surviving sepsis, 2013 kristy molnar, critical care consultants
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Surviving Sepsis: Improving Care, Saving Lives Kristy Molnar Critical Care Consultants (sponsored by Philips Healthcare, Alberta Health Services and supported by Edwards Lifesciences)TRANSCRIPT
SURVIVING SEPSIS: Improving Care …
Saving Lives
Kristy Molnar
Professional Education Services, Critical Care Consultants
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Sepsis … Claiming LivesLeading cause of morbidity and
mortality worldwide
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The “Face” of SepsisSystemic inflammatory response initiated by a source of infection
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http://www.sepsisalliance.org/resources/video/
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Rory Staunton’s Story(Profiled on Today’s Show & Dr. Oz)
Performance Gaps!http://www.youtube.com/watch?v=k3qz9wCc69w
http://www.youtube.com/watch?v=MTeBukCSot8
http://www.youtube.com/watch?v=xwOKZsKlwWs
http://www.youtube.com/watch?v=J-bLDoVHYSs
Leading to NY State Department’s Cuomo Initiative & Legislation
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What does this mean?
Critical Care UpdateSponsored By
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ICU admissions from EDs up nearly 50% in U.S. U.S. researchers looked at data from the National Hospital Ambulatory Care Survey and found that intensive care admissions from the emergency department rose by nearly 50%, from 2.79 million in 2002-2003 to 4.14 million in 2008-2009. Of all the ED patients, those aged 85 and older had the highest increase in the rate of ICU admissions. The findings appear in the journal Academic Emergency Medicine. Nurse.com (5/15)
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THE BURDEN OF SEPSISHealthcare Resources
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Human Costs?
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Sepsis Costs!
• 40% of total ICU expenditure• Average cost per individual case is
approximately $22,000.00
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GAPS IN CAREQuality Improvement Initiatives - IHI
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Sepsis Detection & ManagementRapid
Response Systems
Patient Flow for Efficiency &
Safety
Early Warning Systems
DIFFUSE SYMPTOMSOccult, systemic wide responses
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CRITICAL SIGNS …MEDICAL EMERGENCY!
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http://www.sepsisalliance.org/resources/video/
SCORING SYSTEMSAPACHE II, SOFA … not Screening Systems
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Phases & Degrees of Sepsis
“A Clinical Spectrum”
http://www.sepsisalliance.org/resources/video/
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TERMSSIRS, SEPSIS, SEVERE SEPSIS, SEPTIC SHOCK, MODS …
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SUSPICION OF SIRSSystemic Inflammatory Response Syndrome
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INTERVENTION IN SIRSSpeedy Intervention & Response for Survival
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The Challenge … The Campaign
The Response
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SEPSIS IS A TRAGIC & DEADLY DISEASE
Increasing Awareness
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ESTABLISHING BEST PRACTICE
Surviving Sepsis Guideline updates (using the GRADE system)
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TRIAGEImproving Identification & Initiating Timely Intervention
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TIMELINESSaving Tissue, Reducing Mortality
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WHO IS RESPONSIBLE?Fighting the War on Sepsis
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TRANSITIONS IN CARE
Seamless
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Recommendations & Guidelines
The Global Sepsis Alliance
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THE GLOBAL SEPSIS ALLIANCE
International Guidelines for the Management of Severe Sepsis & Septic Shock
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GUIDELINES & ALGORITHMS2004, 2008 … Current Updates
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Sepsis updates (2004, 2008, 2012)
2012 update on YouTube (1 hr, 28 min): https://www.youtube.com/watch?v=v08mYfxBJAE
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2005 Manual/User’s Guide (SCCM, ESICM, ISF) Participation in the Surviving Sepsis CampaignSurviving Sepsis Campaign Web site. www.survingsepsis.org
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“Implications of the New International Sepsis Guidelines for Nursing Care”
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Kleinpell, R., Aitken, L., & Shorr, C.A.: AJCC, May 2013, Volume 22, No 3, 212-222.
ENSURING BEST PRACTICES
http://www.sepsisalliance.org/resources/video/
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EDUCATION & COMMITMENTTo ALL on the “Front Line” … a Call to Action …
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Sepsis video resources: YOUR SEPSIS TEAM
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http://www.sepsisalliance.org/resources/video/
GAP ANALYSISWhere do you stand in Sepsis Detection & Management?
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THE SCIENCE & MODEL FOR IMPROVEMENT
Evidence-Based, Organized & Efficient Care
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SCREENING & IMPLEMENTATION OF THE BUNDLES
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ENSURING EFFECTIVE & SEAMLESS TRANSITIONS
The Clinical Environment
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Clinical Decision Support Tools & Documentation
Clinical Approaches
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CONSISTENT APPLICATION OF EVIDENCE-BASED PRACTICE
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GOALS & WORKFLOWImproving Communication
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PROTOCOLSPaper-Based and/or Electronic Clinical Decision Support Tools?
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The “Bundles” & SSC Algorithm
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“BUNDLE”
Evidence-Based, Organized Practice Guidelines within an Organized Process
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PROTOCOLS & PATHWAYSCustomization within Clinical Environments
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WORKING TOGETHERAchieving Better Outcomes?
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Screening Bundle: Timely Triage
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EARLY RECOGNITION!Clinical Assessment, Screening, Monitoring & Surveillance
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TAKING ACTION!Early Warning and Rapid Response Systems
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SCREENING TOOLS FOR SIRSCritical Care Consultants, 2013
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TIMELY NOTIFICATION & COMMUNICATION
Standarized Orders/Protocols?
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Initial Resuscitation Bundle: Time for Action!
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BLOOD CULTURESPrior to Antibiotic Administration
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BROAD-SPECTRUM ANTIBIOTICS
Improve Time to Administration
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SERUM LACTATE
Early identification: Lactate Measures … When, Why and How Much?
http://www.youtube.com/watch?v=LVqt0z4-k6E
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QUESTIONS & DEBATES ABOUT SERUM LACTATE
Identification of Hyperlactatemia &/or Reduced Lactate Clearance
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Hyperlactatemia
• Regardless of the mechanism of hyperlactatemia, numerous studies show that blood lactate is a relevant prognostic marker of morbidity and mortality in various critical care settings, including patients with Sepsis.
• Increased lactate also correlates well with ScvO2
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SSC International Guidelines
• Lactate levels of > 4 mmol/L• Is Lactate > 4 mmol/L or impaired Lactate
clearance an obligatory criterion for the diagnosis of septic shock?
• No significance difference in 28-day mortality across Lactate categories (non, intermediate & high)
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Missed Identification?
• Although a useful adjunct for hypoperfusion … lactate is not present in 45% of septic patients … it may not be adequate as the only marker … we may miss 45% of patients if Lactate used as a sole obligatory criteria.
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Lactate as sole indicator?
• One of the fundamental problems of using lactate clearance as a sole resuscitation target is that a normal lactate (< 2mM/L) can be present in 25-50% of septic shock patients.
• The mortality of these patients is 20-50% even with aggressive therapy.
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2012 findings
• 2012 studies by the Shock Society found that aggressive resuscitation may be beneficial even in the “normal range” lactate concentration.
• How Low? … Lactates of 1.4 – 2.3 mmol/L may also be associated with an adverse outcomes! (2 – 2.5 should be a trigger at admission!)
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2012 findings
• Yes, Hyperlactatemia had a good sensitivity (86%) for prediction of mortality
• But, Lactate cannot be used in isolation due to a low specificity (27%)
• The clinician must use other perfusion markers such as ScvO2 and UO to enhance the prediction value.
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Lactate as an endpoint for Resuscitation?• These observations indicate that using
lactate and ScvO2 are complimentary endpoints, and not mutually exclusive.
(8 references; 1993 - 2012)
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Lactate as an Indicator of Tissue Hypoxia?• Journal of Critical Care - 2012 study• Almost ½ of patients with vasopressor-
dependent septic shock did not express lactate on presentation, although a high mortality remains in this population!
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Lactate as an Indicator of Tissue Hypoxia?• Use of lactatemia as the sole indicator for
additional IV fluid or an end point of resuscitation in septic shock may be inadequate.
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FLUID MANAGEMENTTreat Hypotension, Hypoperfusion & Elevated Lactates
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MAINTAIN APPROPRIATE PRELOAD STATUS
CVP, SVV, PPV, SV for Volume Responsiveness
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Hemodynamics…Blood Flow!
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MAINTAIN MAPVasopressors for ongoing Hypotension?
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Administration of Blood Products?
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VENOUS OXYGEN SATURATION
Maintain Adequate Central Venous Oxygen Saturation
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(Management) Septic Shock Bundle:
Meeting the Goals
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Source Control
• Within 12 hours• Surgical debridement, draining• Removal of infected devices• Infection prevention!
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STEROIDS?Critical Care Consultants, 2013
GLYCEMIC CONTROL GOALCritical Care Consultants, 2013
INSPIRATORY PLATEAU PRESSURE GOAL
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Patient OutcomesReducing Sepsis Mortality & Morbidity
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Implications for Practice
• Integration of the new recommendations can help ensure that critically ill patients with sepsis receive expert nursing care to promote optimal outcomes.
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Implications for Practice
• By initiating resuscitative measures and indicated sepsis care that are based on the new guidelines, critical care nurses can improve care for patients with sepsis.
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Resources, Workflow & Efficiencies
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Early Identification
“ Observe for the convergence of nonspecific diagnostic criteria and physical assessment cues early in the development of the condition and positively affect outcomes”.Karen Giuliano, 2006
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Continuous Monitoring, Physical Assessment & Surveillance Giuliano KK, Kleinpell R.AACN Clin Issues. 2005 Apr-Jun;16(2):140-8
Comprehensive Sepsis Treatment• Antibiotic administration• Circulatory assessment & support …
Fluids, inotropic agents, vasopressors• Supportive treatment with oxygenation &
ventilation
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Comprehensive Sepsis Treatment• Use of measures recommended in sepsis
guidelines• Monitoring & Surveillance• Reporting patients’ response to treatment
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World Federation of Critical Care Nurses (WFCCN)International task force – produced/published a companion guide to the 2008 guidelines in 2011 that outlines 63 additional recommendations.• http://en.wfccn.org/resources_sepsis.php• Crit Care Med. 2011; 39(7):1800-1818
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World Federation of Critical Care Nurses (WFCCN)Crit Care Med. July 2011; 39(7):1800-1818
“Nursing considerations to complement the Surviving Sepsis Campaign guidelines”
http://journals.lww.com/ccmjournal/Fulltext/2011/07000/Nursing_considerations_to_complement_the_Surviving.25.aspx
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“EXTEND THE CHAIN”Improve the Flow of Care
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SEPSIS PRACTICE SUPPORTIndustry, Professional Associations & Practice Groups
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Critical Care Survival Guide – Sepsis Managementhttps://www.youtube.com/watch?v=rSIoG_QuMmg
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iMedicalSchool:Update in Sepsis, 2013
http://www.youtube.com/watch?annotation_id=annotation_377513&feature=iv&src_vid=o8K3IC1RrP8&v=UcivGHBfSb4
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Documentation & Reporting
Compliance & Quality Improvement
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COMPLIANCE & QUALITY IMPROVEMENT
Achieving Compliance within the Resuscitation & Management Bundles?
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DATA COLLECTION & REPORTING
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Call to Action
Implementing the Surviving Sepsis Campaign … 10 years later!
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2012 Surviving Sepsis Guidelines - Summary
http://www.youtube.com/watch?v=v08mYfxBJAE
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“From Time Zero ….” http://www.youtube.com/watch?v=v08mYfxBJAE
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World Sepsis Day (September 13, 2013)
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Winning the War on Sepsis
Stories of Success & Improvement
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Phase IVSCCM Surviving Sepsis Campaign
2012 Guidelines – YouTube video
2013 … Winning IF we stay in the game
2016 - Focus on Guidance, Involvement, Compliance, Quality,
Technologies/Processes … ongoing Mortality reductions!
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Surviving SepsisImproving Care … Saving Lives
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http://www.survivingsepsis.org
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THANK YOUCongratulations