storming and norming: sepsis, covid, and the critical

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Storming and Norming:

Sepsis, COVID, and the

Critical Importance of Early

Recognition and Response

Tuesday, September 15, 2020

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Presenter

Diane Hanson MM, BSN, RN, FNAPChief Nursing Officer, EBSCO Clinical Decisions

Editor-in-Chief, Dynamic Health

@DianeHansonRN

After spending several years working in a hospital organization in various clinical and leadership

positions, Diane has been focused on improving quality and evidence-based practice at the point

of care through clinical decision support, health informatics and analytics. Diane brings over 25

years of experience in the healthcare industry to EBSCO Clinical Decisions, most recently as Vice

President of Product Strategy & Management at Vizient Inc. Diane is a published author and

speaker on evidence-based practice and clinical decision support. She holds a degree in nursing

from Grand Valley State University and a Masters in Management degree from Aquinas College.

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Presenter

Kathleen Walsh MSN, MBA, RN, CCRN Medical Writer & Lead Nurse Planner, Accreditation Programs

Dynamic Health

Kathleen Walsh is a nurse practitioner who serves as the Lead Nurse Planner for Dynamic

Health’s Nursing and Health Professions Continuing Education Department. She oversees the

accreditation and management for EBSCOs five largest accrediting agencies. Her background is

in surgical critical care nursing, focusing on trauma and organ transplant. Kathleen has taught

anatomy and physiology at the university level and worked as a hospital-based educator. Her

experience over the past 12 years at EBSCO as writer, senior editor, and team member with the

media group, is a great foundation for her work in our professional development programs.

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Presenter

Colleen Seeber-Combs MSN, RNSection Editor, Medical-Surgical

Dynamic Health

Colleen Seeber-Combs, MSN, RN, is a mastered-prepared registered nurse with 34 years of experience in a variety of settings. Colleen manages the medical-surgical collection for EBSCO’s Dynamic Health. She lives in Philadelphia, Pennsylvania, with her husband and two sons.

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Learning

Outcomes

• Review the medical and financial crisis

sepsis presents worldwide

• Recognize the causes and common clinical

symptoms of sepsis and septic shock

• Understand the best evidence elements of

the Hour-1 and Hour-6 treatment bundles

• Understand the role of pro-inflammatory

and anti-inflammatory cytokines in the

pathophysiology of sepsis

• Compare and contrast best practices for

Sepsis and Covid-19 according to the

latest guidelines

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Worldwide Impact of Sepsis

• Affects 45-50 million people annually worldwide, leading to 11 million deaths

• 1 in every 5 deaths worldwide is associated with sepsis

• Sepsis is the #1 cause of death in hospitals

• Single most expensive condition treated in hospitals

• #1 cause for readmissions– 20% of patients with sepsis are readmitted within

30 days

• Every 2.8 seconds someone dies from sepsis

• As many as 80% of sepsis deaths could be prevented with rapid diagnosis

and treatment

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Be

Sepsis

Smart

Take

The Test

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Mortality

increases

every hour

that treatment

is delayed

True False

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One can

only get

sepsis in the

hospital

True False

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Sepsis is

preventable True False


Sepsis in a Nutshell…

Anyone can get an infection and almost

any infection and lead to sepsis.

Immune System Working Too Hard Sepsis

More is

NOT

Better!


Sepsis – An Extreme Response to Infection

Former definition: Overwhelming and life-

threatening response to an infection, without

the appropriate and timely treatment, could

lead to organ failure, amputation, and death

2016: A life-threatening organ dysfunction

caused by a dysregulated host response to

infection

Rhodes, M.B., Evans, L.E., Alhazzani, W., et al. (2017)

Surviving Sepsis Campaign: International Guidelines for

Management of Sepsis and Septic Shock: 2016.

Critical Care Medicine, 45(3).


Q: Why is

sepsis different

from other

infections?

A: “Aberrant or dysregulated

host response and presence

of organ dysfunction” (Your

immune system response is

out of control and causes

organ damage and death)Singer M. Deutschman, C.S., Seymour C.W., et al (2016)

The Third International Consensus Definition

for Sepsis and Septic Shock (Sepsis-3).

The Journal of American Medical Association, 315(8)


Sepsis: Who is at Risk

• Sepsis is non-discriminatory. There is no gender or race bias in

its victims. However, it does seek out the most vulnerable

patients

• Who is most at risk?

− Very young (children < 1 year of age)

− Older adults (> 65 years of age)

− Pregnant women (causes nearly 260,000 maternal deaths worldwide)

− People with chronic conditions (diabetes, kidney or lung disease)

− People with weakened immune systems (cancer, multiple sclerosis,

AIDS)


The NEW Road to Sepsis

SIRS (SEP2)

Any 2 of the following:

• Temp > 38.3 C/100.9 F

or < 36.0 C/96.8 F

• HR > 90 beats/min

• RR > 20 breaths/min

• WBC > 12,000/mm3

(leukocytosis)

or < 4,000/mm3

(leukopenia) or 10%

Bands/Neutrophils

(PCO2 < 32 mmHg

[norm 35-45])

Sepsis (SEP3)

Confirmed or suspected

infection

+

2 of more qSOFA criteria*

*Issued by SCC

Consensus Committee but not

recommended as best practice

by SSC Guideline group

Severe Sepsis(SEP2)

Sepsis

+

Evidence of Organ

Dysfunction(Lactate >4 mmol)

Septic Shock (SEP3)

MODS* Amputation

Long-Term Morbidity)

Sepsis

+

Refractory Hypotension

(< SBP 90 mmHg)

+

Lactate > 2 mmol/L

Death

*MODS-Multiple Organ Dysfunction Syndrome

X X

Stop


SOFA and qSOFA

qSOFA(Quick SOFA Score) “HAT”

Fast and easy bedside criteria to predict

morbidity/mortality in adult patients with sepsis (2 elements + known infection suggests organ dysfunction)

❑H – Hypotension (SBP 100 mmHg)

❑A – Altered mental status (GCS < 15)

❑T – Tachypnea (RR ≥ 22 breaths/min)

SOFA (Sequential Organ Failure Assessment Score)

Indicates severity of organ dysfunction by evaluating:

❑ Cardiovascular system

❑ CNS

❑ Coagulation

❑ Liver function

❑ Renal function

❑ Respiratory function

Note: qSOFA has been found to be poorly sensitive but reasonably specific for mortality risk.

SIRS ranks higher for screening purposes.

Annals of Internal Med 6 Feb 2018, 168(4), 266-275


Sepsis Definition Common Clinical Symptoms

Confirmed or

Suspected Infection

Refractory

Hypotension*(SBP < 90 despite fluid resuscitation)

SEPSIS

Shivering (rigors), fever, very cold

Extreme pain (“worst ever”) or general discomfort

Pale or discolored, clammy or sweaty skin

Sleepy, difficult to rouse, confused, disoriented

“I feel like I might die” (sense of doom)

Shortness of breath

Abnormal heart rate

S

E

P

S

I

S

Factoids…

Q: Is sepsis the same as septicemia?

A: No. Septicemia (known as blood poising) is the condition

of bacteria entering the bloodstream. Sepsis is the

overwhelming of life-threatening response to infection.

Q: Is septicemia the same as bacteremia?

A: No. Bacteremia is the presence of bacteria in the blood

(likely occurs each time we brush our teeth). Septicemia is

the presence and multiplication of bacteria in the blood (has

a clinical component that involves inflammation).

Mortality

14.9%


Septic Shock

SepsisTwo or More

qSOFA Criteria(Hypotension, ALOC, Tachypnea)

Lactate > 2 mmol/L

Septic Shock Risk Factors

Suppressed immune system

Extreme age

People who’ve revived an organ transplant

Surgical procedures

Indwelling devices

Sickness

S

E

P

S

I

S

Mortality

34.2%


Sepsis is a Healthcare Crisis and Requires Emergency Response

More people have heard about Ebola (non-existent in the U.S.) than

sepsis. More than 40% of American adults DO NOT KNOW what sepsis is!

Family and Friends Message!

If you suspect sepsis (observe a combination of the

common S/S), see your medical professional

immediately, CALL 911, or go to a hospital with an

advocate and say, “I AM CONCERNED ABOUT

SEPSIS.” Don’t just sit in the ED waiting room, hoping

someone will recognize sepsis. TIME IS TISSUE!!

Sepsis Cliff

• Rapid deterioration is common in septic patients

• 2/3 of patients in the ED with normal BP in triage became

hypotensive (MAP< 65 mmHg) within 2 ½ hours *

*Shirvanian, et al. Sepsis Cliff: Development

of Hypotension While in the Emergency

Department


Mortality as

a function of

failing organs

Sepsis

Severe Sepsis

Septic Shock

Incidence

37%

30%

15%

ICU Mortality

27%

32%

54.1%

Organ dysfunction

evidence by ≥

One of the Following:

• SBP < 90 or NAP < 65, of SBP

decreased of more than

40mmHg from previous SBP

• Creatinine > 2.0 or urine output <

0.5 ml/kg/hour for 2 hours

• Bilirubin > 2 mgldl

• Platelet count < 100,000

• INR > 1.5 or aPTT > 60 sec

• Lactate > 2 mmol/L


AHRQ Failure to Rescue Definition

• Inability to save a patient’s life (or prevent a permanent disability)

after the development of a complication that was not present on

admission

• Failure to Recognize: Vital signs or status deteriorating over time

with no response by caregiver

• Failure to Communicate: Delay in physician response to a call for

assistance; inadequate communication between caregivers

• Failure to Plan: Deterioration of a patient while waiting for a transition

in care

AHRQ.org (Agency for Healthcare Research and Quality)


The Bundles

Sepsis/Septic Shock

Hour-1* Treatment Bundle

• Draw initial lactate level**

• Draw blood cultures prior to antibiotics (to be

drawn from 2 different areas)

• Administer broad spectrum antibiotics (administer asap w/in 1 hour if possible)

• Rapid administration of 30 mL/kg crystalloid

for hypotension (≥ 65 mmHg) or lactate ≥ 4

mmol/L• Pt weight/kg: ______

• Crystalloid (NS) total volume: ___mL

• Draw initial lactate level**

*Time zero is measured from triage in ED or from earliest

chart annotation consistent with all elements of septic

shock

**Repeat lactate if > 2 mmol/L

Sepsis/Septic Shock

Hour-6* Treatment Bundle

• Vasopressor for refractory hypotension to

maintain MAP ≥ 65 mmHg

• Reassess volume status and tissue perfusion

if persistent hypotension (< 65 mmHg) or if

initial lactate ≥ 4 mmol/L

• Redraw lactate if initial level elevated (> 2

mmol/L

• Document:

• CVP measurement

• ScvO2 measurement

• Bedside cardiovascular ultrasound

• Passive leg raise or fluid challenge

• CVP (central venous pressure) – poor predictor of fluid

responsiveness

• ScvO2 (central venous oxygen saturation) - used to

detect change in oxygen delivery and consumption

• PLR (raising both legs 45-10% increase in pulse

pressure of arterial tracing) 11x more likely to respond

to fluids


What’s behind the Hour-1 SEP3 controversy?

• Triage time not realistic – many patients develop organ

dysfunction over time, not within 1 hour in ED

• Foster unnecessary abx administration

• Drown patients with fluids - risk to CHF and ESRD patients)

• Fear that CMS would rapidly adopt 1-hour bundle and facilities

would be unable to comply

Pulmonary-Critical Care docs gathered 6,000

signatures to protest 1-hour bundle


Early Therapy = Survival


So, how do we save lives?

• Sepsis alerts for sepsis and septic shock – EMR Software

• Hardwiring bundles for early implementation

• Physician order sets and nursing standardized procedures

• Automatic lactate orders for lab redraws, critical result notification

for LA >4

• Screen all patients in ED and once a shift on the INP units

• Critical result notification for LA >4

• Immediate access (in the units) to broad spectrum antibiotics

• Code Sepsis (Code Sepsis varies with facility. Typically includes Sepsis 1-Hour Bundle, rapid evaluation by attending

clinician supported by infectious disease specialist, and initiation of a Sepsis hand-off form in preparation for transfer to ICU)


Post-Sepsis

Symptoms

(PSS)*Requires

Ongoing

ManagementSepsis survivors…

• Have a shortened life-expectancy

• Suffer life-long consequences of sepsis – 38 sepsis-related

amputations daily, psychological and cognitive disabilities

• Are 42% are more likely to commit suicide

- Global Sepsis Alliance


YOU Can Make a Difference!

• TIMELY screening of

patients for sepsis

• TIMELY identification of

septic patients

• TIMELY treatment of septic

patients

Sepsis MnemonicUse this mnemonic to help improve

sepsis outcomes

S – SOFA Score – Calculate it!

E – Early Recognition

P – Protocols – Follow Them!

S – Start Treatment Right Away

I – Improve Outcomes

S – Share Results


A Closer Look at Pathophysiology

This Photo by Unknown Author is licensed under CC BY-SA

https://en.wikipedia.org/wiki/Objective_(optics)

https://creativecommons.org/licenses/by-sa/3.0/


Source: Xi-zhiJ. Guo, et al, 2017

What is a

Cytokine?

-Protein mediators

-Activate both the

innate and adapted

immune system

-Pro-inflammatory and

Anti-inflammatory

What is a

Cytokine?• Protein mediators

• Activate both the

innate and adapted

immune system

• Pro-inflammatory and

Anti-inflammatory


Proinflammatory cytokines

Anti-inflammatory cytokines

Pathophysiology


Early

and Late

Cytokine

ResponseAdapted from : Honore, P.M., Hoste, E., Molnár, Z. et al. Cytokine removal in human septic shock: Where are we and where are we going?. Ann. Intensive Care 9, 56 (2019).


End-Organ

Damage

• Brain

• Kidneys

• Lungs

• Blood

• Liver

• Pancreas

Frontiers in Cell and

Developmental Biology


ARDS


Wiersinga WJ, Rhodes A, Cheng AC, Peacock SJ, Prescott HC. (COVID-19): A Review

[published online ahead of print, 2020 Jul 10]. JAMA. 2020


Sepsis

Phenotypes

Alpha: This was the most common, least fatal

Beta: Older adults most chronic illnesses and

renal dysfunction.

Gamma: Elevated measures of inflammation

and pulmonary dysfunction.

Delta: Least common liver dysfunction and

shock highest in-hospital mortality rate


COVID-19COVID-19


1.Crystalloids

2.Avoid hydroxyethyl starch

3.Avoid dopamine

4.Supplemental O2 for Sat less

than 92%

5.Avoid incremental PEEP

SSC COVID-19 Guidelines and Sepsis


COVID-19

Guidelines

• Fitted N-95 masks or

respirators

• Neg pressure rooms

• Vasopressin for

second line agent

• Target O2 sat (92-

96%)

• High flow oxygen

• Higher PEEP

• Careful use of fluids


Surviving

Sepsis

Campaign

survivingsepsis.org

• Since its inception in 2002, the Campaign has

achieved several key milestones.

• Goals of Campaign to reduce mortality from sepsis

using a 7-point agenda:

• Building awareness of sepsis

• Improving diagnosis

• Increasing the use of appropriate treatment

• Educating healthcare professionals

• Improving post-ICU and discharge care

• Developing guidelines of care

• Implementing a performance improvement

program


Questions?

Kathleen Walsh MSN, MBA, RN, CCRN

[email protected]

Colleen Seeber-Combs, MSN, RN

[email protected]

Diane Hanson, MM, BSN, RN, FNAP

[email protected]

mailto:[email protected]

mailto:[email protected]


References

• Alhazzani W, Møller MH, Arabi YM, et al. Surviving Sepsis Campaign:

Guidelines on the Management of Critically Ill Adults with Coronavirus

Disease 2019 (COVID-19). Crit Care Med. 2020;48(6):e440-e469.

doi:10.1097/CCM.0000000000004363

• Cancer Therapy Advisor: Pediatric Respiratory Failure – Acute Hypoxemic

Respiratory Failure – ARDS

• Guo XJ, Thomas PG. New fronts emerge in the influenza cytokine storm.

Semin Immunopathol. 2017;39(5):541-550. doi:10.1007/s00281-017-0636-y

• Henderson LA, Canna SW, Friedman KG, et al. American College of

Rheumatology Clinical Guidance for Pediatric Patients with Multisystem

Inflammatory Syndrome in Children (MIS-C) Associated with SARS-CoV-2

and Hyperinflammation in COVID-19. Version 1 [published online ahead of

print, 2020 Jul 23]. Arthritis Rheumatol. 2020;10.1002/art.41454.

doi:10.1002/art.41454

• Honore, P.M., Hoste, E., Molnár, Z. et al. Cytokine removal in human septic

shock: Where are we and where are we going?. Ann. Intensive Care 9, 56

(2019

• Howell MD, Davis AM. Management of Sepsis and Septic Shock. JAMA.

2017;317(8):847–848. doi:10.1001/jama.2017.0131

• Nedeva C, Menassa J, Puthalakath H. Sepsis: Inflammation Is a Necessary

Evil. Front Cell Dev Biol. 2019;7:108. Published 2019 Jun 20.

doi:10.3389/fcell.2019.00108

• Prescott HC, Girard TD. Recovery From Severe COVID-19: Leveraging the

Lessons of Survival From Sepsis. JAMA. 2020;324(8):739-740.

doi:10.1001/jama.2020.14103

• Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign:

International Guidelines for Management of Sepsis and Septic Shock: 2016.

Intensive Care Med. 2017;43(3):304-377. doi:10.1007/s00134-017-4683-6

• Seymour CW, Kennedy JN, Wang S, et al. Derivation, Validation, and

Potential Treatment Implications of Novel Clinical Phenotypes for Sepsis.

JAMA. 2019;321(20):2003-2017. doi:10.1001/jama.2019.5791

• Singer M, Deutschman CS, Seymour CW, et al. The Third International

Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA.

2016;315(8):801-810. doi:10.1001/jama.2016.0287

• Sinha P, Matthay MA, Calfee CS. Is a "Cytokine Storm" Relevant to COVID-

19? [published online ahead of print, 2020 Jun 30]. JAMA Intern Med.

2020;10.1001/jamainternmed.2020.3313.

• Venet F, Rimmelé T, Monneret G. Management of Sepsis-Induced

Immunosuppression. Crit Care Clin. 2018;34(1):97-106.

doi:10.1016/j.ccc.2017.08.007

• Wiersinga WJ, Rhodes A, Cheng AC, Peacock SJ, Prescott HC. (COVID-

19): A Review [published online ahead of print, 2020 Jul 10]. JAMA. 2020

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