 65 If hypotension persists or initial lactate 4 Measure CVP Measure ScvO 2 Remeasure lactate Surviving Sepsis Campaign, 2012

6-Hour Bundle Target: CVP 8 mm Hg, ScvO 2 70%, normalization of lactate Surviving Sepsis Campaign, 2012

Sepsis Care Overview Step 1: Continue fluid administration Step 2: If MAP <65 mmhg despite adequate fluid administration: Initiate vasopressors to target MAP 65 mmhg Step 3: If hypoperfusion persists: Initiate inotropic therapy

Sepsis Care Overview Step 4: Consider mechanical ventilation Step 5: Consider blood product administration

Sepsis Care Step 1: Continue fluid administration if there is continued hemodynamic improvement Central Venous Pressure (CVP)** Pulse Pressure Stroke Volume Variation (SVV) or Pulse Pressure Variation (PPV) Arterial Blood Pressure (ABP) Heart rate

Sepsis Care Step 1 Central Venous Pressure (CVP)** Static preload assessment Limited use as a marker for intravascular volume status and potential fluid responsiveness Right ventricle is very compliant and adjusts to meet cardiovascular needs Dellinger, et al., Critical Care Medicine, 2013; 588

Sepsis Care Step 1 Central Venous Pressure (CVP)** A low CVP can be relied on to support continued volume resuscitation Will not give us an effective endpoint for fluid resuscitation Dellinger, et al., Critical Care Medicine, 2013; 588

SVV & PPV Sepsis Care Step 1 Dynamic assessment Can be used to assess fluid responsiveness Requires patient to be mechanically ventilated with controlled tidal volumes Equipment: PPV: arterial line SVV: special monitor (FloTrac, Vigileo) and an arterial line Dellinger, et al., Critical Care Medicine, 2013; 597 Enomoto TM, Harder L. Crit Care Clin. 2010;26(2): 307-21

Sepsis Care Step 1 Fluid responsiveness: PPV: >13% difference in systolic peak between inspiration and expiration SVV: >13% difference in SVV Dellinger, et al., Critical Care Medicine, 2013; 597 Enomoto TM, Harder L. Crit Care Clin. 2010;26(2): 307-21

Sepsis Care Step 1 SVV & PPV Utility is limited: Atrial fibrillation Right heart failure Spontaneous breathing (modern ventilation techniques) Low pressure support ventilation Low tidal volumes (<10 ml/kg) Dellinger, et al., Critical Care Medicine, 2013; 597 Enomoto TM, Harder L. Crit Care Clin. 2010;26(2): 307-21

Sepsis Care Step 1 What if your patient is spontaneously breathing? Inferior vena cava ultrasound Looks at collapsibility of the vessel Passive leg raise Bolus the patient from their own systemic circulation Enomoto TM, Harder L. Crit Care Clin. 2010;26(2): 307-21

Sepsis Care Step 1 Passive leg raise Raise legs to 45 for 2 minutes Boluses 100-300 ml into central circulation

Sepsis Care Step 1 Passive leg raise Does the stroke volume or MAP improve? 9% increase in stroke volume 10% increase in pulse pressure 10% increase in mean arterial pressure (MAP) If yes, patient is likely fluid responsive Enomoto TM, Harder L. Crit Care Clin. 2010;26(2): 307-21

Sepsis Care Step 1 Goals of fluid administration MAP >65 mmhg CVP 8 mmhg Surviving Sepsis Campaign, 2012

Sepsis Care Step 2: If MAP <65 mmhg despite adequate fluid administration: Initiate vasopressors to target MAP 65 mmhg 1 st choice: Norepinephrine 2 nd choice: Norepinephrine + epinephrine or Norepinephrine + vasopressin Surviving Sepsis Campaign, 2012

Sepsis Care Step 2 Norepinephrine Initial vasopressor of choice Primarily α1 with few β1 effects Vasoconstriction increasing SVR & MAP Minimal impact on heart rate Titrate every 5-15 minutes to reach a target MAP of 65 mmhg Allen, Journal of Infusion Nursing, 2014; 82-86

Sepsis Care Step 2 Vasopressin Given in combination with norepinephrine Vasopressin levels may be lower in Septic Shock V1 receptor agonist causing vasoconstriction in high doses Recommended dose: 0.03 units/min Target MAP 65 mmhg Allen, Journal of Infusion Nursing, 2014; 82-86 Dellinger, et al., Critical Care Medicine, 2013; 597

Sepsis Care Step 3: If hypoperfusion persists despite adequate fluid volume & adequate MAP: Initiate inotropic therapy Dobutamine Surviving Sepsis Campaign, 2012

Sepsis Care Step 3 Dobutamine Inotropic agent of choice β1 adrenergic agonist Increases cardiac contractility Titrate up to 20 mcg/kg/min Titrate every 5-15 minutes to reach target ScvO 2 of 70% Allen, Journal of Infusion Nursing, 2014; 82-86 Dellinger, et al., Critical Care Medicine, 2013; 597

ScvO 2 Sepsis Care Step 3 Mixed venous oxygen saturation Measurement of the relationship between O 2 consumption & delivery Measured in the superior vena cava or right atrium A decrease in O 2 supply or increase in O 2 demand will lead to a deviation of ScvO 2 from the normal range

Sepsis Care Step 3 ScvO 2 Normal: 65-80% Goal in Septic Shock: 70% Surviving Sepsis Campaign, 2012

Sepsis Care Step 4: Consider mechanical ventilation Especially in patients with Sepsis-Induced Acute Respiratory Distress Syndrome (ARDS) Recommended tidal volume of 6 ml/kg Recommended to utilize PEEP to avoid alveolar collapse Surviving Sepsis Campaign, 2012

Sepsis Care Step 5: Consider blood product administration Once tissue hypoperfusion is resolved, transfuse for Hgb <7 g/dl Goal Hgb = 7-9 g/dl or Hct 30% Surviving Sepsis Campaign, 2012

Endpoints of Resuscitation Lactate normalization ScvO 2 Base Deficit The use of a combination of endpoints is likely the goal

Endpoints of Resuscitation Lactate normalization Measure of cellular level hypoperfusion** Recommended when ScvO 2 is not available Prolongation of lactate clearance is associated with increased mortality Example: <24 hours Survival 24-48 hours 25% mortality >48 hours 86% mortality Surviving Sepsis Campaign, 2012 Abramson, D. J Trauma, 1993, 35, 584-599

Endpoints of Resuscitation Lactate normalization Cautions**: Lactate is also a marker of metabolic stress and not only related to tissue hypoxia Increased lactate may be an important adaptive survival response in sepsis May be a better marker of disease severity rather than a treatment endpoint Marik PE, Bellomo R. OA Critical Care, 2013, Mar 01; 1(1):3

Endpoints of Resuscitation ScvO 2 Normal: 65-80% Goal in Septic Shock: 70% Surviving Sepsis Campaign, 2012

Endpoints of Resuscitation Achieving a reduction in lactate with an ScvO 2 70% is associated with improved outcomes Surviving Sepsis Campaign, 2012

Endpoints of Resuscitation Base Deficit Indicator of anaerobic metabolism Reflective of serum bicarb utilization to buffer acidosis (amount required to titrate 1L of blood to normal ph) Resuscitation measures to restore tissue perfusion and cellular oxygenation should produce a reduction in base deficit as acidosis resolves

Endpoints of Resuscitation Base Deficit Normal: +2 to -2 Mild: -3 to -5 Severe: >-10 Base deficit >-6 mmol/l is associated with severe injury and potential higher mortality Davis, JW et al. J Trauma, 1998, 45, 873-877

Resources International Guidelines for Management of Severe Sepsis and Septic Shock: 2012 (Surviving Sepsis Campaign) Dellinger et. al, Crit Care Med. 2013, 41(2): 580-637 Understanding Vasoactive Medications Allen, JM. Journal of Infusion Nursing, 2014, 37(2): 82-86 Lactate clearance as a target of therapy in sepsis: A flawed paradigm. Marik PE, Bellomo R. OA Critical Care, 2013, Mar 01; 1(1):3 Lactate clearances and survival following injury Abramson, D. J Trauma, 1993, 35, 584-589 Base deficit in the elderly: a marker of severe injury and death. Davis et. al, J Trauma, 1998, 45, 873-877 AACN Advanced Critical Care Nursing, 2009

SEPSIS What is it? How do we find it? How do we fix it? Mark Blaney RN, BSN, CEN WSHA Training - 2014

SEPSIS Session 4: Sepsis Recognition for Ancillary Staff Mark Blaney RN, BSN, CEN WSHA Training - 2014

Session 4 Objectives Recognize the importance of the early identification of Sepsis Define your role as a member of the Sepsis care team Identify 3 signs and symptoms that patients can display during the progression of Sepsis

You are caring for a 84 y/o female admitted to Med-Surg with a urinary tract infection. She s been in the unit for 2 days. You go in to take a set of vitals and notice that she s acting more confused than she was a few hours ago. Vitals: HR 98, RR 22, BP 98/55, T 38.4 C

You inform the RN who then calls the provider. Before you know it, labs are being drawn, and IV fluid is being hung. After the IV fluids are completed, you are asked to complete a few more sets of vital signs. Shortly after, your patient is transferred up to the Critical Care Unit.

What happened?

WHY SHOULD WE CARE ABOUT SEPSIS?

Sepsis Why do we care? 6 th leading reason for hospitalization in the USA (2009) 836,000 cases annually (primary diagnosis) 829,500 cases annually (secondary diagnosis) 210,000 deaths per year $15.4B per year Agency for Healthcare Research & Quality, 2011

Sepsis Why do we care? Mortality: Severe Sepsis: 30-50% Septic Shock: 50-60% Mortality has changed little since the 1960s (until recently).

Sepsis Why do we care? Every hour of delay in antibiotic administration reduces survival by 7.6% Dellinger, 2004; Kumar, 2006 Recommendation is to give antibiotics within 1 hour of sepsis recognition Must be given within 3 hours to be compliant with the 3-hour bundle Surviving Sepsis Campaign, 2012

Sepsis Why do we care? Takeaways: Early recognition is critical to patient outcome Vital sign abnormalities and changes in patient condition can be useful to help identify Sepsis early

WHAT IS SEPSIS?

Sepsis a systemic, deleterious host response to an infection. (Dellinger, et al., Critical Care Medicine, 2013, 583) Must be treated like a medical emergency Can progress rapidly to severe sepsis & septic shock within 24 hours (AACN Practice Alert, 2010) Healthcare workers have just hours to deliver the right care

Sepsis Sepsis is a disease state continuum : SIRS (as a result of an infection) Sepsis Severe Sepsis Septic Shock Death

Condition Systemic Inflammatory Response Syndrome (SIRS) Definition Temp < 36 C (97 F) or > 38.3 C (101 F) HR > 90 beats/min RR > 20 breaths/min or PaCO2 < 32 mm Hg WBC > 12,000 cells/mm 3 (leukocytosis) or < 4,000 cells/mm 3 (leukopenia) or Bands > 10% immature (band) forms Sepsis Infection + 2 SIRS criteria Severe Sepsis Sepsis + organ dysfunction, hypoperfusion, or hypotension Septic Shock Severe Sepsis + hypotension despite adequate fluid resuscitation, + presence of perfusion abnormalities that requires pharmacological intervention (vasopressors and/or inotropic agents)

Sepsis Risk Factors for Severe Sepsis or Septic Shock: <1 and >65 years old Post surgery Malnourishment Broad spectrum antibiotic use Chronic illness Diabetes Immunodeficiency (AIDS, immunosuppressive agents, etc) Cancer Chronic Renal Failure Etc

Pathophysiology 1. A bacterial infection releases endotoxins which initiate an inflammatory response (pneumonia, UTI, etc) 2. The inflammatory response triggers the: a) Release of white blood cells b) Injury and vasodilation of the blood vessels c) Amplification of the immune response d) Creation of fibrin strands and the development of clots

Pathophysiology 3. This systemic inflammatory response can lead to maladaptive SIRS (usually in patients with risk factors) 4. These components act on vascular endothelium causing: a) Blood vessel injury b) Capillary leakage c) Microthrombi formation d) Impaired fibrinolysis

Pathophysiology 5. This damage results in a systemic imbalance between cellular O 2 supply and demand leading to global tissue hypoxia Global Tissue Hypoxia is a central concept in the understanding of the sepsis continuum.

SEPSIS SIGNS & SYMPTOMS

Sepsis: Signs & Symptoms SIRS symptoms Temperature alterations (T <36 or >38.3 C) Tachypnea (RR >20) Tachycardia (HR >90) or white count Weakness Infection source-specific signs and symptoms Most common: Urinary Tract Infection & Pneumonia

Signs & Symptoms Severe Sepsis & Septic Shock: Vital signs alterations Tachycardia (HR >90) Tachypnea (RR >20) Hypotension (SBP <90) Hypoperfusion (MAP <65)

Signs & Symptoms Severe Sepsis & Septic Shock cont.: Skin signs Color: Pale or mottled Temperature: Cool or cold Moisture: Clammy or wet Organ dysfunction Confusion Decreasing urine output

SEPSIS TREATMENTS

Sepsis Sepsis Treatments Lab draws (CBC, blood cultures, lactate) Antibiotics Frequent vital signs

Sepsis Treatments Severe Sepsis Frequent vital signs Volume resuscitation Fluid Challenge Normal saline 30 ml/kg @ 2L/hr

Septic Shock Sepsis Treatments Transfer to Critical Care Frequent vital signs Continued IV fluid administration IV medications to improve blood pressure and perfusion status Potential intubation Potential blood product administration

ROLE IN SEPSIS CARE

Sepsis Role in Sepsis Care Frequent vital signs Facilitate lab draws Severe Sepsis Frequent vital signs Obtain IV tubing, IV pumps, pressure bags, or rapid infuser Assist with other patients in your assignment

Role in Sepsis Care Septic Shock Frequent vital signs Assist with other patients Facilitate transport to Critical Care Unit

Resources International Guidelines for Management of Severe Sepsis and Septic Shock: 2012 (Surviving Sepsis Campaign) Dellinger et. al, Crit Care Med. 2013, 41(2): 580-637 Understanding Vasoactive Medications Allen, JM. Journal of Infusion Nursing, 2014, 37(2): 82-86 Lactate clearance as a target of therapy in sepsis: A flawed paradigm. Marik PE, Bellomo R. OA Critical Care, 2013, Mar 01; 1(1):3 Lactate clearances and survival following injury Abramson, D. J Trauma, 1993, 35, 584-589 Base deficit in the elderly: a marker of severe injury and death. Davis et. al, J Trauma, 1998, 45, 873-877 AACN Advanced Critical Care Nursing, 2009

Upcoming Safe Table Events January 28, 2015: Safe Table Web Conference Radiology February 10, 2015: Safe Table Obstetrics February 17, 2015: Safe Table Web Conference Infections February 25, 2015: Safe Table Radiology http://www.wsha.org/events.cfm