Sepsis: Identification and Management in an Acute Care

Sepsis: Identification and Management in an Acute Care

Sepsis: Identification and Management in an Acute Care Setting Dr. Barbara M. Mills DNP Director Rapid Response Team/ Code Resuscitation Stony Brook University Medical Center SEPSIS LECTURE NPA 2018 OBJECTIVES

To understand and be able to identify the differences between SIRS, Sepsis, Severe Sepsis, and Septic Shock. To understand the morbidity and mortality of Sepsis in relation to length of stay, current guidelines, cost to health care systems. To understand modalities of treatment which include management, such as fluid

resuscitation and pharmacological interventions. In-hospital death 8X higher compared to other diagnoses .http://www.cdc.gov/nchs/data/databriefs/db62.pdf accessed August 7, 2015 Sepsis Bundle Project (SEP) National Hospital Inpatient Quality Measures SEP-1 Early Management Bundle,

Severe Sepsis/Septic Shock Discharges 10-01-2015 (4Q15) through 06-30-16 (2Q16) 7 SEPSIS ECONOMICS Sepsis is a major and economically significant disease in the ICU, costing over $20 billion in the United States in 2011 (5.2% of all U.S.

hospital costs) with costs growing to over $23 billion in 2013 (6.2% of all U.S. hospital costs) SEPSIS ECONOMICS Sepsis: major health problem with increasing prevalence, high costs, and poor

outcomes. SEPSIS ECONOMICS Increased hospitalizations for more than 1 million people in 2008 SEPSIS ECONOMICS Between 1999 and 2014: 2,470,666 deaths with sepsis on the death certificate with

increase annual sepsis related deaths by 31% SEPSIS ECONOMICS Severe Sepsis and Septic Shock are subsets of sepsis conditions with at least one organ dysfunction, which accounts for 25-50% of in-hospital mortality

SEPSIS ECONOMICS that can range with a 45%65% mortality within 6 months of discharge. INFECTION INFECTION SEPSIS INFECTION

SEVERE SEPSIS SEPSIS Those who survive tend to have increasing complications, morbidity, high costs of care,

and decreasing quality of life. HISTORICAL PERSPECTIVE Source: CHEST 1992 SIRS Criteria ( > 2) Temperature > 38 C < 36 C Heart rate > 90 bpm Respiratory rate > 20 /min

or a PaCO2 < 32 mmHg White blood cell count > 12,000 / cu mm or < 4,000 / cu mm, or > 10 bands NEW SEPSIS DEFINITION Guidelines were revised in 2008, 2012, and most recently updated in 2015. These guidelines have shaped how

hospitals must identify and treat patients who are identified as having sepsis, severe sepsis, and septic shock. NEW SEPSIS DEFINITION The Surviving Sepsis Campaign (SSC) international guidelines were developed for early detection and treatment of severe sepsis and

septic shock NEW SEPSIS DEFINITION Sepsis is a life threatening organ dysfunction caused by a dysregulated host response to an infection. The European Society of Intensive Care Medicine/Society of Critical Care Medicine Third International Consensus definitions for Sepsis and Septic Shock task force (the Sepsis-3 task force)

NEW SEPSIS DEFINITION Persistent hypotension requiring vasopressors to keep MAP > 65 mmHg despite adequate fluid resuscitation Serum lactate > 2 mmol/L JAMA 2016 SEPSIS SCORING TOOL QUICK SOFA / QSOFA

> 22/ min SBP 100mmHg In patients with infection a qSOFA score > 2 is associated with higher mortality and prolonged ICU stay. RESEARCH TRIALS

ProCESS ARISE Enrollment <2 hours from detection of shock 2.8 hours (median) from presentation

to ED Antibiotics 75% received prior to enrollment Fluids 70 minutes (median) from

presentation to ED 2515ml (mean) >2 liters prior ot prior to enrollment enrollment SEP-1 TWO CLOCKS 3 hour

SEP-1 TWO CLOCKS SEP-1: EARLY MANAGEMENT BUNDLE 6 hr. Sepsis 3 hr. Severe

Time Zero Interventions Required: Blood culture before antibiotics Antibiotics Lactate level Interventions Required: Lactate level repeated (If elevated) Set Measure ID # SEP-1-8; Early Management Bundle, Severe Sepsis/Septic Shock

SEP-1 TWO CLOCKS TO BE COMPLETED WITHIN 3 HOURS OF TIME OF PRESENTATION: 1. Obtain blood cultures prior to administration of antibiotics. 2. Measure lactate level. 3. Administer broad spectrum antibiotics. 4. Administer 30ml/kg crystalloid for hypotension, defined as a mean arterial pressure MAP<65 or lactate 4mmol/L.

2012 NQF: SEPSIS 0500 SEP-1 TWO CLOCKS Focused Exam SEP-1 TWO CLOCKS Delays in administering all four guidelines recommendations, even when they did not exceed 3 hours, were associated with

a significant increase in in-hospital mortality. SCCM journal April 2018. Volume 46. Number 4 SEPTIC SHOCK ONLY 6 hr. 33 hr. hr. Severe Sepsis

Time Zero Interventions Required: Persistent Hypotension Within 1 hour of fluid add VASOPRESSOR Persistent Hypotension OR Lactate > 4 Shock Assessment (1 of 2) Interventions Required: ALL of Severe Sepsis +

Fluid 30 ml/kg (NO exclusionary criteria) Shock Assessment Physical Exam (ALL)

Vital Signs (T, HR, RR, BP) Cardiopulmonary exam Capillary refill evaluation Peripheral Pulse evaluation Skin evaluation Hemodynamics (2 of 4)

CVP SVO2 Bedside cardiovascular ultrasound Passive leg raise / fluid challenge SEP-1 TWO CLOCKS TO BE COMPLETED WITHIN 6 HOURS OF TIME OF PRESENTATION: 1. Apply vasopressors (for hypotension that

does not respond to initial fluid resuscitation to maintain a mean arterial pressure (MAP) 65mmHg) 2012 NQF: SEPSIS 0500 MEAN ARTERIAL PRESSURE 65 mm Hg 75 mm Hg 85 mm Hg Urinary output (mL)

49 +18 Capillary blood flow (mL/min/100 6.0 + 1.6 g) Red Cell 0.42 + Velocity (au) 0.06 Pico2 (mm Hg) 41 + 2

13 + Pa-Pico2 (mm Hg) 3 56 + 21 5.8 + 11 0.44 +016 47 + 2

17 + 3 F/LT 43 +13 .60/.71 5.3 + 0.9 .59/.55

0.42 + 0.06 .74/.97 46 + 2 .11/.12 16 + 3 .27/.40 Adapted from Table 4, page 2731, from LeDoux, Astiz ME, Carpati CM, Rackow ED. Effects of perfusion pressure on tissue perfusion in septic shock. Crit Care Med 2000; 28:2729-2732

SEP-1 TWO CLOCKS TO BE COMPLETED WITHIN 6 HOURS OF TIME OF PRESENTATION: 2. In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate 4 mmol/L (36mg/dl): Measure central venous pressure (CVP) Measure central venous oxygen saturation (ScvO2) 3. Remeasure lactate if elevated

2012 NQF: SEPSIS 0500 FLUID RESUSCITATION RESEARCH SUPPORTING FLUID RESUSCITATION BUNDLE CHOICE OF FLUIDS Crystalloids Ringers

Lactate Normal Saline Colloids Gelatins Albumin Hetastarch IV FLUID COMPOSITIONS

Crystalloids 0.9% NaCl Lactated Ringer's (LR) Hartman's Ringer's Acetate (RA) Plasma-Lyte/Normosol-R Na+ 154 130 131

130 140 mEq/L ClLactate 154 0 111 29 109 29 112

0 98 0 Acetate 0 0 0 27 27 FLUID REPLACEMENT

CHALLENGES End Stage Renal Disease on Dialysis Compensated Congestive Heart Failure HEMODYNAMIC CHANGES IN SEPTIC SHOCK

Interstitial Edema in Septic Shock Lungs Brain Kidney Dellinger RP. Cardiovascular management of septic shock. Crit Care Med 2003;31:946-955. During Septic Shock

End Diastole End Systole 10 Days Post Shock End Diastole End

Systole Courtesy of Joe Parrillo Hackensack NJ RESEARCH RECOMMENDATION SCCM recommends that, in the resuscitation of sepsis-induced hypoperfusion, at least 30 ml/kg of IV crystalloid fluid be given within the first 3 hours (strong recommendation, low quality of evidence).

ANTIBIOTIC THERAPY Started within 3 hrs after severe sepsis presentation Monotherapy vs. Combination Therapy COMBINATION THERAPY

Choose Aminoglycosides or Aztreonam or Ciprofloxacin Cephalosporins, (1st and 2nd Generation) - or Clindamycin - or - Daptomycin - or Glycopeptides - or - Linezolid - or Macrolides - or - Penicillins CHOICE OF VASOPRESSERS First Line Norepinephrine

Second Line Epinephrine Niche Drugs Dopamine (sinus bradycardia)

Low Dose Vasopressin (.01-.03 units/min) Phenylephrine (high cardiac output or serious tachyarrhythmias and salvage) SURVIVING SEPSIS CAMPAIGN 2016

We suggest against using IV hydrocortisone to treat septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability. If this is not achievable, we suggest IV hydrocortisone at a dose of 200 mg per day SURVIVING SEPSIS CAMPAIGN 2016 No ACTH stimulation tests or serum cortisol

testing No additional mineralocorticoid 7 days Taper WHAT DO WE KNOW? Hydrocortisone provides adequate glucocorticoid and mineralocorticoid effects so fludrocortisone is not needed. Tapering of steroids is recommended. Although the current hypothesis for the use

of steroids in septic shock is to treat relative adrenal insufficiency, current evidence suggests no value in measuring this with a corticotropin response test. WHAT DO WE KNOW? Steroids are of no benefit in the treatment of severe sepsis in the absence of shock. Low dose steroid therapy reduces time to reversal of septic shock Still controversial as to whether or not there

is a meaningful reduction in mortality. The more severely ill and hemodynamically unstable the patient is the more likely to benefit from stress-dose steroids. TO SAVE LIVES..... Early identification Early antibiotics Early fluid resuscitation

Thank You!

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