Sepsis

Mechanism of Disease

Quick Overview

Last Updated on 2/25/2014

So why are we here ?

Building awareness of Sepsis

Improving your ability to recognize sepsis early

Increasing the use of Early Goal Directed Therapy

Educating healthcare professionals

Developing guidelines of care

Using the Code Sepsis Rapid Response System

Building Awareness of Sepsis

Dr. Emanuel Rivers

Formally conceptualized severe sepsis and/or septic shock in 2001 with a landmark paper

Developed an Algorithm for the management of Sepsis

EGDT

Early Goal Directed Therapy

Recommendations have been replicated in many publications since 2001

European Society of Intensive Care Medicine and the Society of Critical Care Medicine

Connect the Dots….

Did you know?

The word “Sepsis” was derived from the

Ancient Greek for

ROTTEN FLESH AND PUTREFACTION

Did you know?

Sepsis is growing healthcare challenge

1. It is the #1 cause of death in non-coronary ICU

2. 11th leading cause of death overall

3. 28-day mortality: 30- 50%

4. >750,000 US cases annually

5. Long term complications and treatment may qualify the patient for transfer to an Acute Long Term Care Hospital

Did you know?

Sepsis is growing healthcare challenge

6.  Incidence is growing faster than overall population

7. Sepsis is the most expensive reason for hospitalization ($17.0 billion cost of treatment in the US)

8. Sepsis is a major cause of mortality throughout the world killing about 1,400 per day

RISK Factors for Developing Sepsis

Age (Newborn or over 35 years old)

Being pregnant

Having chronic disorders such as Diabetes or Cirrhosis, Lupus, Cancer, Poly-Substance Abuse

Having a weakened immune system (HIV, taking immune modulating drugs, chemotherapy, etc.)

Having medical devices inserted into the body (catheters, tubes, etc).

What is Sepsis?

Sepsis

is defined as a suspected or documented infection in

the presence of two or more Systemic Inflammatory

Response Syndrome Identifiers (SIRS).

Similar to acute MI, Stoke and Poly-trauma, rapid

treatment (within the first few hours) influences the

outcome.

Defining SIRS

The causes of SIRS are broadly classified as: Infectious or Noninfectious

The Symptoms Associated with SIRS:

Hypothermia (temp < 97◦) or Fever (temp >100◦)

Tachycardia (HR >100bpm)

Tachypnea (resp>20/min) or Hypocapnia (arterial CO2 <32mmHg)

Leukopenia or Leukocytosis

AMS

Noninfectious causes of SIRS include

Trauma

Burns

Pancreatitis

Ischemia

Hemorrhage

Complications of surgery

Adrenal Insufficiency

Pulmonary Embolism

Complicated Aortic Aneurysm

Cardiac Tamponade

Anaphylaxis

Drug Overdose

People Admitted To The Hospital With Serious Diseases Are At The Highest Risk For Sepsis Because Of:1. Underlying diseases such as diabetes, cancer, etc.

2. Presence of drug resistant bacteria in the hospital

3. The fact that they often require an Invasive Lines

4. Being Immuno – compromised / Auto-Immune Disease

5. Surgery / Invasive procedure

6. Mechanical ventilation

7. Having wounds or injuries from burns, a car crash or a bullet

There are 3 Levels of Sepsis

Sepsis:

2 SIRS identifiers with a confirmed source of infection

Severe Sepsis:

Sepsis plus Organ Dysfunction (24 to 72 hrs)

Septic Shock:

Is Severe Sepsis with persistent hypotension and hypo-perfusion, which can lead to cell death, end-organ damage, multi-system organ failure and death.

What is Severe Sepsis?Inflammation + Infection + Organ Dysfunction

The progression:

SIRS: Manifested by two or more of the following:

• Temp > 100.4 or < 96.9

• HR > 90 bpm

• RR > 20 cpm

• WBC > 12,000 or <4000 or bands >10%

• AMS

The Symptoms of Septic Shock:

Hypotension BP< 90 despite fluid bolus of 20 ml/kg.

Map <65

High lactic acid levels > 4mmoL

Hypothermia (temp < 97◦) or fever (temp >100◦)

Tachycardia (HR >100bpm)

Tachypnea (resp>20/min) or hypocapnia (arterial CO2 <32mmhg)

Resp. Rate >20 bpm

Diagnosing Sepsis

Routine screening of potentially infected patients (12 hrs)

Sudden development of high or low temperature

Rapid heart or breathing rate

Low blood pressure

Positive blood or suspected cultures

Laboratory Data

Use of the sepsis bundles may lead to reduced mortality and improvement in sepsis care.

Subtle Changes in Your Patient maybe Sepsis

Tests used to identify Sepsis

Blood tests to measure lactic acid levels

Lactate Levels > 4

Cultures and blood cultures to help determine the type and site of infection prior to antibiotic administration

CBC with Diff

Elevated Neutrophil Count

Bands > 10%

Pulse oximetry to measure oxygen levels

Temperature

SCVO2 Levels

We Check and Check and Check Lactatic Acid Levels ?

1.3

5.6

1.3

3.6

>4 is a good Indicator of Sepsis

Goals for Treatment of Severe Sepsis and Septic Shock (EGDT)

Early identification

IV access

Treat infection with empiric antibiotics in a timely manner

Source control

Resuscitation with IV fluids and pressors if necessary(hemodynamic bundle)

Emergency supportive care for acute organ dysfunction

Infection prevention

Treating Sepsis and Septic Shock with FluidsIneffective arterial circulation in patients with severe sepsis and septic shock is due to vasodilatation associated with infection

Crystalloid fluid, such as normal saline can be administered at 30ml/kg over 30 minutes using a pressure bag.

Sepsis – Be A Member of the “Golden Hour” Club

“Sepsis Bundle.”

Lactate Levels

Blood Cultures

Antibiotic Use

And Fluid Resuscitation

Items that need to be completed within 6 hours:

Vaso-pressors for BP not responding to fluid,

Measurement of CVP and SCVO2, MAP,

Re-measure lactate if originally elevated.

Empiric Antibiotic Selection

When the potential infection source or pathogen is not obvious, BROAD SPECTRUM COVERAGE may be an appropriate empiric choice.

If Pseudomonas is NOT suspected:

Vancomycin + Meropenem or Pip/Taz

If Pseudomonas are suspected:

Vancomycin + 2 of the following

»Meropenem »Levofloxacin

»Pip/Taz »Aztreonam

Nurses Role in SepsisSevere Sepsis Screening begins on admission !!!

Recognize early signs and symptoms of sepsis

Re-assess patients at least every 12 hours

Utilize the SEPSIS SCREENING TOOL (Meditech)

SPEAK UP

Call a Code Sepsis

My Patient has a Positive Sepsis Screen – Now what do I do?

Notify your charge nurse / Sepsis Champion to review the screen

If positive call Code Sepsis

Notify the ER Physician / Hospitalist / Intensivest / PCP

Implement Sepsis Bundle

Move patient up to the next level of care

Add Problem to Plan of Care

Document Implementation of Sepsis Bundle

Increasing the use of appropriate treatment

Code Sepsis 1. Obtain a Lactated Level

2. Draw Blood Cultures

3. Give a broad spectrum Antibiotic

4. Normal Saline Bolus at a rate of 30cc / Kg / 30 minutes

5. Prepare for possible transfer to a Higher level of care: ICU

Increasing the use of Appropriate Treatment

(EGDT)Severe Sepsis without Shock

Check lactate q4hrs till less than 2 mmol / L

Check SCVO2

Optimal value is 70%

Tight Glucose Control

Watch for signs of Clinical Deterioration

Severe Sepsis with Shock

Initiate ICU Admission

Airway Management

Arterial Line

Flow-Trac for Hourly Hemodynamic Monitoring

CVP Placement (Pre-Sep Catheter)

CVP Monitoring

Foley Catheter

Tight Glucose Control

Start of Vasopressors

Why Monitor ScVO2Tissue hypoxia is often occult, reaching an advanced and lethal stage before its presence is known and resuscitation is attempted. Lactic Acid and ScVO2 measurements allow us to monitor occult tissue hypoxia.

Vital signs are inadequate for detecting global tissue hypoxia and not adequate as a resuscitation end point. Patients with normal blood pressure can still have global tissue hypoxia.

Up to 50% of patients resuscitated from shock may have continued global tissue hypoxia (Elevated lactate and decreased ScVO2) despite normalized vital signs and central venous pressure.

Vigileo

Precept Catheter

Flow Trac Catheter

Are you Septic Yet ?