nt isepsis

New Treatments for an Ongoing Problem

Steven Marshall, RNIII, CCRNChip Harris, RN, BSN

Moses Cone Surgical ICU – 2300

Sepsis

Material From:Sepsis: New Insights to the Most Lethal Condition in Acute and Critical Care (NTI 2010 Mastery Session)

Incidence, Pathogenesis, and Management of Sepsis. An Overview (AACN Advanced Critical Care Article, Volume 17, Number 4, 2006)

Sepsis: Stopping an Insidious Killer (American Nurse Today Article, January 2007)

Signs of systemic inflammatory response syndrome SIRS include:

a. respiratory acidosisb. painc. hypotensiond. tachypnea

Signs of systemic inflammatory response syndrome SIRS include:

a. respiratory acidosisb. painc. hypotensiond. (tachypnea)

What is the definition of sepsis?

a. infection plus multi organ dysfunctionb. inflammation with high wbcc. infection as the cause of sirsd. presence of positive blood cultures

What is the definition of sepsis?

a. infection plus multi organ dysfunctionb. inflammation with high wbcc. (infection as the cause of sirs)d. presence of positive blood cultures

Which is the treatment of sepsis?

a. hydrocortisone 300mg qd if hypotension resistant to pressorsb. activated protein cc. arachidonic acid inhibitorsd. fluids to keep scvo2 > 70%

Which is the treatment of sepsis?

a. hydrocortisone 300mg qd if hypotension resistant to pressorsb. (activated protein c)c. arachidonic acid inhibitorsd. fluids to keep scvo2 > 70%

What lab test do you want with suspected sepsis?

a. protein cb. procalcitoninc. serum sodiumd. lactate

What lab test do you want with suspected sepsis?

a. protein cb. procalcitoninc. serum sodiumd. (lactate)

A patient is at risk for sepsis when receiving:

a. insulinb. antibioticsc. vasopressorsd. steroids

A patient is at risk for sepsis when receiving:

a. insulinb. (antibiotics)b. (antibiotics)c. vasopressorsd. steroids

What is the first treatment for suspected sepsis?

a. antipyreticsb. activated protein cc. vasopressorsd. fluids

What is the first treatment for suspected sepsis?

a. antipyreticsb. activated protein cc. vasopressorsd. (fluids)

What is the most common organ to fail?

a. pulmonaryb. renalc. cardiovasculard. central nervous system

What is the most common organ to fail?

a. (pulmonary)b. renalc. cardiovasculard. central nervous system

Which of the following is true with activated protein c administration in pt with severe sepsis?

a. patient must have failed all other txb. based on new research xigris is currently not indicatedc. patient must be at high risk of deathd. any patient with sepsis is a candidate for activated protein c

Which of the following is true with activated protein c administration in pt with severe sepsis?

a. patient must have failed all other txb. based on new research xigris is currently not indicatedc. (patient must be at high risk of death)d. any patient with sepsis is a candidate for activated protein c

What is the least valuable tool for rapid response nurse?

a. capnographyb. stethoscopec. point of care lactate, glucose, phd. non invasive stroke volume monitor

What is the least valuable tool for rapid response nurse?

a. capnographyb. (stethoscope)c. point of care lactate, glucose, phd. non invasive stroke volume monitor

How many patients will die of bleeding after receiving protein c?

a.<1/2 of 1%b. 5-10%c. 25%d. 30-40%

How many patients will die of bleeding after receiving protein c?

a.(<1/2 of 1%)b. 5-10%c. 25%d. 30-40%

Why is sepsis so difficult to recognize?

a. very similar to blood stream infectionb. infrequent and overlookedc. presents with subtle signsd. sepsis has no common pattern in how it presents

Why is sepsis so difficult to recognize?

a. very similar to blood stream infectionb. infrequent and overlookedc. (presents with subtle signs)d. sepsis has no common pattern in how it presents

Which of following statement regarding fluid resuscitation in severe sepsis is most correct?

a. both crystalloid and colloid may be usedb. ns is superior to lrc. albumin should not be usedd. hespan has been associated with improved outcome comp to ns

Which of following statement regarding fluid resuscitation in severe sepsis is most correct?

a. (both crystalloid and colloid may be used)b. ns is superior to lrc. albumin should not be usedd. hespan has been associated with improved outcome comp to ns

Which area has the most sepsis cases?

a. icub. hosp floorc. edd. nursing homes

Which area has the most sepsis cases?

a. icub. hosp floorc. (ed)d. nursing homes

Which is the best method to improve outcomes?

a. appropriate use antibioticsb. activated protein cc. prevention of infectiond. use of fluids early in sepsis

Which is the best method to improve outcomes?

a. appropriate use antibioticsb. activated protein cc. (prevention of infection)d. use of fluids early in sepsis

Sepsis is subtle until it is so obvious you can't

miss it

For a diagnosis of SIRS (Systemic Inflammatory Response Syndrome), you need to have 2 of the following criteria:

Tachycardia Tachypnea

Wbc >12 <4 Hypothermic or Hyperthermic

Sepsis is SIRS plus documented or presumed

source of infection

-No need for positive cultures-Only 50% Pneumonias grow

out an organism

Septicemia is infection of the blood stream but is not necessary for sepsis and no

longer a used term

Patients get sick in response to the virus or bacteria

“The patient appears to die from the body's response to

infection rather than from it”Sir William Osler

Common Signs of Acute OrganSystem Dysfunction in Sepsis

Cardiovascular:

TachycardiaDysrhythmiasHypotension

Elevated central venous and pulmonary artery pressures


Respiratory:

TachypneaHypoxemia


Renal:

OliguriaAnuria

Elevated creatinine levels


Hematologic:

JaundiceElevated liver enzymes

Decreased albuminCoagulopathy


Gastrointestinal:

Ileus (absent bowel sounds)


Hepatic:

ThrombocytopeniaCoagulopathy

Decreased protein C levelsIncreased D-dimer levels


Neurologic:

Altered consciousnessConfusionPsychosis

Evidence-based Treatment

Strategies in Severe SepsisLevel A recommendations

Prophylaxis measuresDeep vein thrombosisStress ulcer


Strategies in Severe SepsisLevel B recommendations

Initial resuscitation for sepsis-inducedhypoperfusion

Fluid resuscitation to a central venouspressure of 8–12 mm Hg

Early goal directed therapy (to maximizeperfusion status)

Transfusion of packed red blood cells toachieve a hematocrit of 30%

Administration of inotropic infusion(eg, dobutamine)


Strategies in Severe SepsisLevel B recommendations

Mechanical ventilationLung protective ventilation for acute lunginjury/acute respiratory distress syndrome

Blood product administrationTo target hemoglobin of 7.0–9.0 g/dL

Drotrecogin alfa (activated)For patients with sepsis-induced multiple organfailure with no absolute contraindication related to bleeding risk

Renal replacementFor acute renal failure

Sedation, analgesia, and neuromuscular blockadeTo provide comfort yet avoid prolonged sedation


Strategies in Severe SepsisLevel C recommendations

Enhance perfusion

Fluid therapy

SteroidsFor patients with relative adrenal insufficiency


Strategies in Severe SepsisLevel D recommendations

DiagnosisObtain cultures: at least 2 blood cultures, with one drawn percutaneously and one drawnthrough each vascular access device; culturesof other sites such as urine, wounds, andrespiratory secretions should be obtainedbefore antibiotic therapy isinitiated

Glucose controlTo maintain blood glucose 150 mg/dL


Strategies in Severe SepsisLevel E recommendations

Antibiotic therapyEmpirical antibiotics

Source controlRemoval of potentially infected device, drainageof abscess, and debridement of infectednecrotic tissue

Enhance perfusionVaspressorsInotropic therapy


Strategies in Severe SepsisLevel E recommendations

DiagnosisDiagnostic studies (eg, ultrasound, imagingstudies)

Consideration for limitation of support

Discuss end-of-life care for critically illpatients

Promote family communication to discuss useof life-sustaining therapies


Strategies in Severe Sepsis*These recommendations are based on the following

levels ofevidence: level A research evidence supported by at least 2 level I investigations (large, randomized trials with confident results); level B evidence supported by one level I investigation; level C evidence supported by level II investigations only (small, randomized trials with uncertain results); level D evidence supported by at least one level III investigation (nonrandomized study); and level E evidence supported by level IV (nonrandomized, historical controls, and expert opinion) or level V evidence (case series, uncontrolledstudies, and expert opinion).

Saving Lives from SepsisStep By Step

Evaluate a patient who has an infectionor is receiving antibioticsfor these signs and symptoms ofsystemic inflammatory responsesyndrome (SIRS):• Tachycardia• Tachypnea• Fever• High or low white blood cell count


If the patient has an infection andsigns and symptoms of SIRS, suspectsepsis.

If the patient has sepsis, begintreatment as soon as possible.Start all appropriate therapieswithin 24 hours.


Determine the severity of sepsis:• Obtain lactate levels.• Detemine if the patient is hypotensive.• Obtain central venous oxygen saturation (ScvO2) measurements via a central I.V. line.• Provide fluids, vasopressors, and inotropic agents to raise ScvO2 above 70%.


Obtain blood glucose level. If it’smore than 150 mg/dl, start insulintherapy.

If the patient is hypotensive or hasa low serum cortisol level, give 200to 300 mg of hydrocortisone dailyfor 7 days as replacement corticosteroidtherapy.


If the patient has a high risk ofdeath, administer activated proteinC.


Activated protein C controversiesTherapy with activated protein C is controversial, in part because of its cost. This recombinant DNA protein costs about $7,000 for a 4-day course of therapy. But one study indicates that using activated protein C rapidly and appropriately shaves 4 days off the average intensive care unit length of stay. That translates into a cost savings of about $9,000.

The drug is also controversial because we don’t yet know whom it benefits most. The Food and Drug Administration suggests that it should be given only to patients with a high risk of death and that a high risk of death be determined using an APACHE II score. This method, which estimates the severity of illness, works well at predicting group responses. But many nurses and physicians don’t use APACHE II scores, or they use them incorrectly. In Europe, one indicator of a high risk of death is the failure of at least two organs.

Because no universally accepted criteria exist for defining high risk of death, the best criterion may be the bedside clinician’s assessment. If the bedside clinician believes the patient is at high risk for death, activated protein C therapy should be considered.

Lab tests and Hemodynamic Measurements for Determination of

Sepsis

Hemodynamic response to sepsis:

Hypovolemia – low cvp, low scvo2, tachycardia

Give boluses!


Sepsis

Stroke volume monitoring – swan ganz obsolete except for pa pressure monitoring in pulm htn

Stethoscope is vague – use with guidance

Stroke volume is needed to monitor responses

CVP – research does not support much but it is some marker of success


Sepsis

Stroke Volume may be increased with fluid when CVPs may not

Limitations of pressure measurement:CVP and PAOP (Wedge) should never be

used in isolation


Sepsis

Measures of tissue oxygenation

Lactate/PhNormal lactate 1-2

ph normal 7.35-7.45

If lactate >4 and PH less than 7.30 consider tissue hypoxemia


Sepsis

Triple lumen oximetryExpands ability to assess tissue oxygenation

An easier—less expensive—way to measure ScvO2 levelsMeasuring central venous oxygen saturation (ScvO2) levels requires a central I.V.line. Typically, you’ll take frequent blood samples from the right atrium, using the central I.V. line, so fluids can be titrated to return ScvO2 to 70%.

An easier way to obtain frequent measurements is to use a fiberoptic ScvO2 central line catheter. This tool provides continuous ScvO2 readings. Using a fiberoptic catheter has proven to be cost effective: It reduces length of stay by about 4 days, more than offsetting its cost.


Sepsis

Measurement of blood flowDoppler basedArterial line basedPulse contour technique

Show stroke volume - normal stroke index 25-35 – if decreased get tachycardia to compensate

Noninvasive doppler measurement of blood flow aortic and pulmonic valve flows

Noninvasive co/sv measurementEsophageal doppler on sedated patients

Microcirculation – sublingual blood flow

The latest in sepsis treatment and studies can

be found at:

www.survivingsepsis.org

nt isepsis

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