physiology and management of the septic...
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PHYSIOLOGY AND MANAGEMENT OF THE SEPTIC PATIENT Melanie Sanchez, RN, MSNE, OCN, CCRN Clinical Nurse III City of Hope National Medical Center
HOW THE EXPERTS TREAT HEMATOLOGIC MALIGNANCIES LAS VEGAS, NV MARCH 14, 2018
DISCLOSURES
I do not have anything to disclose.
“WHEN NURSES KNOW BETTER THEY DO BETTER”
GOAL is to Increase Nurse’s – Knowledge
– Skills – Confidence
….. to better care of Oncology patients
REVIEW
Sepsis incidence Visual of sepsis pathophysiology Sepsis recognition Early goal directed therapy – one hour sepsis bundle Sepsis recognition and treatment
Incidence and Prevalence of Severe Sepsis and Septic Shock
• 19 million cases worldwide • 750,000 cases in United States annually
– 2% of all hospital admissions – 10% of all ICU admissions
• Historic mortality in 1980’s up to 80% • Current mortality rates range from 20-30%
Risk Factors for Severe Sepsis and Septic Shock
• Cancer • Transplant-related immunosuppression • Graft-versus-host disease • Neutropenia • Loss/compromise of mucosal barriers • In-dwelling venous access devices • Acquired immunodeficiency syndrome • Chronic obstructive pulmonary disease • Age (infants, elderly)
Sites of Infection
• Most common sites of infection – Pneumonia – Intraabdominal sites – Urinary tract
• Blood cultures positive in 1/3 of patients • 1/3 of patients have no positive cultures from any site
Microbiological Causes of Sepsis
• In survey of 14,000 septic patients: – 62% gram negative organisms – 47% gram positive organisms – 19% fungal organisms
• Most common pathogens – Staphylococcus aureus – Streptococcus pneumoniae – Escherichia coli – Klebsiella species – Pseudomonas aeruginosa
UNDERSTANDING THE IMPORTANCE Sepsis is the LEADING cause of non‐relapse MORTALITY in oncology patients
https://learn.premierinc.com/ebooks/sepsis-infographic
1. 2. 3.
2012 Sepsis Definition was too complicated
Definition Sepsis: Life-threatening Organ Dysfunction caused by a dysregulated host Response to infection Septic Shock: Subset of sepsis with circulatory and cellular dysfunction associated with increased mortality
SEPSIS + REFRACTORY HYPOTENSION &/or Lactate >= 4mmol/L
(JAMA Network, 2016)
(Surviving Sepsis Campaign, 2016)
INFECTION LEADS TO SIRS
SIRS (Systemic Inflammatory Response Syndrome) activated by Infection
Positive Criteria for SIRS >=2: – Temperature ≥ 38 C or ≤ 36 C – HR ≥ 90 beats per minute – RR ≥ 20 breaths per minute or PaCO2 < 32 mmHg – WBC ≥ 12,000/mm3, ≤ 4,000/mm3, or > 10% bands
SITE OF INJURY PATHOPHYSIOLOGY
Capillary Leak ALL VESSELS ARE INJURED
Guideline: Meet Criteria 1, 2, &3 for Severe Sepsis Order Set 1. Known or Suspected Infection - Pneumonia, UTI, Cold/Flu, Diarrhea, Vomiting, CMV, VRE, CDIFF, MRSA,
Wound, Recent Surgery, Rigors, Chills
2. Meet 2 Criteria:
1. Temp > 38.3* or < 36* -Fever or Hypothermia
2. WBC < 4.0 -Immunosuppression WBC > 12.0 -Infection Response or Bad Disease Blasts > 10% -Bad Marrow
3. HR > 90 -Tachycardia
4. RR >20 -Tachypnea
5. Altered LOC -Somnolence or Confusion /etc.
SBP < 90 SBP Decrease > 40 (from Baseline) Lactate > 4 Acute Organ Dysfunction-Low Urine Output or ↑ serum creatinine or acute lung injury
ORGAN DYSFUNCTION & QSOFA
qSOFA Score >= 2 : Predictor of ↑ Mortality
(JAMA Network, 2016)
Hypothermia/
Low WBC or High WBC ↑ Heart Rate
Extremely Tired or Sleepy
Acute Rise in serum creatinine or bilirubin
FLUID RESUSCITATION
30ml/kg • Average 2 Liters NS over 1 Hour
(each 1LNS over 30min)
• Rate: @ 999ml/hr for each1L NS Bag
• Albumin 5% 500ml?
FILL MY EMPTY TANK
of Blood Vessels
Within 1 Hour
*ANTIBIOTICS* TREAT PRIMARY CAUSE OF SEPSIS
• Every Hour Antibiotics are delayed Mortality ↑ almost 8%!
• 6 Hours = 48% Mortality Rate
Within 1 Hour
STAT LABS Within 1 Hour
Might as Well Draw Labs All at Once
Blood cultures x 2 Arterial blood gas, lactate, and ionized calcium
CBC, platelets and differential PT / PTT / INR / fibrinogen Comprehensive metabolic profile ScvO2 (mixed venous saturation of oxygen) Q 30 minutes Urinalysis, culture & sensitivity
Lactate <=1.6
ScvO2 = 70%
SBP >100 OR MAP >=65
CVP (8-12) non-intubated
CVP (12-15) intubated
Goals & Monitoring
LACTATE GOAL < 1.6
• When the body experiences inadequate tissue perfusion Lactate Increases
• Lactate gives you a baseline for how bad the patient’s oxygen demand is & allows you to monitor trends to guide treatment
• Does pt need more Fluids? RBC’s? FIO2? Immediate ICU transfer?
• Ionized Ca+: drops in Sepsis and can lead to Cardiac Dysfunction
– <0.75 possible treat <0.5 Critical, needs Replacement
What is ScvO2, & why a Goal of >70% Definition ScvO2: Oxygen saturation of blood being dumped back into the right atrium by the SVC after
it has circulated through your tissues, reflecting the balance between oxygen delivery and oxygen consumption
Normal Oxygen Tissue Extraction ~25-30%
Why is it so Important to Monitor?
Normal values of: BP, MAP, CVP, HR DO NOT RULE OUT TISSUE HYPOXIA
Values can look alright, but patient might still be hypoperfused and need fluids, red blood cells, dobutamine
Want to make sure patient is being well perfused/hydrated to decrease damage to organs by tissue hypoxia
ScvO2 Goal >70% ScvO2 Status
70-80% Normal
50-69% Compensatory
30-49% Exhaustion
25-29% Severe Lactic Acidosis
<25% Cell DEATH
Draw line Proximal to Heart
ScvO2 Goal >70%: amount of O2 in blood serum
• Versus intravascular volume & CHF in sepsis Cardiac Output
• FIO2 amount of inspired oxygen • PEEP open up alveoli allowing O2 exchange Oxygen supply
• Pt can be hemodiluted/bleeding in sepsis
Increased oxygen consumption
Hemoglobin / Hematocrit
What Effects ScvO2%————> O2 Delivery & O2 Consumption
• Fever, chills, pain, injury
Reduce oxygen demand
EARLY GOAL DIRECTED THERAPY Within 1Hour
ABG with LACTATE Ca+
Blood Cultures (ScvO2 c Labs can be drawn same
time as cultures)
*Antibiotics* Source Control
Fluids 30ML/KG 2Liters avg for 150lb pt
*TEAMWORK*
GOAL MEDS -LEVOPHED -HYDROCORTISONE -VASOPRESSIN -EPINEPHRINE ? DOBUTAMINE ?
GLUCOSE <180
TIDAL VOLUME 6ml/kg
Stress Ulcer Prophylaxis
DVT Prophylaxis
Monitoring CVP MAP ScvO2 Lactate
Monitor ScvO2
After Monitor Goals
Hgb<8.5 or Hct<28 Transfuse RBC
Monitor Lactate ScvO2
SBP or MAP CVP
LOOK AT BIG PICTURE - SBP - SCVO2 - LACTATE TREND
• Fill the tank – For SBP < 90 – fluid resuscitation at 30 mL / kg
• Squeeze the vessels – If SBP < 90 after bolus
• Start vasopressor (Dopamine non-ICU; Levophed ICU) • Increase oxygen perfusion
– If SBP > 90 and ScvO2 < =70% • ? Fluids ? RBC ? Dobutamine • ? FiO2 ? Intubation • ? Pain meds ? Ice packs
• ? Pressors too high • ? All antibiotics on board
SEPSIS SCENARIOS • But first……
• https://www.youtube.com/watch?v=FcNa7S4U0ok
CASE STUDY Jane Doe 62F AML s/p Chemo & Allogenic Transplant Day +8
History of VRE, CDIFF, AFIB, DM2 Problems:
Nausea, Vomiting, Diarrhea for the last week Dry Cough & Runny Nose
CASE 1 • You are a Nurse precepting a new grad, the new grad asks you:
Why does the patient’s blood pressure drop so much with
Sepsis?
CASE 2 • Your septic patient is in DIC (Disseminated Intravascular Coagulation)
and the new grad nurse asks you
– What is DIC and what caused it in your Septic Patient?
CASE 3 NON-ICU FLOOR • Your patient starts showing signs of worsening sepsis. Dr Parker
orders the NON-ICU Sepsis Order Set
• Can you draw a ScvO2 from a PICC line?
• The new grad asks you the precepting nurse why we have to draw ScvO2 every 30minutes until at goal on your septic patient?
What do we want to make sure we get done within an hour?
THANK YOU!