Sepsis Early Recognition and Management Therese Hughes, PhD, MPA, RN

Sepsis a Deadly Progression Affects millions around the world each year, killing one in four Contributes to approximately 50% of all hospital deaths Mortality Rates 20% for sepsis 40% for severe sepsis More than 60% for septic shock Best outcomes through early identification and treatment

Severe Sepsis vs. Current Care Priorities US Incidence # of Deaths Mortality Rate AMI 900,000 225,000 25% Stroke 700,000 163,500 23% Trauma (Motor Vehicle) 2.9 million (injuries) 42,643 1.5% Severe Sepsis 751,000 215,000 29%

Early Identification Key *Sepsis is one of the most common but least recognized diseases

Surviving Sepsis Campaign A National Quality Improvement Initiative committed to reducing mortality from severe sepsis worldwide. Follows 2012 International Guidelines for Managing Severe Sepsis and Septic Shock Main objectives: Increase awareness Early recognition Timely treatment of sepsis for hospitalized patients (3 and 6 hour order bundles)

To be completed within 3 Hours Sepsis To be completed within 3 Hours Measure Lactate Level Obtain blood cultures prior to administration of antibiotics Administer broad-spectrum antibiotics (shortest infusion time first) Administer 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L *Time of Presentation is defined as the time of a positive nurse triage in the ED or as an inpatient, or if presented from another venue, from the earliest chart annotation consistent with all elements of severe sepsis or septic shock ascertained through chart review.

To be completed within 6 Hours Sepsis To be completed within 6 Hours Apply vasopressors (for hypotension that does not respond to initial fluid bolus) to maintain a SBP >90 or MAP >65 mmHg In the event of persistent arterial hypotension despite volume resuscitation, or initial lactate ≥4mmol/L (Septic Shock) you must complete a “Septic Shock Focused Exam” within 6 hours of septic shock diagnosis: fluid bolus must be completed prior to assessment; Refer to Septic Shock Focused Exam. Form must be printed from Optio Re-measure lactate acid if initial lactate was elevated > 2 (within 6 hrs) *Time of Presentation is defined as the time of a positive nurse triage in the ED or as an inpatient, or if presented from another venue, from the earliest chart annotation consistent with all elements of severe sepsis or septic shock ascertained through chart review.

Definitions Sepsis = Presence of infection together with systemic manifestations of infection Temperature >100.9°F or < 96.8°F Systolic B/P <90 or MAP < 65 Heart rate > 90/min Respiratory rate > 20 Acute changes in mental status (confusion, falls) WBC >12 or < 4 Systemic Inflammatory Response Syndrome (SIRS) when any two of the above are met

Definitions cont. Severe sepsis = sepsis plus sepsis induced organ dysfunction or tissue hypoperfusion Sepsis induced hypotension Lactate > 2 *Excellent indicator of organ failure Creatinine > 2 mg/dl Bilirubin > 2 mg/dl Platelets < 100,000 INR > 1.5 Hyperglycemia without history of diabetes Urine output <0.5ml/kg/hr for more than 2 hours with adequate fluids Acute lung injury

Definitions cont. Septic Shock = Severe sepsis with hypotension despite adequate fluid resuscitation Hypotension <90 systolic *Key marker for severe sepsis if no other explanation for low B/P or MAP < 65 mm Hg Lactate ≥4 mmol/L

Early Identification of Sepsis Without early identification significant improvements in outcomes will not be seen For each hour delay, risk of hospital death increases by 7.6% Timely Antibiotics reflect the best outcomes (within 3 hours or identification, and after blood cultures drawn if possible). *Within one hour is even better. Patients appropriately diagnosed and treated also saw a shorter length of stay, 11 days vs. 14

Tools For Early Identification and Treatment Nurse Sepsis Screening Tool All ED patient screened in triage Inpatients screened for sepsis at the beginning of each shift (Every 12 hours unless previously positive)

Sepsis Orders-3 hour bundle Bundle to be completed within 3 Hours: Measure lactate level (re-measure within 6 hours if >2) Obtain blood cultures (prior to administration of antibiotics if possible) Administer broad-spectrum antibiotics within 3 hours of recognition of sepsis-1 hour even better! Vancomycin 20mg/kg IV x1 Stat AND one of the following: Zosyn 4.5 gm IV X 1 or Meropenem 1 gm IV X 1 over 15 minutes. *shortest antx first Reassess and narrow antibiotic regimen after culture results and at least every 24 hours Note: *If you know source, use the appropriate antibiotic--i.e., if a respiratory source and suspect pneumonia, use the pneumonia protocol and give Rocephin Administer 30 mL/kg crystalloid for hypotension or lactate ≥ 4 mmol/L

Bundle-6 hour bundle- !Septic Shock-To be completed within 6 hours-* For patients with continued hypotension (Systolic < 90 or MAP < 65 despite fluid resuscitation and/or lactate level = > 4). 5) Apply vasopressors to maintain a systolic B/P > 90 or MAP ≥ 65 mm Hg 6) Reassess patient per focused exam within 6 hours of septic shock diagnosis and after fluid bolus Norepinephrine (LEVOPHED) is the preferred vasopressor. The others may be used if LEVOPHED is not successful.

Fluid Bolus For patients with septic shock the fluid orders have been prebuilt to infuse 30 mL/kg. Remember anything LESS than 30 mL/kg will not meet CMS requirements. There are NO exclusions on this measure!

Diagnostics Blood Cultures Urinalysis and Culture Respiratory culture with gram stain Portable Chest X-Ray-rule out infiltrates Wound Cultures if indicated

Case Study 75 year old female living at home presented to the ED complaining of cramping abdominal pain, diarrhea and weakness X 4 days. Seen by physician at 2:10 pm Stated she had fallen at home a couple of times, which was new for her Denied any blood in her stools. Denied any recent use of antibiotics. No fever, chills or tachycardia. Systolic B/P 66-70 WBC 6.4, HGB 13.6,Creatinine 2.9 History of Hypertension, Colitis and Hiatal Hernia Treatment initiated for IV fluids, occult blood, stool PCR for C-Diff and CT of the Abdomen.

Case Study Continued B/P increased to 97 systolic after 2 liters of IV fluids administered wide open ABD CT scan inconclusive--showed possible small bowel obstruction verses gastroenteritis The patient was admitted to the ICU Did not get first antibiotic until 10:20 PM-- 8 hours after arrival in the ED *Risk of death increases 7.6 percent every hour sepsis goes untreated Lab tests next morning revealed a lactic acid of 3.5 U/A and C&S reflected a UTI with Klebsiella Pneumonia Patient went into Renal failure and expired later that day

Another Look if screening tool used Infection suspected or documented: Yes, ruling out C-Diff and possible gastroenteritis SIR (any 2 of the following) temp >100.4 < 96.8-No HR>90-No RR>20-No -Acute Mental Status Change-Yes, recent falls at home, new -If known: WBC>12000 or < 4000-? Glucose > 120 (w/no diabetes hx)-? SBP <90 (decreased >40 mmHg from baseline)-YES (*key indicator for septic shock-MAP < 65-Not measured Sepsis Screen: Positive Next Steps-Notify physician and start severe sepsis protocol

Sepsis 3 hour order bundle Stat blood cultures Stat Lactate Level Administer broad-spectrum antibiotics Vancomycin 20mg/kg IV x1 Stat AND one of the following: Zosyn 4.5 gm IV X 1 or Meropenem 1 gm IV X 1 over 15 minutes -*shortest antibiotic first Administer 30 mL/kg crystalloid for hypotension or lactate ≥ 4 mmol/L

Thank you! Questions?