URMC- Adult Non-Invasive Sepsis Resuscitation Protocol

Overview

URMC – Adult Non-Invasive Sepsis Resuscitation ProtocolFor use with Adult* patients where goals of care are curative

Guidelines are intended to be flexible. They serve as reference points or recommendations, not rigid criteria. Guidelines should be followed in most cases, but there is an understanding that, depending on the patient, the setting, the circumstances, or other factors, guidelines can and should be tailored to fit individual needs.

Patient has 2 or more of the following criteria:Temp <36 or >38RR >20HR>90WBC <4 or > 12 or > 10% bandsAcute Mental Status Change

Patient has known or suspected infection?

Notify provider for orders Obtain Blood Cultures** Broad spectrum antibiotics after cultures** STAT Lactate**

Source Control? Infected Catheter

? Operative Intervention?Drainable pus

Supplemental Oxygen to maintain SpO2 >92%

Does not meet sepsis criteria, continue supportive care

SBP <90 or Lactate ≥ 4***

RRT CONSULT - ADMITTED PATIENTS

Crystalloid Bolus – 30mL/kg**(bolus as rapidly as possible)

SBP <90Lactate ≥ 4 ***or <20% lactate

clearance

SIRS

SEPS

ISSE

VERE

SEP

SIS

SEPT

IC S

HO

CK

Review goals of care with patient/family.Goals of care remain curative?

ICU CONSULT – ALL PATIENTSCrystalloid Bolus – 30mL/kg**(bolus as rapidly as possible)

HOUR 1

START SEPSIS CLOCKHOUR 0

Comfort oriented care

• Continue supportive care• Monitor for s/sx of hypoperfusion

• Acute mental status change• ↓ urinary output• Cool/clammy skin• Delayed capillary refill• Cyanosis

• Recheck lactate in 2-4 hours• If lactate ↑ or SBP <90 restart protocol

Continue rapid fluid resuscitationGoal: MAP >65, Normal Serum Lactate

(Most pts with severe sepsis/septic shock require ≥ 5L in the first 6 hrs)Obtain consent and establish central venous access

Initiate Septic Shock Management Protocol

Y

Y

Y

Y

Y

Y

N

N

N

N

N

***Lactate ≥ 2 and <4

Consider VS q2hrs x2 then q4 x3

* - refer to attached guidelines** - provider order required

RAPID RESPONSE TEAM CONSULT - ADMITTED PATIENTS

HOUR 3

ICU CONSULT - ALL PATIENTS

Identify reasons for SIRS criteriaConsider VS q4hrs x3

© University of Rochester Medical Center

URMC – Adult Septic Shock Management ProtocolFor use with Adult* patients where goals of care are curative

Guidelines are intended to be flexible. They serve as reference points or recommendations, not rigid criteria. Guidelines should be followed in most cases, but there is an understanding that, depending on the patient, the setting, the circumstances, or other factors, guidelines can and should be tailored to fit individual needs.

Ensure Sepsis Resuscitation Protocol Initiated

CVP < 8(CVP <12 if intubated) MAP <65 ScvO2 < 70

(only after CVP & MAP goals met)

NS 500mL boluses q 30 min until goal Initiate Vasopressor(see below)

Consider PRBC transfusion for HCT < 30

Maintenance IVF once target CVP met ≥8(≥ 12 if intubated) Titrate to MAP ≥ 65

Consider Dobutamine 2.5-20 mcg/kg/min

(see below)

Recheck CVP after each bolus until goaland then in 4 hours

Obtain ScvO2

(central venous oxygen saturation)

Recheck ScvO2 q 2 hours until ≥70and then in 4 hours

Check lactate q 2 hours until > 20 % lactate clearance and then in 4 hoursGoal – normalization of lactate

Consider the following therapies for continued management of septic shock

Vasopressors:1) Norepinephrine as the first choice vasopressor. (usual range 1-80 mcg/min )2) Epinephrine (added to and potentially substituted for norepinephrine) when an additional agent is needed to maintain adequate blood pressure. (usual range 0.01- 1 mcg/kg/min)3) Vasopressin can be added to norepinephrine (NE) with intent of either raising MAP or decreasing NE dosage in the setting of refractory hypotension. (usual range 0.01-0.04 units/min)4) Dopamine as an alternative vasopressor agent to norepinephrine only in highly selected patients (eg, patients with low risk of tachyarrhythmias and absolute or relative bradycardia). (usual range 1-20 mcg/kg/min)5) Phenylephrine is not recommended in the treatment of septic shock except in circumstances where (a) norepinephrine is associated with serious arrhythmias, cardiac output is known to be high and blood pressure persistently low or (c) as salvage therapy when

combined inotrope/vasopressor drugs and low dose vasopressin have failed to achieve MAP target. (usual range 20-200 mcg/min)

Inotropic Therapy:1) A trial of dobutamine infusion may be administered or added to vasopressor (if in use) in the presence of (a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or (b) ongoing signs of hypoperfusion, despite achieving

adequate intravascular volume and adequate MAP (usual range 2.5-20 mcg/kg/min)

* - refer to attached guidelines © University of Rochester Medical Center

Sepsis: Epidemiology

•750,000 cases per year

•200,000 deaths per year

•Increased incidence and mortality with age and co-

morbidity

•2/3 occur in hospitalized patients

•Incidence increasing in the North America

Angus et.al., CCM 2001:291303-1310

Systemic Inflammatory Response Syndrome (SIRS)

A complex systemic response which includes two or

more of the following manifestations:

•Fever or hypothermia (>38oc or < 36oc)

•Tachycardia (> 90 beats/min)

•Tachypnea (> 20 breaths/min)

•WBC count of > 12,000 or <4,000 cells/mm3

or > 10% immature neutrophils

CCM 20:864-874, 1992

•Assess if the patient has 2 more of the following criteria

• Temp <36 or >38

• RR>20

• HR>90

• WBC <4 or >12 or >10% bands

• Acute Mental Status Change

•Additional findings

• SBP <90

• Lactate > or = to 4

• Lactate clearance <20%

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Increased systemic vascular resistance“clamped down” – poorer outcomes

Correction for Acidosis Compensation for

hypotension – intravascular shifts

Immature cells… we have

exhausted frontline defenses

Fluid leaking into

tissue

By product of anaerobic

metabolism

Decrease in cerebral profusion

pressure, end organ

hypoperfusion, elevated C02

Elderly patients have a blunted immune response

– late signs

Nursing Interventions• Blood cultures x 2 – add Lactate

• Culture from lines as well (HD/CVC/PICC/IVAD/PD cath)

• Fungal culture? Immunosuppressed? – Isolator tubes

• Urine analysis with culture (Urosepsis?)

• Strict I/O – “is the tank full?” watch UO with IVF – UO is the “poor mans CVP” – if we give IVF

and have adequate UO (30 cc/hr) we have “a full tank” think next steps…vasopressors (next

slide)

• Hemodynamic monitoring

• CVP (normal= 5-10) – CVC port for reading

• Arterial line

• Obtain ABG (Lactic acidosis Metabolic acidosis)

• Fluid resuscitation is crucial… patients may receive 5 and 6 liters of NS

• Fluid overload? Maintain ventilation 7

Vasoactive Medications1) Norepinephrine as the first choice vasopressor. (usual range 1-80 mcg/min )2) Epinephrine (added to and potentially substituted for norepinephrine) when an

additional agent is needed to maintain adequate blood pressure. (usual range 0.01- 1 mcg/kg/min)

3) Vasopressin can be added to norepinephrine (NE) with intent of either raising MAP or decreasing NE dosage in the setting of refractory hypotension. (usual range 0.01-0.04 units/min)

4) Dopamine as an alternative vasopressor agent to norepinephrine only in highly selected patients (eg, patients with low risk of tachyarrhythmias and absolute or relative bradycardia). (usual range 1-20 mcg/kg/min)

5) Phenylephrine is not recommended in the treatment of septic shock except in circumstances where (a) norepinephrine is associated with serious arrhythmias, cardiac output is known to be high and blood pressure persistently low or (c) as salvage therapy when combined inotrope/vasopressor drugs and low dose vasopressin have failed to achieve MAP target. (usual range 20-200 mcg/min)

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ICU Sepsis information

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CVP < 8(CVP <12 if intubated)

MAP <65ScvO2 < 70

(only after CVP & MAP goals met)

NS 500mL boluses q 30 min until goal

Initiate Vasopressor(see below)

Consider PRBC transfusion for HCT < 30

Maintenance IVF once target CVP met ≥8(≥ 12 if intubated)

Titrate to MAP ≥ 65

Consider Dobutamine 2.5-20 mcg/kg/min

(see below)

Recheck CVP after each bolus until goaland then in 4 hours

Obtain ScvO2

(central venous oxygen

saturation)

Recheck ScvO2 q 2 hours until ≥70

and then in 4 hours

Sepsis Severe Sepsis

•Confirmed or

suspected infection,

plus > 2 SIRS criteria

•Sepsis plus > 1 organ

dysfunction

CCM 20:864-874, 1992

Septic Shock

Sepsis with hypotension (SBP < 90 mm Hg or a

reduction of > 40 mm Hg from baseline) despite

adequate fluid resuscitation along with perfusion

abnormalities:

•Lactic acidosis

•Oliguria

•Altered mental status• CCM 20:864-874, 1992

Sepsis: Etiology

•1/2 culture positive cases are gram negative organisms

•1/2 gram positive organisms

•2 - 5% fungi or mixed infections

•Mycobacteria, rickettsiae, viruses and protozoans may cause sepsis

•1/3 of cases culture negative

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Sepsis Defined “Sepsis is a clinical syndrome characterized by systemic inflammation due to infection…

Even with optimal treatment, mortality due to severe sepsis or septic shock is

approximately 40 percent and can exceed 50 percent in the sickest patients”

“Sepsis results when the response to infection becomes generalized and involves normal

tissues remote from the site of injury or infection”

“Significant derangement in metabolic autoregulation, the process that matches oxygen

availability to changing tissue oxygen needs, is typical of sepsis. In addition,

microcirculatory and endothelial lesions frequently develop during sepsis. These lesions

reduce the cross-sectional area available for tissue oxygen exchange, disrupting tissue

oxygenation and causing tissue ischemia and cellular injury”

UpToDate2013 SIRS

Overview from the Cleveland Clinic

Sepsis: A Network of Cascading Events

FIBRINOLYSIS

PROINFLAMMATORYMEDIATORS

INFECTION

TF

ANTI-INFLAMMATORYMEDIATORS

INFLAMMATION

Activated Protein C

Protein C

Activated Protein C

T TM

COAGULATION

PAI-1T-PATAF-1

ENDOTHELIAL INJURY

Copyright © 2001, Eli Lilly and Company. All rights reserved.

Circulation

Hypotension is related to the process where at a cellular vasodilators are released in a effort to match the oxygen demand or organs and tissue. The result is systemic vasodilation which further impairs profusion.

There is also a decrease in ADH (vasopressin levels) which can also affect blood pressure

In the heart an large blood vessels there is decreased systolic and diastolic performance. Cardiac output can be maintained via Frank Starlings mechanism but not all patients can compensate.

In small vessels leading to and from organs there is impaired vasoconstriction which

leads to hypoperfusion In the capillaries the cells lose the ability to extract oxygen maximally

In the endothelium cellular changes result in coagulopathies and increased membrane permeability which leads to tissue edema.

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Lungs/Nervous system

Endothelial injury affect capillary blood flow which enhances

microvascular permeability which leads to alveolar pulmonary

edema.

There is a ventilation-perfusion mismatch that leads to

hypoxemia. Can result in ARDS.

The most common sign is encephalopathy.

Changes in metabolism and alterations in cell signaling are due to

inflammatory mediators.

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GI tract/Liver/Kidneys

The gut’s normal barrier function is impaired which leads to bacterial

movement and a worsened septic response.

The liver normally acts as the first line defense in clearing bacteria but

dysfunction can lead to spillover of these bacteria into the systemic

circulation.

Patients with sepsis often suffer from acute renal failure where

hypoperfusion and hypoxia lead to renal injury. Patients may require

dialysis and can improve survival rates.

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