STOP Sepsis6-hour Strategies to Timely Obviate the Progression of Sepsis

6-hour STOP Bundle

Early Goal-Directed Therapy

in the Treatment of Severe Sepsis and Septic

Shock

PathophysiologySepsis is a condition in which organisms enter into the bloodstream,causing activation of the host inflammation defense mechanism →release of cytokines and the activation of plasma protein cascade systems→ septic shock → multisystem organ failure. Cancer patients are at anincreased risk for sepsis due to ↓ WBC and poor immune systems.

Systemic Inflammatory Response Syndrome

• Temp < 36 ° C or > 38.3 ° C• HR > 90• RR > 20 or PCO2 < 32• WBC < 4K or > 12K or bands >

10%

SepsisSepsisSIRSSIRS Severe SepsisSevere Sepsis Septic ShockSeptic Shock

Bone et al. Chest 1992;101:1644

SepsisSIRS Severe Sepsis Septic Shock

Bone et al. Chest 1992;101:1644

SIRS with Infection

SepsisSIRS Severe Sepsis Septic Shock

Bone et al. Chest 1992;101:1644

Sepsis plus Organ Dysfunction

• Elevated Creatinine (>2)• Elevated INR (DIC)• Altered Mental Status (GCS

<12)• Elevated Lactate (>4)• Hypotension that responds

to fluid

SepsisSIRS Severe Sepsis Septic Shock

Bone et al. Chest 1992;101:1644

Severe Sepsis and Hypotension

• Hypotension that does NOT respond to fluid (500 cc bolus)

Diagnostic Tests■ CBC with differential ( or ↓ WBC)■ Serum chemistries, bilirubin, serum lactate (increased), liver functiontests (abnormal), and protein C (decreased)■ Insulin resistance with elevated blood glucose■ ABGs (hypoxemia, lactic acidosis)■ Urine, sputum, wound, and blood cultures■ Activated partial thromboplastin time (increased), international normalized ratio (increased), and D-dimer (increased)

Criteria to initiate the bundleSIRS plus source of

infection plus a

• SBP < 90 mmHg after a 20 mL/kg fluid bolus

• Lactate > 4 mmol/L• Organ dysfunction

STOPSEPSIS

STOP Bundle Strategies

• Hemodynamic monitoring (CVP/ScvO2) within 2 hours

• Broad spectrum antibiotics administered within 4 hours

• EGDT achieved at 6 hours, including CVP ≧ 8

mmHg, MAP ≧65 mmHg, ScvO2 ≧70%

• Monitor for decreasing lactate; and administer steroid if on a vasopressor

Sepsis Resuscitation BundleWithin 6 hours of diagnosis of severe sepsis:■ Measure serum lactate.■ Obtain blood cultures prior to antibiotic administration.■ Administer broad-spectrum antibiotic within 3 hours of ED admissionand within 1 hour of non-ED admission.■ If hypotension is present and/or serum lactate is >4 mmol/L,deliver an initial minimum of 20 mL/kg of crystalloid or equivalentand administer vasopressors for hypotension not responding tofluid resuscitation to maintain mean arterial pressure (MAP) at>65 mm Hg.■ In the case of persistent hypertension and/or elevated lactate levels,achieve a central venous pressure (CVP) of >8 mm Hg, and a centralvenous oxygen saturation of >70% or a mixed venous oxygensaturation of >65%.

Sepsis Management BundleWithin 24 hours of presentation with severe sepsis or septic shock:■ Administer low-dose steroids for septic shock.■ Administer drotrecogin alpha (activated).■ Maintain glucose control at >70 but <150 mg/dL.■ Maintain a median inspiratory plateau pressure of <30 cm H2O formechanically ventilated patients.

Other Nursing Care■ Assess vital signs and consider arterial line placement. Monitor meanarterial pressure and maintain at >65 mm Hg.■ Support BP by administering vasopressors (e.g., vasopressin,Levophed, dopamine).■ Assess hemodynamic status. Consider pulmonary artery catheterplacement. Maintain CVP at 8–12 mm Hg.■ Assess respiratory status.■ Monitor ABGs and note ↓ pH, ↓ PaO2, and PaCO2.

■ Administer O2 via nasal cannula, mask, or mechanical ventilation. Useminimum positive end-respiratory pressure to achieve tidal volumeand end-inspiratory plateau pressure goals.■ Position patient to promote optimal O2 exchange. Reposition every2 hours.■ Institute skin care protocols.■ Keep head of bed (HOB) elevated 45°.

■ Institute ventilator-associated pneumonia precautions if patient is onmechanical ventilation.■ Treat fever if present.■ Assess neurologic status for changes in mentation.■ Insert Foley catheter and monitor intake and output. Maintain urineoutput at >0.5 mL/kg/hr.■ Administer IV colloids and crystalloids, and fluid challenge asnecessary. Assess fluid and electrolyte balance.

■ Assess nutritional status. Provide enteral feeding or total parenteralnutrition (TPN) and lipids.■ Perform cortisol stimulation test. Start continuous low-dose steroidinfusion.■ Administer antibiotics within 1 hour of sepsis diagnosis, and re-evaluate 48–72 hours afterward.■ Administer vasopressors and inotropes. Consider Vasopressin for refractory shock.

■ Monitor blood glucose levels and maintain tight glucose

control at 80–110 mg/dL. Consider insulin infusion.

■ Administer platelets if platelet count is <5,000/mm3.

■ Institute stress ulcer and DVT prophylaxis.

■ Prevent nosocomial infections.

■ Sedate patient as necessary.

■ Administer drotrecogin alfa (Xigris): An anticoagulant,

profibrinolytic,anti-inflammatory agent.

Fever, general malaise, poor appetite for days

DM, HTN

70/40 mmHg, 39 ° C

Thank you