Sepsis 3 Definitions, - CACCN · 1. Define sepsis and septic shock using the Third International...

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Sepsis 3 – Definitions, Identification and Management Barbara Fagan, BScN, MEd, RN, CCNE, CNCC(c) Faculty, Critical Care Nursing Program Registered Nurses Professional Development Centre, Halifax, NS

Transcript of Sepsis 3 Definitions, - CACCN · 1. Define sepsis and septic shock using the Third International...

Page 1: Sepsis 3 Definitions, - CACCN · 1. Define sepsis and septic shock using the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). 2. Apply qSOFA and SOFA

Sepsis 3 – Definitions,

Identification and Management

Barbara Fagan, BScN, MEd, RN, CCNE, CNCC(c)

Faculty, Critical Care Nursing Program

Registered Nurses Professional Development Centre,

Halifax, NS

Page 2: Sepsis 3 Definitions, - CACCN · 1. Define sepsis and septic shock using the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). 2. Apply qSOFA and SOFA

Declarations

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About RNPDC

We are moving to one regulator for all nurses in the province – LPN, RN,

NP (One regulator, one nursing body)

RNPDC receive our funding from NS department of health and wellness

to meet the needs for specialty training in the province

IEN entry – Maritime assessment center

Interprofessional faculty and offer interprofessional programming

We now fall under IPPL umbrella in NSHA

REBRANDING is coming

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Little bit about NS/NSHA

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Adult ICUs in NSHA

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Sepsis Defined/The Global Impact - WHO, 2018

Sepsis arises when the body’s response to any infection injures its own

tissues and organs. If not recognized early and managed promptly, it

can lead to septic shock, multiple organ failure and death.

Sepsis is a global complication of infections in all countries (estimated to

affect 30 million people worldwide yearly/6 million deaths)

Sepsis particularly affects low- and middle-income countries

Sepsis remains a major cause of maternal and neonatal morbidity and

mortality.

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The Global Impact of Sepsis - WHO, 2018

Sepsis is frequently underdiagnosed at an early stage when it is still

potentially reversible.

In the community setting, sepsis often presents as the clinical

deterioration of common and preventable infections.

Sepsis also frequently results from infections acquired in health care

settings, which are one of, if not the most frequent adverse events

during care delivery. As these infections are often resistant to

antibiotics, they can rapidly lead to deteriorating clinical conditions.

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Canadian Data – CIHI (2016) “Care in Canadian ICUs”

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Canadian Sepsis Foundation (2018)

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Problem is not new…so who are the key EBP players?

IHI in early 2000s – VAP and CLABSI bundles

ESICM in 2002 Barcelona Declaration (2002):

We have the technology and resources today to treat most conditions

and injuries yet infection, which has been killing people since history

began, still defeats us.”

“Physicians have tried their best to tackle the scourge of sepsis but

without greater resources, education, and awareness, their efforts

can only have limited success.”

-Prof. Graham Ramsay, ESICM President

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Barcelona Declaration (2002)

Tackle Sepsis using 5 points:

1. Diagnosis - Facilitate early and accurate diagnosis through the

adoption of one, single, clear definition of sepsis.

2. Treatment - Ensure appropriate and timely use of treatments and

interventions via consistent clinical protocols.

3. Referral - Recognize universally acceptable referral guidelines in all

countries of the world.

4. Education - Provide leadership, support, and information to clinicians

about sepsis management.

5. Counseling - Post-ICU care and counseling for sepsis patients to

ensure continuous quality care by providing a framework for

improving and accelerating access to post-ICU care and counseling

for patients

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Who are the other key EBP players?

SCCM in US; American College of Chest Physicians; Canadian Critical

Care Society

Surviving Sepsis Campaign – formed following the Barcelona Declaration;

Published guidelines 2004, 2008, 2012, 2016, 2018 Bundle update…

International Consensus Definitions – 1991, 2001 and latest 2016 (task

force made up of members of SCCM & ESICM)

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Sepsis 3 - Objectives

1. Define sepsis and septic shock using the Third

International Consensus Definitions for Sepsis and

Septic Shock (Sepsis-3).

2. Apply qSOFA and SOFA criteria to identify those at

risk outside the ICU and identify those with end-

organ dysfunction.

3. Select and apply best practice management

strategies for patients with sepsis.

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Sepsis -3 Definitions (2016)

Sepsis should be defined as life-threatening organ

dysfunction caused by a dysregulated host response

to infection.

For clinical operationalization, organ dysfunction can be represented

by an increase in the Sequential [Sepsis-related] Organ Failure

Assessment (SOFA) score of 2 points or more, which is associated

with an in-hospital mortality greater than 10%.

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Sepsis -3 Definitions (2016)

Septic shock should be defined as a subset of sepsis

in which particularly profound circulatory, cellular,

and metabolic abnormalities are associated with a

greater risk of mortality than with sepsis alone.

-patients with septic shock require vasopressors to maintain a mean

arterial pressure of 65mmHg or greater and serum lactate level

greater than 2 mmol/L (>18mg/dL) in the absence of hypovolemia.

This combination (vasopressor support and increased lactate) is

associated with hospital mortality rates greater than 40%.

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SOFA criteria

Organ dysfunction can be identified as an acute change in total SOFA

score greater than or equal to 2 points consequent to the infection.

• The baseline SOFA score can be assumed to be zero in patients not

known to have preexisting organ dysfunction.

• A SOFA score of greater than or equal to 2 reflects an overall mortality

risk of approximately10% in a general hospital population with

suspected infection. Even patients presenting with modest

dysfunction can deteriorate further, emphasizing the seriousness of

this condition and the need for prompt and appropriate intervention,

if not already being instituted.

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qSOFA

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Case Study

Mr. John Smith, a 72 year old, 80kg male is admitted direct from OR

following abdominal surgery

• Earlier in the day he presented to ER with abdominal pain

• PMedHx - ↑BP, Dyslipidemia, ETOH abuse and a cognitive impairment• In ER his assessment reveals: drowsy and confused when roused, peripherally cold

and cyanosis; Vitals: T 38.0, HR 129, RR 24 B/P 75/50; abd tense and distended• I L of crystalloid given for hypotension• CT abd shows extraluminal gas & feces, perforated sigmoid colon; cultured (blood x

2, urine when foley inserted; unable to obtain sputum) and given broad spectrum IV antibiotics and then taken immediately to the OR for repair

What is Mr.Smith’s qSOFA score?

Page 21: Sepsis 3 Definitions, - CACCN · 1. Define sepsis and septic shock using the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). 2. Apply qSOFA and SOFA

Arrival in ICU

• Post Hartmann’s – re-anastamosis and abd washout

• Anesthetized and fully ventilated on FiO2 of .4

• Arterial line and central line in place

• Levophed infusion to support BP

• EBL -500mls – 4L of crystalloid and minimal BP, U/O during case

• Vitals: T- 35.6, HR 120, RR 12 (vent), BP 88/52

• Initial ABGs show pH 7.32, paCO2 28mm Hg, pa02 85mm Hg, HCO3

20 mmol/L, Lactate 3 mmol/L

Think/Pair/Share: What considerations do you need to think

about/data do you need to calculate out SOFA score? What are your

thoughts regarding Mr.Smith’s care? What are the priorities?

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Kleinpell, 2017

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2016 Surviving Sepsis Guidelines

Sepsis and septic shock are medical emergencies and we recommend that treatment and resuscitation begin immediately.Best Practice Statement

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Source Control

• We recommend that a specific anatomic diagnosis of infection requiring emergent source control be identified or excluded as rapidly as possible in patients with sepsis or septic shock, and that any required source control intervention be implemented as soon as medically and logistically practical after the diagnosis is made.

(Best Practice Statement).

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Antibiotics

• We recommend that administration of IV antimicrobials be initiated as soon as possible after recognition and within 1 h for both sepsis and septic shock.

(strong recommendation, moderate quality of evidence).

• We recommend empiric broad-spectrum therapy with one or more antimicrobials to cover all likely pathogens.

(strong recommendation, moderate quality of evidence).

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Fluid Resuscitation

• We recommend that in the resuscitation from sepsis-induced hypoperfusion, at least 30ml/kg of intravenous crystalloid fluid be given within the first 3 hours.

(Strong recommendation; low quality of evidence)

• We recommend that following initial fluid resuscitation, additional fluids be guided by frequent reassessment of hemodynamic status.

(Best Practice Statement)

Page 27: Sepsis 3 Definitions, - CACCN · 1. Define sepsis and septic shock using the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). 2. Apply qSOFA and SOFA

Fluid Therapy

• We recommend crystalloids as the fluid of choice for initial resuscitation and subsequent intravascular volume replacement in patients with sepsis and septic shock

(Strong recommendation, moderate quality of evidence).

• We suggest using albumin in addition to crystalloids when patients require substantial amounts of crystalloids

(weak recommendation, low quality of evidence).

Page 28: Sepsis 3 Definitions, - CACCN · 1. Define sepsis and septic shock using the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). 2. Apply qSOFA and SOFA

Blood Pressure

We recommend an initial target mean arterial pressure of 65 mmHg in patients with septic shock requiring vasopressors. (Strong recommendation; moderate quality of evidence)

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Vasopressor Therapy

• We recommend norepinephrine as the first choice vasopressor

(strong recommendation, moderate quality of evidence).

• We suggest adding either vasopressin (up to 0.03 U/min) or epinephrine to norepinephrine with the intent of raising MAP to target, or adding vasopressin (up to 0.03 U/min) to decrease norepinephrine dosage.

(weak recommendation, low quality of evidence)

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If shock is not resolving quickly…

• We recommend further hemodynamic assessment (such as assessing cardiac function) to determine the type of shock if the clinical examination does not lead to a clear diagnosis.

(Best Practice Statement)

• We suggest that dynamic over static variables be used to predict fluid responsiveness, where available.

(Weak recommendation; low quality of evidence)

Page 31: Sepsis 3 Definitions, - CACCN · 1. Define sepsis and septic shock using the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). 2. Apply qSOFA and SOFA

Lactate can help guide resuscitation

• We suggest guiding resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion.

(Weak recommendation; low quality of evidence)

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Summary of 2016 Guidelines

• Start resuscitation early with source control, intravenous fluids and antibiotics.

• Frequent assessment of the patients’ volume status is crucial throughout the resuscitation period.

• We suggest guiding resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion.

Page 33: Sepsis 3 Definitions, - CACCN · 1. Define sepsis and septic shock using the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). 2. Apply qSOFA and SOFA

User’s Guide to the 2016 Surviving Sepsis Guidelines

Page 34: Sepsis 3 Definitions, - CACCN · 1. Define sepsis and septic shock using the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). 2. Apply qSOFA and SOFA

User’s Guide to the 2016 Surviving Sepsis Guidelines

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Remember our Case Study - Mr. Smith

Data for SOFA?

Considerations for treatment?

Priorities?

Page 36: Sepsis 3 Definitions, - CACCN · 1. Define sepsis and septic shock using the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). 2. Apply qSOFA and SOFA

Feb 2018 - AJN

Page 37: Sepsis 3 Definitions, - CACCN · 1. Define sepsis and septic shock using the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). 2. Apply qSOFA and SOFA

March 2018 NEJM - Steroids – ADRENAL study results

Page 38: Sepsis 3 Definitions, - CACCN · 1. Define sepsis and septic shock using the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). 2. Apply qSOFA and SOFA

July 2014 CCM - Fluids- Balanced vs. Crystalloids

-fluid choice and amount has been very controversial in the literature

-Much in the past was on crystalloids vs. colloids

Debate on how to choose between crystalloids for resuscitation

-RL/Plasmalyte have electrolyte compositions which are more similar to

plasma

Fluid resuscitation with NS → NS +++chloride content and strong ion

difference and has been known to contribute to hyperchloremia and

metabolic acidosis which is associated with undesirable

consequences.

RCTs underway…

Page 39: Sepsis 3 Definitions, - CACCN · 1. Define sepsis and septic shock using the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). 2. Apply qSOFA and SOFA

June 2018 – CCM Surviving Sepsis Campaign Bundle

update HOUR-1 Bundle (Levy & Rhodes)

Page 41: Sepsis 3 Definitions, - CACCN · 1. Define sepsis and septic shock using the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). 2. Apply qSOFA and SOFA

Questions?

Feel free to contact me:

[email protected]

Page 42: Sepsis 3 Definitions, - CACCN · 1. Define sepsis and septic shock using the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). 2. Apply qSOFA and SOFA

References

Canadian Sepsis Foundation (2018). Sepsis. Retrieved from:

https://canadiansepsisfoundation.ca/

Canadian Institute for Healthcare Information (2016). Care in Canadian

ICUs. Ottawa, ON: Author.

Dellinger, R.P, Schorr, C.A. & Levy, M.M. (2017). A users’ guide to the

2016 surviving sepsis guidelines. Critical Care Medicine, 45(3), 381-

385.

Dumont, T., Francis-Frank, L, Chong, J., & Balaan, M.R. (2016). Sepsis

and septic shock: Lingering questions. Critical Care Nursing

Quarterly, 39(1), 3-13.

Fairmann, M. (2016). My story with sepsis. Retrieved from:

https://www.youtube.com/watch?v=mZqG8X6dUoI

Flynn Makic, M. B. & Bridges, E. (2018). Managing sepsis and septic

shock: Current guidelines and definitions. American Journal of

Nursing, 118(2), 34-39.

Howell, M.D., & Davis, A.M. (2017). Management of sepsis and septic

shock. JAMA, 317(8), 847-848.

Kleinpell, R.M., Schorr, C.A, & Balk, R.A. (2016). The new sepsis

definitions: Implications for critical care practitioners. American

Journal of Critical Care, 25(5), 457-464.

Page 43: Sepsis 3 Definitions, - CACCN · 1. Define sepsis and septic shock using the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). 2. Apply qSOFA and SOFA

References

Levy, M.M. & Rhodes, A. (2018). The surviving sepsis campaign bundle:

2018 Update. Critical Care Medicine, 46(6), 997-100,

Montanaro, N. (2016). Sepsis resuscitation: Consensus and

controversies. Critical Care Nursing Quarterly, 39(1), 58-63.

Raghunathan, K., Shaw, A. Nathanson, B, Sturmer, T., Brookhart, A. …&

Lindenauer, P.K. (2014). Association between choice of IV crystalloid

and in-hospital mortality among critically ill adults with sepsis.

Critical Care Medicine, 42(7), 1585-159.

Rhodes, A., Evans, L.E., Alhazzani, W., Levy, M.M., Antonelli, M. &

Dellinger, R.P. (2017). Surviving Sepsis Campaign: International

Guidelines for Management of Sepsis and Septic Shock: 2016.

Critical Care Medicine, 45(3), 487-552.

Seckel, M.A. (2017). Sepsis-3: The new definitions. Nursing2017

Critical Care, 12(2), 37-43.

Society of Critical Care Medicine (2018). Surviving Sepsis Campaign.

Retrieved from: http://www.survivingsepsis.org/Pages/default.aspx

Venkatesh, B., Finfer, S. Cohen, J. Rajahandari, D. …& Myburg, J. (2018).

Adjunctive glucocorticoid therapy in patients with septic shock.

NEJM, 378(9), 797-808.

World Health Organization (2018). Sepsis. Retrieved from:

http://www.who.int/sepsis/en/