“A Closer Look at New Evidence-Based Sepsis Guidelines for Adult Patients in Acute Care”

Christopher de la Victoria, MSN, RN, CMSRN, CSRN, CDP, CADDCTProvider approved by the California Board of Registered Nursing, Provider # CEP16812, for 2 Contact Hours

Course Overview

This course presents current evidence-based approaches in identifying and managing sepsis in adult patients, guided by specialty standards structured to

promote positive patient outcomes.

Learning ObjectivesUpon completion of the course, participants should be able to: • Describe the updated definition of sepsis, guided by the Third International Consensus

Definitions for Sepsis and Septic Shock (Sepsis-3). • Discuss the pathological features and risk factors of sepsis. • Compare and contrast the evidence-based screening tools for patients likely to have sepsis. • Identify indications for the initiation of sepsis protocols. • Discuss the Surviving Sepsis Campaign Bundles.• Describe the collaborative interventions in the plan of care. • Describe the importance of patient education in the prevention and early recognition of sepsis. • Discuss the positive effects of early screening and timely interventions in sepsis management.• Discuss the challenges in sepsis management.

Sepsis Definition: A Work in Progress!• Sepsis: life-threatening organ dysfunction caused by a dysregulated

host response to infection (Singer, et al., 2016).• Sepsis definition is a “work in progress…” (Journal of American Medical Association [JAMA], 2016).• New definitions DO NOT change the primary focus of early sepsis

identification and initiation of timely treatment (Surviving Sepsis Campaign, 2016).

Sepsis Definition: A Work in Progress!• It is insidious and often leads to life threatening outcomes if not

treated promptly and appropriately (Picard, et al., 2006, p. 43).

• Early detection and rapid initiation of treatment reduce in-patient mortality from severe sepsis/septic shock (Westphal, et al., 2011).

Cases• More than 220,000 patients with sepsis die annually (Butcher, 2016).

• Sepsis treatment costs around $24 billion each year, according to the Agency for Healthcare Research and Quality (Butcher, 2016).

What differentiates sepsis from infection?“What differentiates sepsis from infection is an aberrant or dysregulated host response and the presence of organ dysfunction” (Singer, et al., 2016).

Pathophysiology of Sepsis• “In patients with sepsis, inflammation, coagulation, and fibrinolysis

are closely related, and the balance among them must be restored to improve outcomes” (Picard, O’Donoghue, Young-Kershaw, & Russell, K.J., 2006).

SEPSISINFLAMMATION

COAGULATION

FIBRINOLYSIS

BalanceBalance

Balance

Pathophysiology of Sepsis (Picard, et al., 2006)

• Inflammatory response to microbial infection release of cytokines that initiate inflammatory response microvascular permeability and vasodilation. • Damage to blood vessel linings from inflammation clots form impaired

tissue perfusion

• Coagulation: Fibrin clot formation impaired tissue perfusion to organs organ dysfunction (i.e., decreased myocardial performance)• Impaired fibrinolysis: With an infection, an excess of plasminogen

activator inhibitor -1 impairs normal fibrinolytic response thrombus formation impaired tissue perfusion

Risk factors (Picard, 2006)

• Extremes of age (<1 year and > 65)• Malnutrition • Hypothermia• Use of central venous catheters• Endotracheal intubation/mechanical ventilation• Aspiration• Chronic illness (i.e., diabetes, renal failure, hepatic failure)• Immunodeficiency (i.e., AIDS, Alcoholism, use of chemotherapeutic agents)• Use of surgery or invasive procedures

Spot the Septic!

Systemic Inflammatory Response Syndrome • Sepsis results from a host’s systemic inflammatory response

syndrome (SIRS) to infection: Two or more of: • Temperature > 38 celcius or <36 celcius• Heart rate > 90/min• Respiratory rate >20 or PaCO2 <32 mmHg• WBC count > 12000/mm3 or < 4000/mm3 or >10% immature bands

*** considered by the sepsis task force to be unhelpful because these changes can also be caused by “other insults” (Singer, 2016).

Screening for Patients Likely to Have Sepsis (Singer, et al., 2016)

• Sequential (Sepsis-related) Organ Failure Assessment (SOFA) Scoring (next slide): predicts mortality based on different lab results. • SOFA score of 2 or greater identified a 2 to 25-fold increased risk of

death, compared with patients with SOFA score <2• Requires lab testing and thus may not promptly capture dysfunction

in individual systems.

(Rezaie, 2016) Emergency Physicians Monthly

(JAMA, 2016)

Screening for Patients Likely to Have Sepsis (Singer, et al., 2016)

• Quick Sequential Organ Failure Assessment (qSOFA) and incorporating altered mentation (GCS of 13 or less), systolic blood pressure of 100 mmHg or less, and respiratory rate of 22/min or greater, provides simple bedside criteria to identify adult patients with suspected infection who are likely to have poor outcomes.• Sepsis bedside criteria, outside critical care setting (JAMA, 2016)

• Does not require lab tests• Can be assessed quickly and repeatedly • Positive qSOFA criteria should also prompt consideration of possible infection in

patients not previously recognized as infected. • qSOFA does not define sepsis, but the presence of two qSOFA criteria is a predictor of

both increased mortality and ICU stays of more than three days in non-ICU patients (SSC, 2016).

qSOFA (“qSOFA,” 2016)

Other Diagnostic Criteria (Dellinger, et al., 2013)

Other Diagnostic Criteria• Procalcitonin: induced by the activation and adherence of monocytes

to the endothelial layer of blood vessels as occurs during sepsis (Carr, 2015, p. 2).

• Normal = <0.1 ng/mL• Reliable marker of sepsis and certainly the best of the biomarkers yet to be

identified.

• Serum Lactate level: Determines lactic acidosis from decreased tissue perfusion (LeMone, Burke, & Bauldoff, 2011).• C-reactive protein: Level rises during the inflammatory process (Williams &

Hopper, 2011).

Surviving Sepsis Campaign: How it Started• “The Surviving Sepsis Campaign is a joint collaboration of the

Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM) committed to reducing mortality from severe sepsis and septic shock worldwide” (SSC,

n.d.).

Surviving Sepsis Campaign: How it Started• “Initiated in 2002 at the ESICM’s annual meeting with the

Barcelona Declaration, the Campaign progressed in phases that have expanded the scope and reach of the Campaign via publication of 3 editions of evidence-based guidelines, implementation of a performance improvement program, and analysis and publication of data from more than 30,000 patient charts collected around the world” (SSC, n.d.)

Implications of the New Definitions for Screening and Management (SSC, 2016)

• In response to the ESICM and SCCM’s Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3), the Surviving Sepsis Campaign (SSC) offers clarification on the implications of the new definition statements and guidance for hospitals and practitioners.

Implications of the New Definitions for Screening and Management (SSC, 2016)

• “TIME OF PRESENTATION is defined as the time of triage in the emergency department or, if presenting from another care venue, from the earliest chart annotation consistent with all elements of severe sepsis or septic shock ascertained through chart review.”• Triage time is time zero!• A percentage of patients may not meet criteria for severe

sepsis or septic shock at ED triage.

Stomp Sepsis!

Implications of the New Definitions for Screening and Management (Surviving Sepsis Campaign, 2016). • Step 1: Screening and Management of Infection• qSOFA criteria can be a useful tool.• Use signs and symptoms of infection to promote early

identification of patients with suspected or confirmed infection. • Management of patients identified as having infection: • Blood and other cultures as indicated• Administering tailored antibiotics as appropriate• Simultaneously obtaining laboratory results to evaluate the patient for

infection-related organ dysfunction.

Implications of the New Definitions for Screening and Management (Surviving Sepsis Campaign, 2016)

• Step 2: Screening for Organ Dysfunction and Management of Sepsis• Lactate level greater than 2 mmol/L. • qSOFA in patients who have screened positive for infection may be

used as a secondary screen to identify patients at risk for clinical deterioration. • qSOFA elements were determined through analysis of data-driven model

to predict deterioration. • Practitioners, monitor the high-risk patients closely!

Step 2: Screening for Organ Dysfunction and Management of Sepsis (Surviving Sepsis Campaign, 2016).

• If organ dysfunction is identified, ensuring that the three-hour bundle elements have been initiated continues to be a priority.

1. Measure the lactate level.2. Obtain blood cultures prior to administration of antibiotics.3. Administer broad-spectrum antibiotics.4. Administer 30 mL/kg crystalloid for hypotension or lactate

greater than or equal to 4 mmol/L.

Implications of the New Definitions for Screening and Management (Surviving Sepsis Campaign, 2016)

• Step 3: Identification and Management of Initial Hypotension• (+) infection, hypotension, lactate level > or = to 4 mmol/L, provide

30 mL/kg crystalloid with reassessment of volume responsiveness or tissue perfusion. • 6-hour elements of care should be completed! Take note, for the 6-

hour bundle, repeat lactate level is also recommended if initial lactate level was greater than 2 mmol/L.

Step 3: Identification and Management of Initial Hypotension (Surviving Sepsis Campaign, 2016).

• TO BE COMPLETED WITHIN 6 HOURS: • Apply vasopressors (for hypotension that does not respond

to initial fluid resuscitation to maintain a MAP > or = 65 mmHg. • In the event of persistent hypotension after initial fluid

administration (MAP < 65 mmHg) or if initial lactate was > or = 4 mmol/L, reassess volume status and tissue perfusion and document reassessment findings. • Recommended: Re-measure lactate if initial lactate greater

than 2 mmol/L.

Document Reassessment of Volume Status and Tissue Perfusion (Surviving Sepsis Campaign, 2016)

• Either: Repeat focused exam (after initial fluid resuscitation) by licensed independent practitioner (LIP) including vital signs, cardiopulmonary, capillary refill, pulse, and skin findings. • OR TWO OF THE FOLLOWING: • Measure Central Venous Pressure (CVP)• Measure Central Venous O2 Saturation (ScvO2)• Bedside cardiovascular ultrasound• Dynamic assessment of fluid responsiveness with passive leg raise or fluid

challenge.

Interventions (Picard, et al., 2006)

Treatment Nursing Action Expected OutcomesFluid replacement

Assess fluid status, monitor CVP, 500 mL fluid challenge every 20 to 30 minutes

CVP maintained at 8-12 mmHg, urine output > 20 mL/hr, clear lungs

Control of BP Monitor mean arterial pressure, adjust dosage of norepinephrine if MAP <65 mmHg after fluid replacement

MAP > 65

Interventions (Picard, et al., 2006)

Treatment Nursing Action Expected OutcomesTissue perfusion Assess for evidence of

adequate tissue perfusion (i.e., heart rate, respirations, urine output, mentation)Begin Dopamine infusion if Central venous O2 sat. (SCVO2) <70% after CVP and MAP correctedMonitor hematocrit

ScvO2 >70% Adequate tissue perfusion: Urine output > 20 mL/hr, skin warm/dry, pulse less palpablenormal mentationBlood transfusion if hematocrit <0.30

Interventions (Picard, et al., 2006)

Treatment Nursing Action Expected OutcomesEarly treatment with antibiotics

Administration of antibiotics within 1 hour of patient’s entry into the protocol. Begin after samples sent for culturing

Therapy with broad-spectrum antibiotics begins early, and treatment is refined according to the results of cultures.

Interventions (Picard, et al., 2006)

Treatment Nursing Action Expected OutcomesAdministration of steroids for adrenal insufficiency

Obtain random blood sample for assay of serum cortisol level and then do a corticotropin stimulation test

Hydrocortisone therapy is started and maintained for patients who do not respond to corticotropin test. (Treatment with low-dose steroids significantly reduces the risk of death in patients with septic shock and adrenal insufficiency).

Interventions (Picard, et al., 2006)

Treatment Nursing Action Expected OutcomesControl of blood glucose levels

Monitor blood glucose levels every hour, adjust dosage of insulin as prescribed.

Blood glucose level maintained (80-120 mg/dL)

Interventions (Picard et al., 2006; Dellinger et al., 2013 )

Treatment Nursing Action Expected OutcomesAdministration of activated protein C (to facilitate clot breakdown)

Begin administration of activated protein C in eligible patients. Assess patients for signs and symptoms of bleeding. Monitor indicators of coagulation.

All eligible patients will receive activated protein to improve outcome.

Interventions (Picard et al., 2006; Dellinger et al., 2013 )

Treatment Nursing Action Expected OutcomesInfection prevention

Infection control practicesSelective oral decontamination to reduce incidence of ventilator-associated pneumonia (VAP). Oral chlorhexidine gluconate used as a form of oropharyngeal decontamination to reduce the risk of VAP in ICU patients with severe sepsis.

No nosocomial infection

Interventions (Picard et al., 2006; Dellinger et al., 2013)

Treatment Nursing Action Expected OutcomesDeep Vein Thrombosis prophylaxis

Daily subcutaneous low-molecular weight heparin twice daily; dalteparin if creatinine clearance is <30 mL/min. Pneumatic compression device

No DVT

Intervention: Nutrition (Dellinger et al., 2013)

• Oral or enteral feedings as tolerated. • IV glucose and enteral nutrition rather than total parenteral nutrition

alone or parenteral nutrition in conjunction with enteral feeding in the first 7 days after a diagnosis of severe sepsis/septic shock. • Nutrition with no specific immunomodulating supplementation in

patients with severe sepsis.

Intervention: Blood Product Administration (Dellinger, et al., 2013) • Once tissue hypoperfusion has resolved: red blood cell transfusion occur

only when hemoglobin concentration decreases to < 7.0 g/dL to target a hemoglobin concentration of 7.0-9.0 g/dL in adults. • No erythropoietin associated with severe sepsis. • No Fresh frozen plasma to correct clotting abnormalities in the absence of

bleeding or planned invasive procedures. • No antithrombin for the treatment of severe sepsis and septic shock.

Intervention: Blood Product Administration (Dellinger, et al., 2013) • In patients with severe sepsis, administer platelets prophylactically

when counts are <10,000mm3 in the absence of apparent bleeding. • Prophylactic platelet transfusion when counts are < 20,000/mm3 if the patient

has a significant risk of bleeding. • Higher PLT counts (>or= 50,000/mm3) are advised for active bleeding, surgery,

or invasive procedures.

Interventions: Sedation, Analgesia, and Neuromuscular Blockade in Sepsis (Dellinger et al., 2013)

• Minimization of continuous or intermittent sedation in mechanically ventilated sepsis patients, targeting specific titration endpoints. • Neuromuscular blocking agents avoided if possible in septic patients

without acute respiratory distress syndrome due to the risk of prolonged neuromuscular blockade following discontinuation. If NMBAs must be maintained, either intermittent bolus as required • Short course of an NMBA for patients with early, sepsis-induced ARDS

and PaO2/FiO2 < 150 mmHg.

Intervention: Bicarbonate Therapy (Dellinger et al., 2013)

• Not recommended for the purpose of improving hemodynamics or reducing vasopressor requirements in patients with hypoperfusion-induced lactic academia with PH >= 7.15

Intervention: Stress Ulcer Prophylaxis (Dellinger et al., 2013)

• H2 blocker or proton pump inhibitor (PPI) recommended to be given to patients with severe sepsis/septic shock who have bleeding risk factors.• PPI suggested, rather than H2 blocker for stress ulcer prophylaxis.• Patients without risk factor: Prophylaxis NOT recommended.

Setting the Goals of Care (Dellinger et al., 2013)

• Prevention is better than cure!• Goals of care be incorporated into treatment and end-of-life care

planning, utilizing palliative care principles where appropriate.• Discussion of goals of care and prognosis, addressed as early as

feasible, no later than within 72 hours of ICU admission.

Positive Outcomes• Reduced mortality after the implementation of a protocol for early

detection (Westphal et al., 2011).

• Improvement of care for patients with severe sepsis and septic shock (Sweet et al., 2010).

• Cost effective (Assuncao et al., 2014)

• Addressing reimbursement (i.e., Centers for Medicare and Medicaid Services measures, insurance).

• Hospital recognition and certification (i.e., Joint Commission Clinical Practice Guidelines) (Martin & Pretto-Sparkuhl, 2016)

• “Culture change: Communication, loyalty, teamwork” (Martin & Pretto-Sparkuhl, 2016)

Challenges• In-service, continuing education programs: Large number of staff

involved in sepsis care- more manpower needed.• Complexities with nursing workload.• Adequacy of staff support needed upon implementation of protocols• Availability of equipment.• Joint Commission Standards: Consistent implementation of Clinical

Practice Guidelines (Martin & Pretto-Sparkuhl, 2016, July 28).

Sample Sepsis Protocol Checklist (St. Helens and Knowsley Teaching Hospitals, 2013)

ICU Severe Sepsis Screening Tool (St. Joseph Mercy Health System, n.d.)

(St. Joseph Mercy Health System, 2013)

Sepsis Bundle Card (Society of Critical Care Medicine & European Society of Intensive Care Medicine, 2016a)

Sepsis Bundle Hanging Card (Society of Critical Care Medicine & European Society of Intensive Care Medicine, 2016b))

The EndThank you!

References• Assuncao et al. (2014). Cost-effectiveness ration of a managed protocol for severe sepsis.

Journal of Critical Care, 29, 692.e1-692e6.• Butcher, L. (2016). Stepping up against sepsis. Hospitals and Health Networks, 90(1), 38-42.• Carr, J.A. (2015). Procalcitonin-guided antibiotic therapy for septic patients in the surgical

intensive care unit. Journal of Intensive Care. Doi 10.1186/s40560-015-0100-9• Dellinger, et al. (2013). Surviving sepsis campaign: International guidelines for management of

severe sepsis and septic shock: 2012. Critical Care Medicine, 41(2), 580-637.• Gornik, I., Vujaklija, A., Lukic, E., Madzarac, G., & Gasparovic, V. (2010). Hyperglycemia in sepsis

is a risk factor for development of type II diabetes. Journal of Critical Care, 25(2), 263-269.• JAMA. (2016). Consensus definitions for sepsis and septic shock [Video]. Retrieved from

https://www.youtube.com/watch?v=1S8l5D2xr6w• LeMone, P., Burke, K., & Bauldoff, G. (2011). Medical-surgical nursing: Critical thinking in patient

care (5th ed.). Upper Saddle River, NJ: Pearson.

References• Martin, D., & Pretto-Sparkuhl, A. (2016, July 28). Managing patient outcomes:

The battle against sepsis. The Joint Commission Certification. Retrieved from https://www.jointcommission.org/assets/1/6/DSC_2016_Sepsis_Webinar_slides_0728.pdf• Picard, K.M., O’Donoghue, S.C., Young-Kershaw, D.A., & Russell, K.J. (2006).

Development and implementation of a multidisciplinary sepsis protocol. Critical Care Nurse, 26(3), 43-54.• qSOFA [Image]. (2016). Retrieved from

http://www.traumayellow.com/education/qsofa-the-new-sepsis-definitions• Rezaie, S.R. (2016). Sepsis gets an upgrade with SOFA/qSOFA. Retrieved from

http://epmonthly.com/article/sepsis-gets-an-upgrade/

References• Surviving Sepsis Campaign. (2016). Surviving sepsis campaign responds to sepsis-3.

Retrieved from survivingsepsis.org. • Surviving Sepsis Campaign (n.d.). About the surviving sepsis campaign. Retrieved

from http://www.survivingsepsis.org/About-SSC/Pages/default.aspx• Singer, et al. (2016). The third international consensus definitions for sepsis and

septic shock (sepsis 3). JAMA 315(8), 801-810.• Society of Critical Care Medicine & European Society of Intensive Care Medicine.

(2016a). Bundle badge card [Image]. Retrieved from http://www.sccm.org/SiteCollectionDocuments/SSCBundleCard_Web.pdf• Society of Critical Care Medicine & European Society of Intensive Care Medicine.

(2016b). Bundle hanging card [Image]. Retrieved from http://www.sccm.org/SiteCollectionDocuments/SSCBundleCard_Web.pdf

References• St. Helens and Knowsley Teaching Hospitals. (2013). Adult sepsis management

pathway. Retrieved from Surviving Sepsis Campaign site: http://www.survivingsepsis.org/SiteCollectionDocuments/Protocols-St-Helens-Adult-Sepsis-Management-Pathway.pdf

• St. Joseph Mercy Health System. (2013a). Surviving Sepsis Campaign Bundles [Image]. Retrieved from Surviving sepsis campaign site: http://www.survivingsepsis.org/SiteCollectionDocuments/Protocols-Pocket-Card-StJoseph.pdf

• St. Joseph Mercy Health System. (2013b). Septic Shock Resuscitation Algorithm [Image]. Retrieved from Surviving sepsis campaign site: http://www.survivingsepsis.org/SiteCollectionDocuments/Protocols-Pocket-Card-StJoseph.pdf

• St. Mary Mercy Health System. (n.d.). Septic shock clinical pathway. Retrieved from Surviving Sepsis Campaign site: http://www.survivingsepsis.org/SiteCollectionDocuments/Protocols-Sepsis-Screening-StJoseph.pdf

References• Westphal, et al. (2011). Reduced mortality after the implementation

of a protocol for the early detection of severe sepsis. Journal of Critical Care, 26, 76-81• Williams, L.S., & Hopper, P.D. (2011). Understanding Medical-Surgical

Nursing (5th ed.). Philadelphia, PA: F.A. Davis.