Sepsis: what every bedside nurse needs to know · Sepsis: what every bedside nurse needs to know...

Sepsis: what every bedside nurse needs to know

4/19/19

Mary C. Sullivan RN, MS, CNSSepsis Project ManagerUniversity of California San Francisco

Outline for today’s presentation

Where we came fromWhat is our current state?How to improve patient outcomes on your unit tomorrow

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Sepsis: A worldwide healthcare issue

§750,000 cases of severe sepsis diagnosed in the United States every year, comprise 10% of ICU admissions

§Septic Shock mortality is as high as 60%§Severe Sepsis and Septic Shock have high morbidity with survivors having reduced quality of life after hospitalization

§Evidence shows that when recognized early, outcomes for patients improve

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Where we came from……

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Old Sepsis Definitions §SIRS (Systemic Inflammatory Response System)

• Temp >38 or <36; HR >90 beats per minute; Respiratory Rate >20 breaths per minute; WBC count >12 or <4

§Sepsis

• Evidence of infection plus evidence of systemic response to infection (Tachypnea, Tachycardia, and Hyperthermia/Hypothermia)

§Severe Sepsis

• Clinical evidence of infection plus evidence of altered organ perfusion (at least one of the following: hypoxemia, elevated lactate, oliguria, altered mentation

§Septic Shock

• Sepsis Syndrome plus hypotension (Systolic blood pressure < 90 or decrease in Mean Arterial Blood Pressure > 40 from baseline

Original Rivers Study: NEJM 2001§Randomly assigned patient with severe sepsis or septic shock to receive either six hours of early goal directed therapy or standard therapy. • EGDT group- central line, CVP, ScVO2 goals, MAP

goals within 6 hours § In-hospital mortality was 30.5 % in the group assigned to early goal-directed therapy, as compared with 46.5 percent in the group assigned to standard therapy

§Conclusion: Early goal-directed therapy provides significant benefits with respect to outcome in patients with severe sepsis and septic shock.

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Surviving Sepsis Campaign

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§ Early goal-directed therapy in severe sepsis and septic shock revisited - Concepts, controversies, and contemporary findings - Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/figure/Algorithm-of-EGDT-Hct-hematocrit_fig3_6698563 [accessed 13 Mar, 2019]

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Sepsis: Current State

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Recent Sepsis Research §ProCESS (2014)- Protocol-based Care for Early Septic Shock

§ARISE (2014)- Australian Resuscitation in Sepsis Evaluation

§ProMISe (2015)- Protocolized Management in Sepsis• Concluded that EGDT does not show improved survival

with invasive hemodynamic resuscitation. Did not support the Surviving Sepsis Campaign Guidelines.

• Controversy with studies as newer studies benefit from overall improved processes in sepsis care, sepsis education, and screening.

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New Sepsis Definitions- 2016§Sepsis is now defined as life threatening organ dysfunction caused by a dysregulated host response to infection.

§Organ dysfunction is newly defined in terms of a change in baseline SOFA (sequential organ failure assessment) score.

§Septic shock is defined as the subset of sepsis with profound circulatory/cellular/metabolic abnormalities that increase mortality substantially – practically speaking, where vasopressors are needed to maintain MAP >=65 and where lactate remains >2 despite adequate fluid resuscitation.

§ Consensus from ESICM and SCCM – Singer et al, JAMA 2016

What is SOFA?Components Neurological Glasgow Coma ScaleCardiovascular Mean Arterial Pressure

Vasopressor UseRenal Serum Creatinine

Urine OutputRespiratory PaO2/FiO2 ratio

Mechanical VentilationHematological Platelet CountHepatic Serum Bilirubin

Surviving Sepsis CampaignUpdates

§Surviving Sepsis Campaign Hour-1 Bundle of Care Elements

‒ Measure lactate ‒ Obtain cultures prior to administration of antibiotics‒ Administer broad spectrum antibiotics‒ Administer 30 ml/kg crystalloid for hypotension or

lactate greater than or equal to 4 mmol/kg‒ Apply vasopressors if hypotensive during or after fluid

resuscitation. ‒ Re-measure lactate if initial lactate elevated.

(>2mmol/L)

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How to improve care on your unit as soon as your next shift….

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First: A Case For Prevention §Handwashing, gloving, gowning, isolation

§Nutrition§Foley removal§Central Venous Catheter care

§Surgical site prep§Attention to environmental surfaces cleaning

§Vaccinate

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Screening at the bedside §Qsofa (Quick SOFA)

• Systolic blood pressure ≤100 mm Hg• Altered mentation• Tachypnea– RR ≥22/min

• Provides simple bedside criteria to identify adult patients with suspected infection who are likely to have poor outcome.

• Useful for patients outside the ICU – does not require laboratory tests and can be assessed quickly and repeatedly.

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Sepsis Screening in the EHR

Sepsis Screening: Every Patient, Every Shift, Every Day

Checklists

§Examples readily accessible from SSC

§Easier to implement on unit

§Easy to adapt or change based on PDSA cycles

§One point in time

§Nurse may not appreciate changes over time

§Task that needs to be completed

§Use your institutional screens, policies, emergency procedures!

Clinical Decision Support

§Real time data

§Continually scanning the EHR

§Earlier identification to escalate treatments.

§One size does not fit all

§Erroneous data/late entries

§Resource dependent

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How to improve care on your unit as soon as your next shift….Break down the Bundle

LactateAntibioticsFluidsVasopressors

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Lactate:

Love §First step for nursing after

positive sepsis screens

§Many institutions use a Nurse drawn protocol

§Easy to obtain

§Results come back quickly

§Very helpful in detecting occult shock

Hate§Lacks precision

§Cannot be used to solely determine sepsis

§ May be overlooked; elevated results may be dismissed or rationalized as another process

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Lactate Protocol

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Case Study:

§66F w/ rectal cancer s/p sigmoid colectomy, c/b left ureteral injury s/p left nephrectomy w/ aborted autotransplantation

§POD #2- BP 90/50 lying, difficult to obtain temperature -eventually 93 degrees oral, low urine output with bolus x 2 already given overnight.

§Patient is exhausted, excruciating incisional pain upon sitting on edge of bed even with pre-medication

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And another Case Study

§43 yo with COPD on 2-3 L home O2, pulmonary HTN, substance abuse, DM, admitted for SOB

§HD #7- RR 24, HR 110, WBC 4.7, increasing from 3 liters to 6 liters O2.

§ Increased work of breathing, patient more altered and refusing blood draws

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Antibiotics: “Treat first, ask questions later”

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High mortality rate with delays in

antibiotics

Overtreatment can lead to adverse events

Nurse’s Role:• Early identification of at risk patient• Blood cultures before broadening• Quick administration of appropriate

antibiotic• Monitoring for reactions• Monitoring after initial treatment.

Critical Care Med 2006

Antibiotic choice

§Sepsis order sets help providers select broad spectrum antibiotics.• Allergy algorithms.• Special patient groups: heme onc, transplant• Hospital acquired versus community acquired

§All should be given STAT!§Antibiotic stewardship in an important part of treatment.§De-escalation is as important as escalation.

Based on patient factors, predicted infecting organism, resistance.

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Fluid resuscitation §Fluid resuscitation helps both the hypovolemic state along with the goal of increasing cardiac output to restore oxygen transport to cells.• No consensus as to the ideal composition of fluid • No consensus on ideal amount

§Evidence from randomized trials and meta-analysis have found no convincing difference between colloids and crystalloid.

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Fluid resuscitation

§Colloids

• Colloids exert an osmotic effect leading to the retention of fluid in the intravascular compartment.

§Crystalloids

• Most commonly used IV solution

• Liberal administration results in hyperchloremia and metabolic acidosis

§Balanced Crystalloids

• Best resemble constituents of human plasma, have minimal effect on the acid-base balance or chloride level.

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Vasopressor Selection §Vasopressors should be begun to target a mean arterial pressure of 65mmHg

§First line agent: Norepinephrine (Levophed)• Vasoconstriction without effect of HR, SV, CO

§Second line agent: Epinephrine §Third line agent: Vasopressin dosed at 0.03 units/min§Arterial line should be used for hemodynamic monitoring

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Deterioration and communication §Effective communication is an important aspect of patient care and has a profound effect on the health care quality and treatment outcomes.

§ A few tips for improving your communication on the unit:• Prepare your case• Anticipate what may be asked to help make a decision• Decide what you want to achieve • Structure (SBAR)• Be your patient’s advocate

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Post Sepsis Recovery

§Weakened immune system, increased risk for another infection.

§About 1/3 of patients will have another hospitalization within 3 months of sepsis episode.

§Other causes of readmissions include heart failure, kidney failure, aspiration.

§Patients are at a heightened risk of further medical setbacks after initial sepsis hospitalization

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Ongoing Sepsis Education For Your Patients

To Summarize §Using screening tools to identify sepsis early can impact mortality

§Lactate is an easy lab value that can help show tissue oxygenation mismatches, but must be used with the entire clinical picture.

§Continued vigilance for shock should be used after initial treatments.

§Care should be taken with inpatients transitions to home to decrease readmission rates.

§Educate your patients/familys/friends on what sepsis is and actions to take when they identify at home.

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MaryC.SullivanRN,MS,CNSUCSFSepsisProjectManagerMarycook.sullivan@ucsf.edu

MelissaLeeRN,MS,CNSClinicalNurseSpecialistMelissa.lee@ucsf.edu