PHYSIOLOGY AND MANAGEMENT OF THE SEPTIC PATIENT Melanie Sanchez, RN, MSNE, OCN, CCRN Clinical Nurse III City of Hope National Medical Center HOW THE EXPERTS TREAT HEMATOLOGIC MALIGNANCIES LAS VEGAS, NV MARCH 14, 2018
DISCLOSURES I do not have anything to disclose.
WHEN NURSES KNOW BETTER THEY DO BETTER GOAL is to Increase Nurse s Knowledge Skills Confidence.. to better care of Oncology patients
REVIEW Sepsis incidence Visual of sepsis pathophysiology Sepsis recognition Early goal directed therapy one hour sepsis bundle Sepsis recognition and treatment
Incidence and Prevalence of Severe Sepsis and Septic Shock 19 million cases worldwide 750,000 cases in United States annually 2% of all hospital admissions 10% of all ICU admissions Historic mortality in 1980 s up to 80% Current mortality rates range from 20-30%
Risk Factors for Severe Sepsis and Septic Shock Cancer Transplant-related immunosuppression Graft-versus-host disease Neutropenia Loss/compromise of mucosal barriers In-dwelling venous access devices Acquired immunodeficiency syndrome Chronic obstructive pulmonary disease Age Infants Elderly
Sites of Infection Most common sites of infection Pneumonia Intraabdominal sites Urinary tract Blood cultures positive in 1/3 of patients 1/3 of patients have no positive cultures from any site
Microbiological Causes of Sepsis In survey of 14,000 septic patients: 62% gram negative organisms 47% gram positive organisms 19% fungal organisms Most common pathogens Staphylococcus aureus Streptococcus pneumoniae Escherichia coli Klebsiella species Pseudomonas aeruginosa
UNDERSTANDING THE IMPORTANCE https://learn.premierinc.com/ebooks/sepsis-infographic Sepsis is the LEADING Cause of Non-Relapse MORTALITY in Oncology Patients
2. 3. 1. 2012 Sepsis Definition was too complicated
Definition Sepsis: Life-threatening Organ Dysfunction caused by a Dysregulated host Response infection to (JAMA Network, 2016) Septic Shock: Subset of sepsis with Circulatory and Cellular dysfunction associated with Increased Mortality (Surviving Sepsis Campaign, 2016) SEPSIS + REFRACTORY HYPOTENSION &/or Lactate >= 4mmol/L
INFECTION LEADS TO SIRS SIRS (Systemic Inflammatory Response Syndrome) activated by Infection Positive Criteria for SIRS >=2: Temperature 38 C or 36 C HR 90 beats per minute RR 20 breaths per minute or PaCO2 < 32 mmhg WBC 12,000/mm3, 4,000/mm3, or > 10% bands
SITE OF INJURY PATHOPHYSIOLOGY
ALL VESSELS ARE INJURED Capillary Leak
Guideline: Meet Criteria 1, 2, &3 for Severe Sepsis Order Set 1. Known or Suspected Infection - Pneumonia, UTI, Cold/Flu, Diarrhea, Vomiting, CMV, VRE, CDIFF, MRSA, Wound, Recent Surgery, Rigors, Chills 2. Meet 2 Criteria: 1. Temp > 38.3* or < 36* -Fever or Hypothermia 2. WBC < 4.0 -Immunosuppression WBC > 12.0 -Infection Response or Bad Disease Bands > 10% -Bad Marrow 3. HR > 90 -Tachycardia 4. RR >20 -Tachypnea 5. Altered LOC -Somnolence or Confusion /etc. SBP < 90 Lactate > 4 SBP Decrease > 40 (from Baseline) Acute Organ Dysfunction-Low Urine Output or Serum creatinine or acute lung injury
ORGAN DYSFUNCTION & QSOFA (JAMA Network, 2016) qsofa Score >= 2 : Predictor of Mortality
Hypothermia/ Extremely Tired or Sleepy Low WBC or High WBC Heart Rate Acute Rise in serum creatinine or bilirubin
FLUID RESUSCITATION Within 1 Hour FILL MY EMPTY TANK 30ml/kg Average 2 Liters NS over 1 Hour (each 1LNS over 30min) Rate: @ 999ml/hr for each1l NS Bag Albumin 5% 500ml? of Blood Vessels
*ANTIBIOTICS* TREAT PRIMARY CAUSE OF SEPSIS Every Hour Antibiotics are delayed Mortality almost 8%! Within 1 Hour 6 Hours = 48% Mortality Rate
STAT LABS Within 1 Hour Blood culture x 2 ABG + Lactate + Ionized Calcium Might as Well Draw Labs All at Once CBC /Platelets / Differential PT / PTT / INR / Fibrinogen Comprehensive metabolic profile ScvO 2 (mixed venous saturation of oxygen) Q 30 minutes Urinalysis, culture & sensitivity
Goals & Monitoring Lactate <=1.6 ScvO2 = 70% SBP >100 OR MAP >=65 CVP (8-12) non-intubated CVP (12-15) intubated
LACTATE GOAL < 1.6 When the body experiences inadequate tissue perfusion Lactate Increases Lactate gives you a baseline for how bad the patient s oxygen demand is & allows you to monitor trends to guide treatment Does pt need more Fluids? RBC s? FIO2? Immediate ICU transfer? Ionized Ca+: drops in Sepsis and can lead to Cardiac Dysfunction <0.75 possible treat <0.5 Critical, needs Replacement
What is ScvO2, & why a Goal of >70% Definition ScvO2: Oxygen saturation of blood being dumped back into the right atrium by the SVC after it has circulated through your tissues, reflecting the balance between oxygen delivery and oxygen consumption Normal Oxygen Tissue Extraction ~25-30% Why is it so Important to Monitor? Normal values of: BP, MAP, CVP, HR DO NOT RULE OUT TISSUE HYPOXIA Values can look alright, but patient might still be hypoperfused and need fluids, red blood cells, dobutamine Want to make sure patient is being well perfused/hydrated to decrease damage to organs by tissue hypoxia
ScvO2 Goal >70% ScvO2 Status 70-80% Normal 50-69% Compensator y 30-49% Exhaustion 25-29% Severe Lactic Acidosis <25% Cell DEATH Draw line Proximal to Heart
ScvO2 Goal >70%: amount of O2 in blood serum What Effects ScvO2% > O2 Delivery & O2 Consumption Cardiac Output Oxygen supply Hemoglobin / Hematocrit Increased oxygen consumption Versus intravascular volume & CHF in sepsis FIO 2 amount of inspired oxygen PEEP open up alveoli allowing O 2 exchange Pt can be hemodiluted/bleeding in sepsis Fever, chills, pain, injury Reduce oxygen demand
EARLY GOAL DIRECTED THERAPY Within 1Hour Blood Cultures (ScvO2 c Labs can be drawn same time as cultures) *Antibiotics* Source Control ABG with LACTATE Ca+ Fluids 30ML/KG 2Liters avg for 150lb pt *TEAMWORK* After Monitor Goals Monitor ScvO2 GOAL MEDS -LEVOPHED -HYDROCORTISONE -VASOPRESSIN -EPINEPHRINE? DOBUTAMINE? Hgb<8.5 or Hct<28 Transfuse RBC GLUCOSE Stress Ulcer DVT <180 Prophylaxis Prophylaxis TIDAL VOLUME 6ml/kg Monitor Lactate ScvO2 SBP or MAP Monitoring CVP MAP ScvO2 CVP Lactate
LOOK AT BIG PICTURE - SBP - SCVO2 - LACTATE TREND Fill the tank For SBP < 90 fluid resuscitation at 30 ml / kg Squeeze the vessels If SBP < 90 after bolus Start vasopressor (Dopamine non-icu; Levophed ICU) Increase oxygen perfusion If SBP > 90 and ScvO 2 < =70%? Fluids? RBC? Dobutamine? FiO2? Intubation? Pain meds? Ice packs? Pressors too high? All antibiotics on board
SEPSIS SCENARIOS But first https://www.youtube.com/watch?v=fcna7s4u0ok
CASE STUDY Jane Doe 62F AML s/p Chemo & Allogenic Transplant Day +8 History of VRE, CDIFF, AFIB, DM2 Problems: Nausea, Vomiting, Diarrhea for the last week Dry Cough & Runny Nose
CASE 1 You are a Nurse precepting a new grad, the new grad asks you: Why does the patient s blood pressure drop so much with Sepsis?
CASE 2 Your septic patient is in DIC (Disseminated Intravascular Coagulation) and the new grad nurse asks you What is DIC and what caused it in your Septic Patient?
CASE 3 NON-ICU FLOOR Your patient starts showing signs of worsening sepsis. Dr Parker orders the NON-ICU Sepsis Order Set Can you draw a ScvO 2 from a PICC line? The new grad asks you the precepting nurse why we have to draw ScvO 2 every 30minutes until at goal on your septic patient?
What do we want to make sure we get done within an hour?
THANK YOU!