Sepsis: Identification and Treatment

Transcription

1 Sepsis: Identification and Treatment Daniel Z. Uslan, MD Associate Clinical Professor Division of Infectious Diseases Medical Director, UCLA Sepsis Task Force

2 Severe Sepsis: A Significant Healthcare Challenge Major cause of morbidity and mortality worldwide Leading cause of death in noncoronary ICU (US) 1 10th leading cause of death overall (US) 2 * More than 750,000 cases of severe sepsis in the US annually 3 In the US, more than 500 patients die of severe sepsis daily 3 * Based on data for septicemia Reflects hospital-wide cases of severe sepsis as defined by infection in the presence of organ dysfunction 1.Sands KE, Bates DW, Lanken PN, et al. Epidemiology of sepsis syndrome in 8 academic medical centers. JAMA 1997;278: National Vital Statistics Reports Angus DC, Linde-Zwirble WT, Lidicker J, et al. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome and associated costs of care. Crit Care Med 2001;29:

3 Severe Sepsis Is Common Severe sepsis is more common than AIDS, colon cancer, and breast cancer combined Incidence Cases/100, AIDS 1 Colon Cancer 2 Breast CHF 3 Severe Cancer 2 Sepsis 4 1. National Center for Health Statistics, American Cancer Society, American Heart Association Angus DC, Linde-Zwirble WT, Lidicker J, et al. Epidemiology of severe sepsis in the United States: Analysis of incidence, outcome and associated costs of care. Crit Care Med. 2001;29(7):

4 What is Sepsis? Sepsis is a body s toxic response to an infection It is a medical emergency that requires early detection & treatment for survival 4

5 Severe Sepsis Physiology Microvascular dysfunction Inflammation Coagulation Fibrinolysis Hypoperfusion/hypoxia Microvascular thrombosis Endothelial dysfunction Organ dysfunction Global tissue hypoxia Direct tissue damage

6 Except on few occasions, the patient appears to die from the body's response to infection rather than from it." Sir William Osler 1904 The Evolution of Modern Medicine

7 The Nurse s Role Prevention of infection Early recognition of patients with signs of sepsis Early initiation of evidence-based practice therapies (bundle) for your area of practice (antibiotics, fluids/blood, and vasopressors) Swift disposition to care areas where the rest of the bundle can be started

8 Prevention of Infection Ventilator-associated pneumonia Hospital acquired pneumonia Central line-associated bloodstream infections Hand washing Are you currently working on strategies to prevent infections?

9 Early Recognition: A Screening Process TIME IS TISSUE!! If you identify patients early then you can intervene and prevent further tissue damage To screen effectively, it must be part of the nurses daily routine Must define a process for what to do with the results of the screen If you don t screen you will miss patients that could have benefited from the interventions

10 What is the difference: Sepsis, Severe Sepsis, Septic Shock 10

11 What does it look like? General Symptoms Fever Hypothermia Heart rate >90 beats per minute (bpm) Fast respiratory rate Altered mental status (confusion/coma) Edema (swelling) High blood glucose without diabetes Inflammatory High white count Low white count Immature white blood cells in the circulation Elevated plasma C-reactive protein Elevated procalcitonin (PCT) Hemodynamic Low blood pressure Low central venous or mixed venous oxygen saturation High cardiac index Organ Dysfunction Low oxygen level Low urine output High creatinine Coagulation abnormalities Absent bowel sounds Low platelets High bilirubin Tissue Perfusion High lactate Decreased capillary filling or mottling 11

12 What else should I look for? Symptoms of sepsis, severe sepsis and septic shock are subtle: Shivering, fever or very cold Extreme pain or general discomfort Pale or discolored skin Sleepy, difficult to rouse, confused Short of breath 12

13 Sepsis: An example _Sepsis_Case3_Part1.mp4 Package I_Sepsis_Case3_Part2.mp4 Package 13

14 Shouldn t the doctor know this? Yes! Sepsis is a relay race and time dependent, if the patient is septic you can see it before the doctor Early recognition is key Kumar A, et al. Crit Care Med. 2006;34: The care of the critically ill patient traverses patient location and depends on critical actions by multiple health care providers and must bridge care between specialties, departments and facilities Peter Safar, MD ( ) 14

15 I m important. What should I do? Answer = Early Identification + Early Treatment Early Identification: Include the evaluation for sepsis in all assessments Complete the sepsis screening tool upon admission and each shift Early Treatment: Implement Nurse Driven Protocol Implement 4 Bundle Elements 15

16 Early Identification: Sepsis Screening Tool For all in-patient units, complete on Admit and with each daily assessment ED - complete at time of triage 16

17 If all questions Yes = Positive Screen Initiate Sepsis Nursing Protocol! You have 60 mins to complete the protocol. If any question No = Negative screen Continue to monitor patient 17

18 Ok, there s a screening tool how are we doing? Not good, it s not being completed accurately. RRUMC SMH 18

19 Early Treatment: What should I do? Page the doctor Initiate the nurse driven protocol Draw blood cultures Draw lactate levels 19

20 Early Treatment: What should I do? 1. Serum Lactate level 2. Blood Cultures X 2 - prior to antibiotics 3. Administer Antibiotics within one (1) hour of time of presentation 4. Fluid Resuscitation - 20ml/kg bolus 20

21 Bundle Compliance - RRUMC 21

22 Bundle Compliance - RRUMC 22

23 Bundle Compliance - SMH 23

24 Bundle Compliance - SMH 24

25 215,000 Deaths/Year

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27 4 Things Blood cultures IV Antibiotics Lactate IV Fluids 20 ml/kg

28 A Sepsis Pilot Recognizes trouble before it start Follows standard operating procedures (SOP) / checklists. Does not take little things for granted. Understands the consequences: Immediate Long term Holds everyone accountable Takes personal responsibility for outcomes.

29 Are there resources? Sepsis Champion on unit = local expert Sepsis Website: Sepsis Coordinator in Quality Unit Director or CNS 29