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Sepsis 2016 Guideline UpdateMari T. Galang, MSN, RN, AGACNP

Definition Update

2012

• Systemic, deleterious host response to infection leading to severe sepsis (acute organ dysfunction secondary to documented or suspected infection) and septic shock (severe sepsis plus hypotension not reversed with fluid resuscitation)

2016

• Life-threatening organ dysfunction caused by a dysregulated host response to infection.

• Septic shock is a subset of sepsis with circulatory and cellular/metabolic dysfunction associated with a higher risk of mortality

SURVIVING SEPSIS CAMPAIGN

• JUNE 2017 – Sepsis awareness month

• Public Media campaign to educate the public and increase awareness

• Treat Sepsis as a medical emergency (think of Heart Attacks, Stroke)

Sepsis is a medical emergency infographic from sepsis.org

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SEPSIS SCREENING

• INSTITUTIONAL EFFORT

• Integration into medical records system

• Prompt recognition and assessment

• Associated with decreased mortality

• Evaluate target metrics

• Collect data

• Re-evaluate and provide feedback

FLUIDS / RESUSCITATION

• Minimum 30 mL/kg in 3 hours

• Crystalloids; consider albumin if still requiring significant volume

• 70 kg person = 2.1 L of crystalloids

• Target MAP 65 mg Hg

• Normalize Lactate

• “Early Goal Directed Therapy” failed to show improved mortality

• “Dynamic assessments”

• Normal CVP range difficult to predict volume responsiveness

• Assess

• Passive Leg Raising

• Stroke Volume Variability

• Fluid Challenges

Crit Care Nurse April 2017vol. 37 no. 2 32-47

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DIAGNOSIS

• Obtain culture data prior to antimicrobial administration

• If not delaying anti-infectives more than 45 minutes

• Obtain blood culture from central access especially if it has been in place >48 hours

Retrieved from: http://www.jems.com/articles/print/volume-41/issue-9/special-focus-septic-alert/south-carolina-ems-integrates-in-hospital-sepsis-care-into-protocols.html. Accessed August 8, 2016.

ANTIMICROBIAL THERAPY

• Be administered within one hour (45 minutes to an hour)

• Institutional effort to have readily available antimicrobials and decreasing operational impacts

• Start broad

• High mortality with inappropriate initial therapy

• Keep fungal and viral etiology in the differential given clinical history

• Dose appropriately given sepsis state (phone a friend/pharmacist)

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Antimicrobial Administration

• Bolus Administration• Cephalosporins

• Aztreonam

• Meropenem

• Intramuscular administration• Imipenem/Cilastatin

• Ertapenem

• Cefepime

• Ceftriaxone

• Aminoglycosides

Garrelts J, Smith D, Ast D, Peterie J. A comparison of the safety, timing and cost-effectiveness of administering antibiotics by intravenous bolus (push) versus intravenous piggyback (slow infusion) in surgical prophylaxis. Pharmacoeconomics. 1992;1(2):116-123. [PubMed]Norrby S, Newell P, Faulkner K, Lesky W. Safety profile of meropenem: international clinical experience based on the first 3125 patients treated with meropenem. J Antimicrob Chemother. 1995;36 Suppl A:207-223. [PubMed]Garrelts J, Wagner D. The pharmacokinetics, safety, and tolerance of cefepime administered as an intravenous bolus or as a rapid infusion. Ann Pharmacother. 1999;33(12):1258-1261. [PubMed]Nowobilski-Vasilios A, Poole S. Development and preliminary outcomes of a program for administering antimicrobials by i.v. push in home care. Am J Health Syst Pharm . 1999;56(1):76-79. [PubMed]

Pharmacodynamics

• Hepatic Dysfunction

• Renal Dysfunction

• Immune Dysfunction

• Increased volume of distribution

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Start strong…

• Vancomycin

• Loading dose of 25-30 mg/kg based on actual body weight

• Starting Goal 15-20

• 70 kg man = 1.75 gm

• Beta-lactams

• Consider frequent dosing (based on renal function) as opposed to bigger doses

• Consider extended infusions

• Pseudomonas does need higher dosing

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• Aminoglycosides

• Daily dosing instead of traditional dosing

• Synergy for Multi-Drug Resistant Organisms

• Ask for pharmacy assistance/Infectious Diseases consultation

• Monitor levels/ototoxicity/nephrotoxicity

De-escalation

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• ~33% of patients with sepsis have negative blood cultures

• Neutropenic patients generally need coverage while lacking

circulating neutrophils

• Treatment duration ~7-10 days depending on scenario

• Quick clinical response

• Negative blood cultures

• No undrained foci of infection

• Not recommended for MRSA/MDROs

• Caution in immunosuppressed patients

• Procalcitonin

SOURCE CONTROL

• Remove lines/catheters if able

• Interventional Radiology/Surgical Intervention

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VASOACTIVE MEDICATIONS

• Start with norepinephrine

• Add vasopressin up to 0.03 units/min

• Consider dopamine (monitor for arrhythmias, not indicated for “renal perfusion”

• Dobutamine in low cardiac output states despite adequate volume resuscitation

• Utilize arterial line monitoring

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CORTICOSTEROIDS

• Not recommended for stable hemodynamics

• If needed consider intravenous hydrocortisone at 200 mg a day and taper when possible

• Etomidate use before low dose steroid associated with increased 28 day mortality

BLOOD PRODUCTS

• No increased risk factors (myocardial ischemia, severe hypoxemia, bleeding, etc); transfuse when Hemoglobin <7 g/dL

• Do not recommend erythropoietin solely for anemia due to sepsis

• Fresh Frozen plasma in setting of active bleeding or planned procedures

• Platelets when below <10K, below 20K if significant risk for bleeding

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MISCELLANEOUS

• Immunoglobulins

• Expensive, not well studied regarding benefits

• Can have reaction

• NOT RECOMMENDED

• BLOOD PURIFICATION

• NOT RECOMMENDED

• ANTITHROMBIN

• NOT RECOMMENDED (increased risk of bleeding)

VENOUS THROMBOEMBOLISM PROPHYLAXIS

• Mechanical and chemoprophylaxis

• Low Molecular Weight Heparin over Unfractionated Heparin (BID)• Low Molecular Weight Heparin had lower incidence of embolism

• Sequential Compression Devices and Graduated Compression

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VENTILATION

• Tidal volume of 6 ml/kg of predicted body weight • Decreased mortality compared to 12 ml/kg

• Upper plateau pressure of 30 cm H2O

• PEEP

• Prone patients

• Neuromuscular Blockade <48 hours

• High Frequency Oscillatory ventilation not recommended

• Head of Bed elevation, weaning sedation protocols

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VENTILATION

• Spontaneous Breathing Trials

• Against Beta-2 Agonist without bronchospasms

GLUCOSE TARGETS

• Target goal <=180

• Avoid hypoglycemia

• Be careful of finger sticks to check glucose

• Check every 1-2 hours when titrating insulin drip then every four hours when stable

RENAL REPLACEMENT

• Not recommended solely for elevated creatinine or oliguria without other indications for dialysis

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BICARBONATE DRIP

• No evidence for hypoperfusion-induced lactic acidosis due to sepsis

STRESS ULCER PROPHYLAXIS

• For increased risk of Gastrointestinal Bleeding

• Mechanical ventilation >48 hours

• Coagulopathy

• Pre-existing liver disease

• Need for renal replacement therapy

• Higher organ failure scores

NUTRITION

• Enteric Nutrition early

• First 7 days: Initiate intravenous glucose and advance enteral feeding

• Suggest prokinetics

• For non-surgical patients: recommend agains routine gastric residual monitoring

• Place post-pyloric feeding tubes in patients with high residuals / risk for aspiration

• Against supplements: omega 3 fatty acid, IV selenium, arginine, glutamine

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GOALS OF CARE

• Initiate discussions regarding goals of care early

• Palliative Care Involvement

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Additional References

• Rhodes, A., et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016