SEVERE SEPSIS/SEPTIC SHOCK. Erica C. DeBoer BSN, MA,CCRN-K, CNL

Transcription

1 SEVERE SEPSIS/SEPTIC SHOCK Erica C. DeBoer BSN, MA,CCRN-K, CNL

2 OBJECTIVES Define severe sepsis and septic shock List core measure/early management steps for severe sepsis and septic shock Describe implementation strategies for compliance with core measures/early identification and management Discuss new literature related to early identification and prediction of severity Apply knowledge to case studies

3 SEPSIS IN THE HEADLINES

4 SEPSIS INCIDENCE, PREVALENCE & MORTALITY

5 SEPSIS OVERVIEW 18 million cases of sepsis worldwide each year Sepsis kills approximately 1400 people worldwide everyday Septicemia was the sixth most common principal reason for hospitalization in the U.S. with 836,000 hospital stays in 2009 Sepsis is a disease spectrum that starts with SIRS (systemic inflammatory response syndrome)

6 Sepsis Review: Disease Progression Insult SIRS Sepsis Severe Sepsis MODS Death Insult: Bacterial Viral Fungal Parasitic Infection Sepsis: SIRS + Infection Clinical response to insult with 2 of the following Temp > 38 C or < 36 C Heart Rate > 90 beats/min Respiration > 20 breaths/min or PaCO2 < 32mm Hg WBC > 12,000/mm3, < 4,000/mm3 or >10% immature bands Severe Sepsis: Sepsis induced hypotension LA >4 UO <0.5mL/kg/hr ALI <250 or <200 based on source Creat>2mg/dL Bili >2 Platelets <100,000 Septic Shock: Sepsisinduced refractory hypotension Dellinger, R P et al. CC Med. 2013

7 PREVALENCE AND INCIDENCE From 1993 to 2009, septicemia related hospital stays more than doubled, increasing by 153% overall, for an average annual increase of 6% The most common identified organism was E. coli for patients with a principal diagnosis of septicemia and MRSA for patients with a secondary diagnosis of septicemia Over 50% of septicemia cases had no organism identified Complication of device, implant, or graft was the most common principal reason for septicemia-related hospitalization(1 of every 5 sepsis related stays)

8 PREVALENCE AND MORTALITY Nearly 1 out of every 23 patients in the hospital (4.2 percent) had septicemia On average, 4,600 new patients per day were treated in U.S. hospitals for this condition In 2009, the in-hospital mortality rate for septicemia was about 16 % (8 times higher than other stays)

9 PREVALENCE AND MORTALITY Strikes more than 750,000 people each year in the US Mortality remains greater than 30% 1 person every 2.5 minutes! Mortality rate has not improved in the last 20 years Impacts Newborn, pediatric, adults, aged Morbidity Surgical sepsis rate is increasing

10 EARLY IDENTIFICATION MEANS EARLY TREATMENT Mortality decreases by 15% with early goal directed therapy For every 6 adults with septic shock who are treated effectively 1 death is prevented Every hour delay in receiving effective antibiotics is associated with 7.6% decrease in survival in adults with septic shock

11 SEPSIS BUNDLES AND CARE STANDARDS

12 SEPSIS BUNDLES

13 ABCS OF SEPSIS CARE A. Initial Resuscitation: Fluids Normalize lactate B. Screening for Sepsis and Performance Improvement C. Diagnosis Cultures Imaging studies to confirm source D. Antimicrobial Therapy Duration of therapy 7-10 days E. Source Control F. Infection Prevention

14 SEVERE SEPSIS IS COSTLY Septicemia was the most expensive reason for hospitalization in 2009 totaling nearly $15.4 billion in aggregate hospital costs Mean LOS days Mean cost/day- $2300 Mean cost/stay $18,500-33,900 AHRQ, 2011

15 THERE IS NO MASTER TREATMENT EARLY RECOGNITION IS THE KEY!

16 INFORM OTHERS ABOUT SEPSIS According to the polls conducted by the Sepsis Alliance, in 2015 an online survey of 2000 participants revealed that only 47% of Americans were aware of sepsis. (86% knew about Ebola and 76% about Malaria) (ABC Online, 2016) CDC recommendation for an acronym to teach others the signs of sepsis: S - Shivering, fever, or feeling very cold E - Extreme pain or general discomfort, as in worst ever P - Pale or discolored skin S - Sleepy, difficult to wake up or confused I - I feel like I might die S - Shortness of breath (CDC, 2015)

17 SEPSIS CORE MEASURE

18 DEFINITION Core Measure or Quality Measure: A set of care standards dictated by Centers for Medicare & Medicaid Services (CMS) that have been demonstrated to improve patient outcomes.

19 SEP-1 EARLY MANAGEMENT BUNDLE, SEVERE SEPSIS/SEPTIC SHOCK Denominator: Inpatients 18 years and older with any diagnosis of Sepsis, Severe Sepsis, or Septic Shock (not just principal diagnosis) and a length of stay < 120 days 28 ICD-10 codes Numerator: Patients meets all applicable elements in the table

20 SEP-1 EXCLUDED PATIENTS Patients receiving IV antibiotics for more than 24 hours prior to presentation of severe sepsis Administrative contraindication to care (refusal of lab draw, fluids, or antibiotics) Transfer in from another acute care facility Directive for Comfort Care within 3 hours of presentation of severe sepsis or 6 hours of septic shock Patients who expire within 3 hours of presentation of severe sepsis or 6 hours of septic shock

21 CORE MEASURE SEVERE SEPSIS Defining Criteria Documentation of a suspected source of clinical infection by a provider Two or more Systemic Inflammatory Response Syndrome (SIRS) criteria Organ Dysfunction Systolic blood pressure (SBP) < 90, or mean arterial pressure < 65, or a SBP decrease of > 40 mmhg from the last previously recorded SBP considered normal for that patient Acute respiratory failure (vent/bipap) Creatinine > 2.0, or urine output < 0.5 ml/kg/hour for 2 hours Bilirubin > 2 mg/dl (34.2 mmol/l) Platelet count < 100,000 INR > 1.5 or aptt > 60 sec Lactate > 2 mmol/l (18.0 mg/dl)

22 CORE MEASURE - SEPTIC SHOCK Severe Sepsis is present and tissue hypoperfusion persists in the hour after crystalloid fluid administration, evidenced by 1 of the following: Blood pressure, 2 consecutive readings: SBP < 90, or Mean arterial pressure < 65 or Decrease in SBP by > 40 points from the last previously recorded SBP considered normal for the patient Initial lactate level is >= 4 mmol/l (septic shock presentation time will be the same as severe sepsis presentation time)

23 Within 3 Hours of Presentation SEPSIS BUNDLES Severe Sepsis Bundle Initial lactate level measurement Broad spectrum or other antibiotics given Blood cultures drawn prior to antibiotics Septic Shock Bundle 3 treatments for severe sepsis plus: Resuscitation with 30 ml/kg crystalloid fluids Within 6 Hours of Presentation Repeat lactate level measurement only if initial lactate level is >2 mmol/l Repeat lactate level measurement only if initial lactate level is >2 mmol/l Volume status and tissue perfusion assessment consisting of either: o A focused exam including: Vital signs, AND Cardiopulmonary exam, AND Capillary refill evaluation, AND Peripheral pulse evaluation, AND Skin examination o Any two of the following four: Central venous pressure measurement Central venous oxygen measurement Bedside Cardiovascular Ultrasound Passive Leg Raise or Fluid Challenge Vasopressors (only required for persistent hypotension)

24 3 RD INTERNATIONAL CONSENSUS FOR SEPSIS AND SEPTIC SHOCK (SEPSIS-3) Seymour, C. W. et al (Feb 2016) JAMA

25 ASSESSMENT OF THE CLINICAL CRITERIA FOR SEPSIS To evaluate the validity of clinical criteria to identify patients with suspected infection who are at risk for sepsis Evaluated Sequential Organ Failure Assessment (SOFA), SIRS criteria, Logistic Organ Dysfunction System (LODS) and a new model Quick Sequential Organ Failure Assessment (QSOFA) 1.3 million electronic health record encounters from identified with suspected infection to compare criteria. Analysis was performed in 4 data sets of 706,399 out-of-hospital and hospital encounters at 165 us and non US hospitals from

26 CONCLUSIONS qsofa scores 2 or higher had a 3-14 fold increase in hospital mortality across baseline risk. (these findings were similar in ext. data sets) For the 24% of the encounters with infection with 2 or 3 qsofa points accounted for 70% of deaths, or ICU stays 3 days or longer The predictive validity for in-hospital mortality of qsofa was statistically greater than SOFA and SIRS suggesting that it can be used as a prompt to consider possible sepsis

27 QSOFA ELEMENTS Glascow Coma Scale ( score of 13 or less) Systolic BP of 100mmHg or less Respiratory Rate of 22/min or more (1 point for each) HAT Hypotension, Altered Mental Status and Tachypnea

28 NEW DEFINITIONS SUGGESTED Sepsis life threatening organ dysfunction caused by dysregulated host response to infection. Increase in the SOFA score of 2 or more Septic Shock subset of sepsis in which profound circulatory, cellular, and metabolic adnormalities are associate with greater risk of mortality. Require vasopressor to maintain MAP of 65mmHg and serum lactate level great than 2 mmol/l in the absence of hypovolemia

29 TIME FOR SOME SCENARIOS

30 SCENARIO 1 35 year old female who presented to the emergency department with abdominal pain rated at 9 and a fever of 101. Patient has no significant medical history and takes a multivitamin daily. No other medications or supplements. NKDA Occasional alcohol use and no tobacco use or drug use.

31 WHAT ARE THE TOP THREE PIECES OF INFORMATION YOU WANT TO KNOW? A. WBC, Current VS, physical exam B. Better pain description, BMP, HCG C. ABG, Lactic Acid, Liver enzymes D. Drug test, Blood alcohol level, CBC

32 VITAL SIGNS AND OTHER ASSESSMENT FINDINGS Physical Exam: Right Upper Quadrant Pain Currently menstruating and on birth control WBC 18,000 Vital Signs: HR 120 RR 28 BP 120/80 Temp 101

33 WHAT IS THE NEXT TEST YOU WOULD RECOMMEND? A. MRI of abdomen B. Ultrasound of abdomen C. CT of abdomen D. HCG

34 FOLLOWING THE CT Upon return from CT pain continues at 7 out of 10 Fentanyl 50 mcg given X2 with minor relief CT of the abdomen revealed significant inflammation of the appendix

35 OTHER INTERVENTIONS AND ASSESSMENT DETAILS 650 mg Tylenol given Antibiotics started Pain assessment reveals that pain has now subsided (out of proportion to the pain meds given)

36 WHAT IS THE MOST APPROPRIATE NEXT INTERVENTION? A. Admit the patient for observation B. Schedule ultrasound to eliminate gynecological cause C. Prepare for emergent surgery D. If pain remains controlled, discharge the patient with instructions to follow up with primary care provider

37 POST OP REPORT Patient was taken emergently to the OR for lap appy Surgery revealed a ruptured appendix Irrigation to the abdomen cavity completed Tolerated the procedure and recovery well Transferred to med/surg unit Post Op VS: Temp BP 100/62 HR 110 RR 20

38 CURRENT STATUS Over night the patient was medicated for surgical site pain and Tylenol for fever; vital signs are currently: Temp Pulse 110 RR 20 BP 82/54 LOC Alert MEWS score?

39 Temp < >101.4 Pulse < RR Blood Pressure < >220 LOC New Agitation/Conf usion Alert Responds to Voice Responds to Pain Unresponsive SCORING SYSTEM

40 MEWS OF 4 Actions: Continuous monitoring Sepsis BPA fired; Lactic Acid and BC drawn Notify the CCC Notify the provider Plan to reassess

41 WHAT DO YOU ANTICIPATE AS THE NEXT INTERVENTION? A. Lactic acid B. Start a vasopressor C. Antibiotic administration D. Fluid resuscitation

42 WHAT IS THE CORRECT FLUID RESUSCITATION FORMULA? A. 10 ml/kg B. 20 ml/kg C. 30 ml/kg D. 40 ml/kg

43 INTERVENTION AND RESPONSE Patient weighs 82 kg = 2500mL of 0.9% Normal Saline Transferred to the ICU for further monitoring CL placed and CVP revealed 2 Lactic Acid 3.8 She is started on 4 L NC

44 ADD QUESTION HOW WOULD YOU DEFINE HER CURRENT STATE? A. SIRS B. Severe Sepsis C. Septic Shock D. Multiple Organ Failure

45 OTHER ANTICIPATED INTERVENTIONS? Repeat LA in 6 hours Consider additional IV fluid boluses for SBP less than 90; MAP less than 60 Ensure antibiotics are ordered Focused assessment and continuous monitoring

46 SCENARIO 2 95 year old female, admitted through the ED from a Nursing Home History of UTI and currently on oral antibiotics Placed on O2 at the nursing home yesterday, not eating or drinking and has become unresponsive Upon admission to the ED her VS were: BP 70/40 Pulse130 Temp103 Labs WBC 11 Plan to Admit to CC with a diagnosis of severe sepsis

47 WHICH IS NOT REQUIRED TO BE COMPLETED WITHIN THE FIRST THREE HOURS A. Labs and Cultures B. Fluid Resuscitation C. Antibiotics Administered D. Foley Placement

48 WHAT OTHER INFORMATION DO YOU WANT TO KNOW? A. Antibiotics Started B. Amount of Fluid Given and Response C. Are the Lactic Acid and Blood cultures drawn? D. All of the Above

49 CRITICAL CARE Upon arrival to the CCU: 2 L of fluids given in the ED NS now hanging at 150 ml/hr Lactic Acid 2.8 Blood Cultures Drawn Broad spectrum antibiotics given in the ED AND continued upon admission Current VS: BP 80/36 HR 120 RR 12 Unresponsive Increasing O2 needs

50 WHAT IS YOUR BEST NEXT INTERVENTION? A. Give an IV Fluid Bolus B. Start Vasoactive Agent C. Start a Central Line D. Intubate the Patient

51 INTERVENTION AND RESPONSE Give an additional bolus of IV fluids and continue to monitor for hypotension A central line and artline are placed CVP is 9 MAP is 50 The provider decides to prepare for intubation

52 BASED ON THIS DATA YOUR NEXT INTERVENTION? A. Administer Another Fluid Bolus B. Start a Vasoactive Agent C. Place a Foley to Monitor Urine Output D. Verify Advanced Directive/Living Will

53 WHICH VASOACTIVE AGENT SHOULD YOU ANTICIPATE? A. Dopamine B. Epinephrine C. Levophed D. Vasopressin

54 VASOACTIVE AGENTS Levophed (norepinephrine) first line agent Epinephrine added to and potentially a substitute for Levophed Vasopressin 0.03units/minute added to Levophed; not recommended for single therapy Dopamine as alternative to Levophed only in patient with low risk of tachyarrhythmias and bradycardia Inotropic Agent: Dobutamine - 20mcg/kg/min for low CO and ongoing signs of hypoperfusion

55 SCENARIO 3 73 yo male admitted to pulmonary with history of COPD and probable pneumonia Requires 2L Home O2, increasing needs to 6L with O2 saturations of 85% currently Current VS: BP 100/50 Pulse 133 Temp 102 RR 25 Altered mental status (A/O to self only)

56 TRANSFERRED TO CRITICAL CARE Placed on BiPAP Central Line Artline Placed Following Transfer VS are: BP 80/45 Pulse 125 Temp 102 RR 26 O2 saturations 87% on 60% BiPAP

57 IDENTIFY NEXT REQUIRED INTERVENTION A. Start fluid resuscitation, BC and LA B. Start vasopressors, sputum culture, bronch C. Chest CT, PA cath, foley D. Check code status, set up for IAH, check procalcitonin

58 CURRENT STATUS IV Fluid Bolus Patient weighs 92 kg = 2800mL Normal Saline bolus Blood cultures and Lactic Acid drawn Antibiotics continued

59 CURRENT CVP IS 4. BP 82/54. WHAT IS THE MOST APPROPRIATE INTERVENTION? A. Administer 500 ml of Albumin B. Initiate Levophed gtt C. Administer 500 ml NS D. Give 1 unit PRBC

60 BRING YOUR SEPSY BACK! BCD8

61 REFERENCES Alsolamy, S., Al Salamah, M., Al Thagafi, M., Al-Dorzi, H. M., Marini, A. M., Aljerian, N., & Arabi, Y. M (2014). Diagnostic accuracy of a screening electronic alert tool for severe sepsis and septic shock in the emergency department. BMC Medical Informatics & Decision Making, 14(1), p. doi: /s American Heart Association Heart and Stroke Statistical Update. Armstrong et al. Results of Implementing a Rapid Response Team Approach in Treatment of Shock in a Community Hospital. 43 rd Annual Meeting of IDSA,Oct 2005 Dellinger et al, Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 2013; 41; Dellinger et al, Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 2004; 32; Wier, L.M., Levit, K., Stranges, E., Ryan, K., Pfuntner, A., Vandivort, R., Santora, P., Owens, P., Stocks, C., Elixhauser, A. HCUP Facts and Figures: Statistics on Hospital-Based Care in the United States, Rockville, MD: Agency for Healthcare Research and Quality, 2010 (

62 REFERENCES Freund, Y et al Biomarkers Nov;17(7):590-6.doi: / X Epub 2012 Jul 21. Hall, M. J., Williams, S. N., DeFrances, C. and Golosinskiy, A (2011) Inpatient Care for Septicemia or Sepsis: A Challenge for Patients and Hospitals. National Center for Health Statistics Kissoon, N. Critical Care 2014, 18:207 Mack, R. (2015). Sepsis: The New Core Measure in Is your Hospital Ready? Peake, S. L., Delaney, A., Bailey, M., Bellomo, R., Cameron, P. A., Cooper, D. J., &... Williams, P.(2014). Goal-directed resuscitation for patients with early septic shock. New England Journal Of Medicine, 371(16), p. doi: /nejmoa Seymour, C. W.; Liu, V. X.; Iwashyna, T. J., et al (2016). Assessment of Clinical Criteria for Sepsis. For the Third International Consensus Definitions for Septic Shock (Sepsis-3) JAMA; 315 (8): doi: /jama Sepsis and Singer,M.; Deutschman, C. S.; Seymour, C. W.; et al. (2016). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) JAMA; 315 (8): doi: /jama Shankar-Hari, M.; Phillips, G. S.; Levy, M. L.; et. al (2016). Developing a New Definition and Assessing New Clinical Criteria for Septic Shock. For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) JAMA; 315 (8): doi: /jama