sepsis: what every bedside nurse needs to know · sepsis: what every bedside nurse needs to know...
TRANSCRIPT
Sepsis: what every bedside nurse needs to know
4/19/19
Mary C. Sullivan RN, MS, CNSSepsis Project ManagerUniversity of California San Francisco
Outline for today’s presentation
Where we came fromWhat is our current state?How to improve patient outcomes on your unit tomorrow
4/19/19
Sepsis: A worldwide healthcare issue
§750,000 cases of severe sepsis diagnosed in the United States every year, comprise 10% of ICU admissions
§Septic Shock mortality is as high as 60%§Severe Sepsis and Septic Shock have high morbidity with survivors having reduced quality of life after hospitalization
§Evidence shows that when recognized early, outcomes for patients improve
4/19/19Presentation Title and/or Sub Brand Name Here3
4/19/19Presentation Title and/or Sub Brand Name Here4
Where we came from……
4/19/19Presentation Title and/or Sub Brand Name Here5
Old Sepsis Definitions §SIRS (Systemic Inflammatory Response System)
• Temp >38 or <36; HR >90 beats per minute; Respiratory Rate >20 breaths per minute; WBC count >12 or <4
§Sepsis
• Evidence of infection plus evidence of systemic response to infection (Tachypnea, Tachycardia, and Hyperthermia/Hypothermia)
§Severe Sepsis
• Clinical evidence of infection plus evidence of altered organ perfusion (at least one of the following: hypoxemia, elevated lactate, oliguria, altered mentation
§Septic Shock
• Sepsis Syndrome plus hypotension (Systolic blood pressure < 90 or decrease in Mean Arterial Blood Pressure > 40 from baseline
Original Rivers Study: NEJM 2001§Randomly assigned patient with severe sepsis or septic shock to receive either six hours of early goal directed therapy or standard therapy. • EGDT group- central line, CVP, ScVO2 goals, MAP
goals within 6 hours § In-hospital mortality was 30.5 % in the group assigned to early goal-directed therapy, as compared with 46.5 percent in the group assigned to standard therapy
§Conclusion: Early goal-directed therapy provides significant benefits with respect to outcome in patients with severe sepsis and septic shock.
4/19/19Presentation Title and/or Sub Brand Name Here8
Surviving Sepsis Campaign
4/19/19Presentation Title and/or Sub Brand Name Here9
§ Early goal-directed therapy in severe sepsis and septic shock revisited - Concepts, controversies, and contemporary findings - Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/figure/Algorithm-of-EGDT-Hct-hematocrit_fig3_6698563 [accessed 13 Mar, 2019]
4/19/19Presentation Title and/or Sub Brand Name Here10
4/19/19Presentation Title and/or Sub Brand Name Here11
Sepsis: Current State
4/19/19Presentation Title and/or Sub Brand Name Here12
Recent Sepsis Research §ProCESS (2014)- Protocol-based Care for Early Septic Shock
§ARISE (2014)- Australian Resuscitation in Sepsis Evaluation
§ProMISe (2015)- Protocolized Management in Sepsis• Concluded that EGDT does not show improved survival
with invasive hemodynamic resuscitation. Did not support the Surviving Sepsis Campaign Guidelines.
• Controversy with studies as newer studies benefit from overall improved processes in sepsis care, sepsis education, and screening.
4/19/19Presentation Title and/or Sub Brand Name Here13
New Sepsis Definitions- 2016§Sepsis is now defined as life threatening organ dysfunction caused by a dysregulated host response to infection.
§Organ dysfunction is newly defined in terms of a change in baseline SOFA (sequential organ failure assessment) score.
§Septic shock is defined as the subset of sepsis with profound circulatory/cellular/metabolic abnormalities that increase mortality substantially – practically speaking, where vasopressors are needed to maintain MAP >=65 and where lactate remains >2 despite adequate fluid resuscitation.
§ Consensus from ESICM and SCCM – Singer et al, JAMA 2016
What is SOFA?Components Neurological Glasgow Coma ScaleCardiovascular Mean Arterial Pressure
Vasopressor UseRenal Serum Creatinine
Urine OutputRespiratory PaO2/FiO2 ratio
Mechanical VentilationHematological Platelet CountHepatic Serum Bilirubin
Surviving Sepsis CampaignUpdates
§Surviving Sepsis Campaign Hour-1 Bundle of Care Elements
‒ Measure lactate ‒ Obtain cultures prior to administration of antibiotics‒ Administer broad spectrum antibiotics‒ Administer 30 ml/kg crystalloid for hypotension or
lactate greater than or equal to 4 mmol/kg‒ Apply vasopressors if hypotensive during or after fluid
resuscitation. ‒ Re-measure lactate if initial lactate elevated.
(>2mmol/L)
4/19/19Presentation Title and/or Sub Brand Name Here16
4/19/19Presentation Title and/or Sub Brand Name Here17
How to improve care on your unit as soon as your next shift….
4/19/19Presentation Title and/or Sub Brand Name Here18
First: A Case For Prevention §Handwashing, gloving, gowning, isolation
§Nutrition§Foley removal§Central Venous Catheter care
§Surgical site prep§Attention to environmental surfaces cleaning
§Vaccinate
4/19/19Presentation Title and/or Sub Brand Name Here19
Screening at the bedside §Qsofa (Quick SOFA)
• Systolic blood pressure ≤100 mm Hg• Altered mentation• Tachypnea– RR ≥22/min
• Provides simple bedside criteria to identify adult patients with suspected infection who are likely to have poor outcome.
• Useful for patients outside the ICU – does not require laboratory tests and can be assessed quickly and repeatedly.
4/19/19Presentation Title and/or Sub Brand Name Here20
Sepsis Screening in the EHR
Sepsis Screening: Every Patient, Every Shift, Every Day
Checklists
§Examples readily accessible from SSC
§Easier to implement on unit
§Easy to adapt or change based on PDSA cycles
§One point in time
§Nurse may not appreciate changes over time
§Task that needs to be completed
§Use your institutional screens, policies, emergency procedures!
Clinical Decision Support
§Real time data
§Continually scanning the EHR
§Earlier identification to escalate treatments.
§One size does not fit all
§Erroneous data/late entries
§Resource dependent
4/19/19Presentation Title and/or Sub Brand Name Here22
How to improve care on your unit as soon as your next shift….Break down the Bundle
LactateAntibioticsFluidsVasopressors
4/19/19Presentation Title and/or Sub Brand Name Here23
Lactate:
Love §First step for nursing after
positive sepsis screens
§Many institutions use a Nurse drawn protocol
§Easy to obtain
§Results come back quickly
§Very helpful in detecting occult shock
Hate§Lacks precision
§Cannot be used to solely determine sepsis
§ May be overlooked; elevated results may be dismissed or rationalized as another process
4/19/19Presentation Title and/or Sub Brand Name Here24
Lactate Protocol
4/19/19Presentation Title and/or Sub Brand Name Here25
Case Study:
§66F w/ rectal cancer s/p sigmoid colectomy, c/b left ureteral injury s/p left nephrectomy w/ aborted autotransplantation
§POD #2- BP 90/50 lying, difficult to obtain temperature -eventually 93 degrees oral, low urine output with bolus x 2 already given overnight.
§Patient is exhausted, excruciating incisional pain upon sitting on edge of bed even with pre-medication
4/19/19Presentation Title and/or Sub Brand Name Here26
And another Case Study
§43 yo with COPD on 2-3 L home O2, pulmonary HTN, substance abuse, DM, admitted for SOB
§HD #7- RR 24, HR 110, WBC 4.7, increasing from 3 liters to 6 liters O2.
§ Increased work of breathing, patient more altered and refusing blood draws
4/19/19Presentation Title and/or Sub Brand Name Here27
Antibiotics: “Treat first, ask questions later”
4/19/19Presentation Title and/or Sub Brand Name Here28
High mortality rate with delays in
antibiotics
Overtreatment can lead to adverse events
Nurse’s Role:• Early identification of at risk patient• Blood cultures before broadening• Quick administration of appropriate
antibiotic• Monitoring for reactions• Monitoring after initial treatment.
Critical Care Med 2006
Antibiotic choice
§Sepsis order sets help providers select broad spectrum antibiotics.• Allergy algorithms.• Special patient groups: heme onc, transplant• Hospital acquired versus community acquired
§All should be given STAT!§Antibiotic stewardship in an important part of treatment.§De-escalation is as important as escalation.
Based on patient factors, predicted infecting organism, resistance.
4/19/1930
Fluid resuscitation §Fluid resuscitation helps both the hypovolemic state along with the goal of increasing cardiac output to restore oxygen transport to cells.• No consensus as to the ideal composition of fluid • No consensus on ideal amount
§Evidence from randomized trials and meta-analysis have found no convincing difference between colloids and crystalloid.
4/19/1931
Fluid resuscitation
§Colloids
• Colloids exert an osmotic effect leading to the retention of fluid in the intravascular compartment.
§Crystalloids
• Most commonly used IV solution
• Liberal administration results in hyperchloremia and metabolic acidosis
§Balanced Crystalloids
• Best resemble constituents of human plasma, have minimal effect on the acid-base balance or chloride level.
4/19/1932
Vasopressor Selection §Vasopressors should be begun to target a mean arterial pressure of 65mmHg
§First line agent: Norepinephrine (Levophed)• Vasoconstriction without effect of HR, SV, CO
§Second line agent: Epinephrine §Third line agent: Vasopressin dosed at 0.03 units/min§Arterial line should be used for hemodynamic monitoring
4/19/1933
Deterioration and communication §Effective communication is an important aspect of patient care and has a profound effect on the health care quality and treatment outcomes.
§ A few tips for improving your communication on the unit:• Prepare your case• Anticipate what may be asked to help make a decision• Decide what you want to achieve • Structure (SBAR)• Be your patient’s advocate
4/19/19Presentation Title and/or Sub Brand Name Here34
Post Sepsis Recovery
§Weakened immune system, increased risk for another infection.
§About 1/3 of patients will have another hospitalization within 3 months of sepsis episode.
§Other causes of readmissions include heart failure, kidney failure, aspiration.
§Patients are at a heightened risk of further medical setbacks after initial sepsis hospitalization
4/19/1935
Ongoing Sepsis Education For Your Patients
To Summarize §Using screening tools to identify sepsis early can impact mortality
§Lactate is an easy lab value that can help show tissue oxygenation mismatches, but must be used with the entire clinical picture.
§Continued vigilance for shock should be used after initial treatments.
§Care should be taken with inpatients transitions to home to decrease readmission rates.
§Educate your patients/familys/friends on what sepsis is and actions to take when they identify at home.
4/19/19Presentation Title and/or Sub Brand Name Here37
4/19/19Presentation Title and/or Sub Brand Name Here38
4/19/19Presentation Title and/or Sub Brand Name Here39
MaryC.SullivanRN,MS,[email protected]
MelissaLeeRN,MS,[email protected]