Surviving Sepsis in the Emergency Department

Clinical ProjectErin Vitale RN, BSN

NUR 7203

Needs Assessment

Sepsis and septic shock are major healthcare problems

In the ED, symptoms may be vague and unclear

Older, younger, or immunocompromised individuals may present with subtle signs

Missing or delayed diagnosis results in greater mortality and morbidity

Timeliness and appropriateness of treatment is crucial

The need is to have staff recognize the time sensitive nature of diagnosis and treatment

Review of the Surviving Sepsis Guidelines by Society of Critical Care Medicine

Purpose

Recognize importance of obtaining regular vital signs

Thorough triage noteNotification of

physician, physician assistant, or nurse practitioner of any indwelling lines, catheters, or wounds

Update medical history including co-morbidities, immunocompromised state, vaccination status, and current medications

Thorough skin assessment noting wounds or rash

Audience

Entire healthcare team◦Physician◦Nurse Practitioner/Physician Assistant◦Residents, medical interns◦Nurse◦Respiratory therapy◦Patient care technician

To appropriately diagnose, treat, and improve outcomes= team effort!

Overview

Review the Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012 specific to the ED environment

Discuss the differences between sepsis, severe sepsis, and septic shock

Describe the different tests that will assist in guiding treatment

Review recommended treatments for ED

Definitions

Sepsis: confirmed or suspected infection with 2 or more of the following◦ General variables◦ Fever (> 38.3°C)◦ Hypothermia (core temperature < 36°C)◦ Heart rate > 90/min◦ Tachypnea◦ Altered mental status◦ Significant edema or positive fluid balance (> 20 mL/kg over 24 hr)◦ Hyperglycemia (plasma glucose > 140 mg/dL or 7.7 mmol/L) in the absence of diabetes◦ Inflammatory variables◦ Leukocytosis (WBC count > 12,000 µL–1)◦ Leukopenia (WBC count < 4000 µL–1)◦ Normal WBC count with greater than 10% immature forms◦ Plasma C-reactive protein more than two sd above the normal value◦ Plasma procalcitonin more than two sd above the normal value◦ Hemodynamic variables◦ Arterial hypotension (SBP < 90 mm Hg, MAP < 70 mm Hg, or an SBP decrease > 40 mm Hg in adults ◦ Organ dysfunction variables◦ Arterial hypoxemia (Pao2/Fio2 < 300)◦ Acute oliguria (urine output < 0.5 mL/kg/hr for at least 2 hrs despite adequate fluid resuscitation)◦ Creatinine increase > 0.5 mg/dL or 44.2 µmol/L◦ Coagulation abnormalities (INR > 1.5 or aPTT > 60 s)◦ Ileus (absent bowel sounds)◦ Thrombocytopenia (platelet count < 100,000 µL–1)◦ Hyperbilirubinemia (plasma total bilirubin > 4 mg/dL or 70 µmol/L)◦ Tissue perfusion variables◦ Hyperlactatemia (> 1 mmol/L)◦ Decreased capillary refill or mottling

Definitions

Severe sepsis◦ Sepsis-induced hypotension◦ Lactate above upper limits laboratory normal◦ Urine output < 0.5 mL/kg/hr for more than 2 hrs despite adequate fluid

resuscitation◦ Acute lung injury with PaO2/FIO2 < 250 in the absence of pneumonia as

infection source◦ Acute lung injury with PaO2/FIO2 < 200 in the presence of pneumonia as

infection source◦ Creatinine > 2.0 mg/dL (176.8 µmol/L)◦ Bilirubin > 2 mg/dL (34.2 µmol/L)◦ Platelet count < 100,000 µL◦ Coagulopathy (international normalized ratio > 1.5)

Septic Shock◦ Sepsis unresponsive to fluid resuscitation

Differential Diagnosis of Shock

Vasodilatory shock SepsisAnaphylaxisAdrenal insufficiencyNeurogenic

Low-output shock states Cardiogenic (eg, massive myocardial infarction, myocarditis, valvular disease)

Hypovolemic (eg, hemorrhagic, gastrointestinal losses, burns, pancreatitis)

Obstructive (eg, massive PE, tension pneumothorax, auto-PEEP, tamponade, abdominal compartment syndrome)

Differential Diagnosis of Shock

This is not an all inclusive list. However, important to recognize the variety of problems that can cause a shock state- not just sepsis

(Adapted from Felner & Smith, 2012)

A patient comes in and has abnormal vital signs and presentation that fulfil previously discussed sepsis criteria, now what? (hypotensive, febrile, etc.)

When suspecting sepsis…

2 peripheral IV saline lock

CBC with differential stat BMP stat Urinalysis and culture

stat ABG Oxygen as needed Place on continuous

heart monitor with 02 sat Document vitals

frequently including an initial temperature

Thorough history and physical

Imaging if appropriate (CXR, CT abdomen/pelvis, CT head)

Timely labs, imaging, and vitals results in a faster diagnosis and treatment!

Surviving Sepsis Bundle

For suspected or confirmed sepsis:

TO BE COMPLETED WITHIN 3 HOURS: LIKELY TO BE IN ED 1) Measure lactate level (gray tube on ice) 2) Obtain blood cultures prior to administration of antibiotics (2 sets), if cultures will

take greater than 45 minutes to obtain, administer antibiotics first . Wound cultures (if present) and send urine samples prior to antibiotic start

3) Administer broad spectrum antibiotics 4) Administer 30 mL/kg crystalloid for hypotension or lactate 4mmol/L

TO BE COMPLETED WITHIN 6 HOURS: LIKELY TO BE IN ICU SETTING 5) Initiate vasopressors (for hypotension that does not respond to initial fluid

resuscitation) for a goal of mean arterial pressure (MAP) ≥ 65 mm Hg 6) In the event of persistent arterial hypotension despite volume resuscitation (septic

shock) or initial lactate 4 mmol/L (36 mg/dL): - Measure central venous pressure (CVP)* - Measure central venous oxygen saturation (ScvO2)* 7) Re-measure lactate if initial lactate was elevated*

*Targets for quantitative resuscitation included in the guidelines are CVP of ≥8 mm Hg, ScvO2 of 70%, and normalization of lactate

Surviving Sepsis

During the first 6 hours of resuscitation goals should include a) CVP 8–12 mm Hg b) MAP ≥ 65 mm Hg c) Urine output ≥ 0.5 mL·kg·hr d) Superior vena cava oxygenation saturation (Scvo2) or mixed venous oxygen saturation (SvO2) 70% or 65%

Fluid resuscitation and treatments should be started in the ED if possible, do not delay until ICU admission

Routine evaluations of patients that are seriously ill for severe sepsis can allow earlier initiation of therapy. This includes re-evaluation of physical exam, vitals, and laboratory values

Antimicrobial Treatment

Administration of effective IV antibiotics within the first hour of recognition of septic shock and severe sepsis without septic shock as the goal of therapy

Initial empiric antibiotic therapy of one or more drugs that have activity against all likely pathogens (bacterial and/or fungal or viral) and that penetrate in adequate concentrations into tissues presumed to be the source of sepsis

Start broad, the admitting team will narrow down based on results and patient’s condition. Base antibiotics on most likely source (lungs vs urinary etc.)

Combination therapy for neutropenic patients with severe sepsis and for patients with difficult-to-treat, multidrug resistant bacterial pathogens

Combination therapy for

patients with severe infections associated with respiratory failure and septic shock

Antiviral therapy initiated as early as possible in patients with severe sepsis or septic shock of viral origin

Hemodynamic Stability

Initial fluid resuscitation of choice: crystalloids

May trial albumin if patient requiring significant amount of crystalloids

Norepinephrine (NE) is first choice vasopressor

Epinephrine is second agent (adjunct or replacement to NE)

Vasopressin can be adjunct to NE

Dopamine as an alternative agent to NE only in specific patients (eg, patients with low risk of tachyarrhythmia’s and absolute or relative bradycardia)

Dobutamine can be trialed if myocardial dysfunction present

Vasopressors should be going through a central line. Ideally, the patient will have an arterial line for BP monitoring

Sepsis in the ED

The primary goal for sepsis in the ED is early identification and treatment initiation

Transition to the ICU will likely be quick since septic patient requires obvious admission

Ordering and obtaining the initial appropriate testing and treatments is crucial to improving patient outcomes

Sepsis guidelines continue for the inpatient side and cover additional information

Sepsis Organ Failure and Mortality

Organ Failure Mortality

One lasting more than one day

20%

Two lasting more than one day

40%

Three lasting more than three days

80%

Table 138-2 Correlation between Organ Failure and Mortality in Sepsis

(Adapted from Felner & Smith, 2012)

Measurable Outcomes for the ED

Time from ED triage to presumptive diagnosis of severe sepsis is less than 2 hours

Time from ED triage to all patients’ meeting severe sepsis criteria having a serum lactate is less than 3 hours

Time from ED triage to appropriate antibiotics given is less than 1 hour

If hypotensive or if lactate > 4.0 mmol, fluid resuscitation is started within 1 hour

If MAP < 65 mmHg and not responsive to adequate fluid resuscitation, vasopressors are started immediately

Date of download: 3/24/2014 Copyright © 2012 McGraw-Hill Medical. All rights reserved.

Sepsis continuum: identifying patients at high risk of death. HR, heart rate; MAP, mean arterial pressure; MODS, multiple organ dysfunction syndrome; PaO2, arterial partial pressure of O2; RR, respiratory rate

Legend:

(Adapted from Ely & Goyette, 2005)

Summary(Adapted from Felner & Smith, 2012)

References

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Ginsberg J.S. (Eds), Principles and Practice of Hospital Medicine. Retrieved March 21, 2014 fromhttp://accessmedicine.mhmedical.com.ezproxy.libraries.wright.edu:2048/content.aspx?bookid=496&Sectionid=41304118Ferris L, English J.C., III (2012). Chapter 181. The Skin in Infective Endocarditis, Sepsis, Septic Shock, and Disseminated Intravascular Coagulation. In Goldsmith L.A., Katz S.I., Gilchrest B.A., Paller A.S., Leffell D.J., Wolff K (Eds), Fitzpatrick's Dermatology in General Medicine, 8e.Retrieved March 24,2014 fromhttp://accessmedicine.mhmedical.com.ezproxy.libraries.wright.edu:2048/content.asp x?bookid=392&Sectionid=41138908.Osborn, T., Nguyen, H., & Rivers, E. (2005). Emergency medicine and the surviving sepsis campaign: an

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