SEPSIS RAPID RESPONSE Sepsis kills up to 50% of those infected. How many deaths will you prevent this year? 1
SEPSIS Back ground: According to the Institute for Health Improvement and the Surviving Sepsis Campaign, severe sepsis carried with it a mortality risk between 30-50%, and in the setting of shock, this rate is even higher. More than 750, 000 cases of severe sepsis occurred annually (year 2000). Sepsis can rapidly progress to severe sepsis, to septic shock and within 24 hours it can harm and kill patients if not treated quickly & increases ICU length of stay and its associated costs. Acute Condition Mortality Rate (%) Sepsis 28.0 50.0* AMI 02.7 09.6 Stroke 09.3 Ruptured abdominal aortic aneurysm 50.0 73.3 * 28-day mortality. 30-day in-hospital mortality rates indicated by literature review of clinical trial data. 14-day mortality amongst patients receiving standard care treatment in the International Stroke Trial. Operative mortality rates It is well accepted that building interventions for a disease such that algorithmic responses are carried out leads to better outcomes. Developing a Sepsis Response team protocol will help to identify patients in early sepsis and facilitate sepsis resuscitation bundle utilization and thereby reduce the mortality rate. Nurses play a huge role in continuous evaluation of the patient in SIRS. Identify sepsis early and mitigate its progression into severe sepsis, septic shock and MODS. Systems in place: Quality and safety continue to be our imperative at UC Irvine healthcare and this is the system we have in place to improve severe sepsis detection and management. The sepsis response team has created the following so far to support this goal. We have: 1. Designed a Sepsis screening tool to be used by nursing every shift 2. Developed order sets that include the drugs, laboratory measures and bundle interventions 2
3. Designed an Algorithm to follow when the order set is initiated A pre-mixed quantity of broad spectrum antibiotics will be made available in the ED and ICUs to be initiated within one hour from the time diagnosis is made 4. A sepsis resuscitation bundle to be completed within 6 hours for ICU patients with severe sepsis, septic shock and or lactate>4mmol/l 3
These strategies/changes in the pipeline will help to reduce the incidence of infections, support failing organs and prevent complications Definitions: There are 4 stages of Sepsis: 1. SIRS(systemic inflammatory response): Any major non infectious insult to the body like: burn, trauma, myocardial infarction, thromboembolism, pancreatitis, vasculitis or surgery where two or more of these are present: 1. Temperature >38.3ºC or <36ºC 2. Heart rate >90 beats/min 3. Respiratory rate >20 breaths/min or PaCO2 <32 mmhg 4. WBC >12,000 cells/mm3, <4000 cells/mm3, or >10 percent immature (band) forms 2. SEPSIS: The presence of SIRS and known OR suspected infection, a culture/gram stain positive for pathogenic micro-organism OR infection identified by visual inspection like a ruptured bowel with free air or a wound with purulent discharge. In many cases of sepsis the actual cause of infection is never identified. The key is to treat infection and monitor the patient for signs and symptoms of organ failure. Sepsis is a medical emergency just like a heart attack because there is an interruption of oxygen and nutrients to the tissues including vital organs like the brain, kidneys, lungs and intestines. 4
3. SEVERE SEPSIS : The presence of SEPSIS and organ dysfunction or at least one of the following signs of hypoperfusion: 1. Areas of mottled skin 2. Capillary refilling requires three seconds or longer 3. Urine output <0.5 ml/kg for at least one hour, or renal replacement therapy 4. Lactate >2 mmol/l 5. Abrupt change in mental status 6. Abnormal electroencephalographic (EEG) findings 7. Platelet count <100,000 platelets/ml 8. Disseminated intravascular coagulation 9. Acute lung injury or acute respiratory distress syndrome (ARDS) 10. Cardiac dysfunction (ie, left ventricular systolic dysfunction), as defined by echocardiography or direct measurement of the cardiac index 4. SEPTIC SHOCK: The presence of SEVERE SEPSIS and hypotension that is unresponsive to a fluid challenge. This is when despite adequate* fluid resuscitation, maintaining a systemic mean BP>80 require: 1. Dopamine >5mcg/kg/min 2. Norepinephrine < 0.25mg/min or 3. Epinephrine <0.25mg/kg/min *Adequate fluid resuscitation is defined as PCWP 12-20, infusion of 20-30ml of starch, CVP 8-12, infusion of 40-60ml/kg of saline. 5
Back to the Basics Every living thing wants to remain in a state of balance/ homeostasis (all physical and psychological systems function smoothly). When homeostasis is disrupted by a stressor the body tries to adjust in an attempt to restore balance. This happens in three stages known as the General Adaptation syndrome: Stage 1: ALARM: Also known as fight or flight the body produces corticoids (adrenaline/epinephrine, cortisone and cortisol) What do we see with increased adrenaline? HR, BP and RR increases in order to supply muscles and brain with more oxygen. Stroke volume is increased- more blood is pumped with each beat of the heart. Air sacs in the lungs dilate to increase oxygen intake increasing the respiratory rate. The liver is stimulated to release more glucose. Blood flow in turn decreases to the stomach, kidneys, skin and liver. The sympathetic nervous system is stimulated and increased cortisone and cortisol suppresses the Immune system. Stage 2: RESISTANCE/ ADAPTATION: This phase begins immediately after the alarm phase starts. The body adjusts in a way that begins to allow the body to return to homeostasis. The body also adapts to its stressor and resources may begin to be depleted leading to disease. The body also tries to develop a long term protection plan and secretes further hormones that increase blood sugar levels to sustain energy and raise blood pressure. Stage 3: EXHAUSTION: The body runs out of its reserve of energy and immunity, the blood sugar drops as the adrenals become depleted and serious illness takes over. Pathophysiology: An insult to the body stimulates cytokine release and the tumor necrosis factor (TNF). This puts the body into an acute phase of response. The growth factor, macrophage and platelets are then released in an attempt to get the body back into homeostasis. If this doesn t happen then the unregulated cytokines release starts toxic reactions and stimulates SIRS. The cytokines and WBC trigger vasodilation (which further increases the core body temperature= fever) to increase capillary permeability, neutrophil activation and adhesions of platelets to the endothelium. 6
The baro receptors in the carotid arteries and Aorta respond to a drop in the patients BP and activate the sympathetic nervous system: this then stimulates the release of potent vasoconstrictors (epinephrine and norepinephrine) to maintain blood flow to the vital organs Increase body temperature = fever (T<36>38.3): The hypothalamic set point may get elevated by cytokines due to insult to the body and heat loss is accelerated through vasodilation and sweating. Elevated body temp increases the demand for oxygen and induces mental changes in some patients. On the other hand, a low body temperature could indicate an overwhelming infection or even SHOCK Tachycardia (HR>90) : As a response to insult the HR increases as an attempt to supply more oxygen Stroke volume is increased- more blood is pumped with each beat of the heart Ventilation/perfusion abnormalities (RR>20 or PaCo2<32): Air sacs in the lungs dilate to increase oxygen intake increasing the respiratory rate. 7
WBC <4>12 or > 10% bands: a high white count may indicate an increased production to fight an infection. A low white count could also indicate the presence of an overwhelming infection that uses up the WBC faster than they can be produced. Sepsis is under reported because clinicians do not recognize it and because co morbidities may cause erroneous cause of death reporting. The Key to successful treatment of sepsis is early recognition and rapid response. Sepsis can progress quickly and rapidly to severe sepsis and septic shock. The NURSE plays a vital role in this because you are the closest to the patient therefore the first to recognize sepsis. What is my role as the nurse? You are the closest in proximity to the patient, take a lead in assessment! Stop the progression of Sepsis and promote early detection and early treatment. 1. Screen for sepsis once a shift and PRN 2. Suspect sepsis if SIRS criteria is met and there is known or suspected infection 3. When the patient screens positive for sepsis notify the doctor providing SBAR 4. If the physician is unable to come to see the patient or there is no response from the primary team within 15 minutes call the Attending. If there is no primary team response within 30mins (total) and the patient displays signs of organ dysfunction, call the Rapid Response Team. 5. Increase the assessment frequency, monitor closely for signs of rapid progression 6. Initiate nursing interventions. Make a call to the physician requesting sepsis 6 orders (labs: STAT lactate and blood cultures, oxygen, fluids, close monitoring of urine output and start antibiotics) 7. Document complete and measurable assessment. 8. If the patient has screened positive place referral in Quest to the Sepsis project manager: Kristi Hare LABS: Two sets of blood cultures should be drawn per hospital policy from at least two separate venipuncture sites before antibiotic administration but should not delay antibiotic therapy. This is the most sensitive method for the detection of bacterimea or fungemia and at least 5 ml of blood will yield a higher detection rate for blood infection. 8
Serum Lactate should be drawn when sepsis is suspected. It shows decreased oxygen delivery to the cells. Elevated levels lead to tissue hypo perfusion and marked acidemia. Impaired tissue oxygenation, leading to increased anaerobic metabolism is responsible for the rise in lactate production. ******Any Questions or concerns please contact: Kristi Hare (Sepsis Project Manager) or Dr. Lanny Hsieh (Sepsis Task Force Chair) ****** SEPSIS RESUCITATION BUNDLE: A bundle refers to a group of interventions that should be initiated together to have better patient outcomes than if the intervention alone is implemented separate from one another. The sepsis resuscitation bundle should be complete within six hours of presentation. 1. Early initiation of supportive care to correct physiologic abnormalities : 1. Administer oxygen for hypoxemia 2. Administer Fluids for Hypotension 2. Early management : ABC S : stabilization of their airway and breathing 3. Obtain serum lactate 4. Obtain blood cultures before giving antibiotics (should not delay antibiotic administration). 5. Start Antibiotics within 1 hour 6. Start IV infusion If MAP <65 or Lactate >4 administer crystalloids like LR/NS first. Colloids may be considered. 7. Monitor CVP keep it >8 or >12 if on mechanical ventilation 9
8. Maintain MAP>65 initiate Vasopressors (first choice being Norepinephrine, 2 nd Vasopressin and Phenylephrine or epinephrine as third line agents), give blood transfusion (PRBC) and Inotropes. Depending on situation, consider steroids. 9. Maintain glycemic control <180mg/dl. Crystalloids: Used for volume expansion, they are capable of passing through a semi-permeable membrane. This solution contains electrolytes and non electrolytes which will diffuse into all body fluid compartments. They come in many preparations and are classified according to their tonicity 1. Isotonic- same tonicity as plasma if given to a well hydrated patient. Will not cause fluid shift between the blood vessels and the cells. (LR, NS, D5W) 2. Hypertonic- they cause water shift from the extra vascular space into the blood stream increasing intravascular volume. 3. Hypotonic- cause water shift from the intravascular space to the extra vascular space and eventually into the tissue cells. Colloids: are IV fluids that contain solutes in the form of large protein molecules, they cannot pass through walls of the capillaries into the cells. They therefore remain in the blood vessels for a longer period of time and can increase intravascular volume. Does not form true solutions and does not dissolve. Examples include: SPA, Albumin, plasma protein factor, dextran and hetastarch. Vasopressor : powerful class of drugs that induce vasoconstriction and thereby elevate the mean arterial pressure. Vasopressors are indicated for a decrease of >30mmHg from baseline SBP or MAP <60 when either condition results in end organ dysfunction due to hypoperfusion. Hypovolemia should be corrected prior to initiating vasopressor therapy. Phenylephrine(Neosynephrine) purely alpha- adrenergic agonist activity- vasoconstriction with minimal cardiac ino/chronotropy 10
Norepinephrine (Levophed) both alpha-1 and beta-1 adrenergic receptors- vasoconstriction without increase in CO. Reflex bradycardia may occur Ephinephrine (Adrenaline) potent beta -1 adrenergic receptor activity and moderate beta-2 and alpha-1 adrenergic receptor effects. Low doses increase CO PRBC: the most desirable fluids for replacement since they transport oxygen to the cells. This is given to restore hematocrit to >30% Inotropes : Increase cardiac contractility Steroids: work by decreasing inflammation and reducing the activity of the immune system. They do this to minimize tissue damage. These may be beneficial for patients who have severe septic shock- SBP <90 for more than one hour despite fluid resuscitation plus vasopressor administration- especially if begun within 8 hours of the onset of shock. Steroids are used to support respiratory and cardiovascular function they can be organ saving and therefore lifesaving. 11
SEPSIS POST TEST 1. Which statement most accurately describes sepsis? a. Its severe infection complicated by tissue hypo-perfusion b. It s a systemic inflammatory response to the presence of infection c. It s an infection-induced hypertensive state that doesn't respond to fluid resuscitation 2. Which isn t a clinical sign of systemic inflammatory response syndrome? a. white blood cell count of 3,800mm3 b. temperature of 35.7 c. respiratory rate of 20breaths/minute 3. Which phrase best defines severe sepsis? a. sepsis induced hypotension that persists despite adequate fluid resuscitation b. systemic manifestations of infection plus a documented infection c. sepsis with organ dysfunction, tissue hypo perfusion, or sepsis induced hypotension 4. Which blood test is used to assess tissue perfusion in a patient with sepsis? a. serum lactate levels b. serum electrolyte levels c. complete blood cell count 5. Antibiotic therapy for suspected sepsis should begin a. before obtaining blood cultures b. immediately after obtaining two separate blood cultures c. after blood culture results and sensitivity tests have been received 12
6. In the presence of severe sepsis, septic shock is diagnosed when the patients lactate level is a. less than 3mmmol/l b. between 3-4mmol/l c. greater than 4mmol/l 7. The cytokines and white blood cells that are released during sepsis trigger a. fibrinolysis b. vasoconstriction c. increased cardiac output d. vasodilation 8. What maybe the first symptom of sepsis noted by clinicians? a. early organ dysfunctions b. fever c. erythema at the site of infections d. purulent exudates 9. When fluid administration fails to restore an adequate arterial pressure and organ perfusion, what therapy should be used: a. broad spectrum antibiotics b. continuous positive airway pressure c. mechanical ventilation d. vasopressor 10. What system do we currently have in place for sepsis detection and management? a. sepsis screening tool b. sepsis order sets c. sepsis algorithm d. sepsis resuscitation bundle e. None of the above f. I don t know 13
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