sepsis mechanism of disease quick overview last updated on 2/25/2014
TRANSCRIPT
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Sepsis
Mechanism of Disease
Quick Overview
Last Updated on 2/25/2014
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So why are we here ?
Building awareness of Sepsis
Improving your ability to recognize sepsis early
Increasing the use of Early Goal Directed Therapy
Educating healthcare professionals
Developing guidelines of care
Using the Code Sepsis Rapid Response System
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Building Awareness of Sepsis
Dr. Emanuel Rivers
Formally conceptualized severe sepsis and/or septic shock in 2001 with a landmark paper
Developed an Algorithm for the management of Sepsis
EGDT
Early Goal Directed Therapy
Recommendations have been replicated in many publications since 2001
European Society of Intensive Care Medicine and the Society of Critical Care Medicine
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Connect the Dots….
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Did you know?
The word “Sepsis” was derived from the
Ancient Greek for
ROTTEN FLESH AND PUTREFACTION
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Did you know?
Sepsis is growing healthcare challenge
1. It is the #1 cause of death in non-coronary ICU
2. 11th leading cause of death overall
3. 28-day mortality: 30- 50%
4. >750,000 US cases annually
5. Long term complications and treatment may qualify the patient for transfer to an Acute Long Term Care Hospital
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Did you know?
Sepsis is growing healthcare challenge
6. Incidence is growing faster than overall population
7. Sepsis is the most expensive reason for hospitalization ($17.0 billion cost of treatment in the US)
8. Sepsis is a major cause of mortality throughout the world killing about 1,400 per day
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RISK Factors for Developing Sepsis
Age (Newborn or over 35 years old)
Being pregnant
Having chronic disorders such as Diabetes or Cirrhosis, Lupus, Cancer, Poly-Substance Abuse
Having a weakened immune system (HIV, taking immune modulating drugs, chemotherapy, etc.)
Having medical devices inserted into the body (catheters, tubes, etc).
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What is Sepsis?
Sepsis
is defined as a suspected or documented infection in
the presence of two or more Systemic Inflammatory
Response Syndrome Identifiers (SIRS).
Similar to acute MI, Stoke and Poly-trauma, rapid
treatment (within the first few hours) influences the
outcome.
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Defining SIRS
The causes of SIRS are broadly classified as: Infectious or Noninfectious
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The Symptoms Associated with SIRS:
Hypothermia (temp < 97◦) or Fever (temp >100◦)
Tachycardia (HR >100bpm)
Tachypnea (resp>20/min) or Hypocapnia (arterial CO2 <32mmHg)
Leukopenia or Leukocytosis
AMS
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Noninfectious causes of SIRS include
Trauma
Burns
Pancreatitis
Ischemia
Hemorrhage
Complications of surgery
Adrenal Insufficiency
Pulmonary Embolism
Complicated Aortic Aneurysm
Cardiac Tamponade
Anaphylaxis
Drug Overdose
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People Admitted To The Hospital With Serious Diseases Are At The Highest Risk For Sepsis Because Of:1. Underlying diseases such as diabetes, cancer, etc.
2. Presence of drug resistant bacteria in the hospital
3. The fact that they often require an Invasive Lines
4. Being Immuno – compromised / Auto-Immune Disease
5. Surgery / Invasive procedure
6. Mechanical ventilation
7. Having wounds or injuries from burns, a car crash or a bullet
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There are 3 Levels of Sepsis
Sepsis:
2 SIRS identifiers with a confirmed source of infection
Severe Sepsis:
Sepsis plus Organ Dysfunction (24 to 72 hrs)
Septic Shock:
Is Severe Sepsis with persistent hypotension and hypo-perfusion, which can lead to cell death, end-organ damage, multi-system organ failure and death.
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What is Severe Sepsis?Inflammation + Infection + Organ Dysfunction
The progression:
SIRS: Manifested by two or more of the following:
• Temp > 100.4 or < 96.9
• HR > 90 bpm
• RR > 20 cpm
• WBC > 12,000 or <4000 or bands >10%
• AMS
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The Symptoms of Septic Shock:
Hypotension BP< 90 despite fluid bolus of 20 ml/kg.
Map <65
High lactic acid levels > 4mmoL
Hypothermia (temp < 97◦) or fever (temp >100◦)
Tachycardia (HR >100bpm)
Tachypnea (resp>20/min) or hypocapnia (arterial CO2 <32mmhg)
Resp. Rate >20 bpm
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Diagnosing Sepsis
Routine screening of potentially infected patients (12 hrs)
Sudden development of high or low temperature
Rapid heart or breathing rate
Low blood pressure
Positive blood or suspected cultures
Laboratory Data
Use of the sepsis bundles may lead to reduced mortality and improvement in sepsis care.
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Subtle Changes in Your Patient maybe Sepsis
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Tests used to identify Sepsis
Blood tests to measure lactic acid levels
Lactate Levels > 4
Cultures and blood cultures to help determine the type and site of infection prior to antibiotic administration
CBC with Diff
Elevated Neutrophil Count
Bands > 10%
Pulse oximetry to measure oxygen levels
Temperature
SCVO2 Levels
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We Check and Check and Check Lactatic Acid Levels ?
1.3
5.6
1.3
3.6
>4 is a good Indicator of Sepsis
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Goals for Treatment of Severe Sepsis and Septic Shock (EGDT)
Early identification
IV access
Treat infection with empiric antibiotics in a timely manner
Source control
Resuscitation with IV fluids and pressors if necessary(hemodynamic bundle)
Emergency supportive care for acute organ dysfunction
Infection prevention
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Treating Sepsis and Septic Shock with FluidsIneffective arterial circulation in patients with severe sepsis and septic shock is due to vasodilatation associated with infection
Crystalloid fluid, such as normal saline can be administered at 30ml/kg over 30 minutes using a pressure bag.
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Sepsis – Be A Member of the “Golden Hour” Club
“Sepsis Bundle.”
Lactate Levels
Blood Cultures
Antibiotic Use
And Fluid Resuscitation
Items that need to be completed within 6 hours:
Vaso-pressors for BP not responding to fluid,
Measurement of CVP and SCVO2, MAP,
Re-measure lactate if originally elevated.
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Empiric Antibiotic Selection
When the potential infection source or pathogen is not obvious, BROAD SPECTRUM COVERAGE may be an appropriate empiric choice.
If Pseudomonas is NOT suspected:
Vancomycin + Meropenem or Pip/Taz
If Pseudomonas are suspected:
Vancomycin + 2 of the following
»Meropenem »Levofloxacin
»Pip/Taz »Aztreonam
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Nurses Role in SepsisSevere Sepsis Screening begins on admission !!!
Recognize early signs and symptoms of sepsis
Re-assess patients at least every 12 hours
Utilize the SEPSIS SCREENING TOOL (Meditech)
SPEAK UP
Call a Code Sepsis
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My Patient has a Positive Sepsis Screen – Now what do I do?
Notify your charge nurse / Sepsis Champion to review the screen
If positive call Code Sepsis
Notify the ER Physician / Hospitalist / Intensivest / PCP
Implement Sepsis Bundle
Move patient up to the next level of care
Add Problem to Plan of Care
Document Implementation of Sepsis Bundle
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Increasing the use of appropriate treatment
Code Sepsis 1. Obtain a Lactated Level
2. Draw Blood Cultures
3. Give a broad spectrum Antibiotic
4. Normal Saline Bolus at a rate of 30cc / Kg / 30 minutes
5. Prepare for possible transfer to a Higher level of care: ICU
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Increasing the use of Appropriate Treatment
(EGDT)Severe Sepsis without Shock
Check lactate q4hrs till less than 2 mmol / L
Check SCVO2
Optimal value is 70%
Tight Glucose Control
Watch for signs of Clinical Deterioration
Severe Sepsis with Shock
Initiate ICU Admission
Airway Management
Arterial Line
Flow-Trac for Hourly Hemodynamic Monitoring
CVP Placement (Pre-Sep Catheter)
CVP Monitoring
Foley Catheter
Tight Glucose Control
Start of Vasopressors
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Why Monitor ScVO2Tissue hypoxia is often occult, reaching an advanced and lethal stage before its presence is known and resuscitation is attempted. Lactic Acid and ScVO2 measurements allow us to monitor occult tissue hypoxia.
Vital signs are inadequate for detecting global tissue hypoxia and not adequate as a resuscitation end point. Patients with normal blood pressure can still have global tissue hypoxia.
Up to 50% of patients resuscitated from shock may have continued global tissue hypoxia (Elevated lactate and decreased ScVO2) despite normalized vital signs and central venous pressure.
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Vigileo
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Precept Catheter
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Flow Trac Catheter
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Are you Septic Yet ?