Sepsis Subtle – Rapid – Deadly

Sepsis Statistics 10th leading cause of death in US 750,000 cases/year 250,000 deaths/year Patients older than 65 years account for 64.9% sepsis cases Mortality from severe sepsis/septic shock 40-50% 50% survivors suffer post sepsis syndrome Pneumonia Early recognition saves lives

Victims of Sepsis http://www.bing.com/videos/search?q=sepsis+alliance+video&FORM=VIRE2#view=detail&mid=D1B58A028C89F931111CD1B58A028C89F931111C

Sepsis Pathophysiology Death in sepsis can occur owing to a hyper-inflammatory response, mediated by a 'cytokine storm', which induces cell and organ injury. Deaths that are due to this hyper-inflammatory response usually occur early during sepsis and therapy directed at downmodulating the immune response might improve survival. Alternatively, as the condition continues, patients develop a hypo-inflammatory response in which they are unable to eradicate the primary infection or they develop secondary hospital-acquired infections owing to immunosuppression. Apoptosis is an important mechanism of immunosuppression by causing depletion of immune cells and inducing an anti-inflammatory cytokine response. Therapy that blocks apoptosis or enhances immune function might improve survival.

Risk Factors for Sepsis Age > 65 Bacteremia Poorly functioning or weakened immune system (cancer, diabetes, other chronic disease, AIDS) Taking immune-suppressing drugs Pneumonia History of drug/alcohol abuse Any co-morbidities Hospitalized Severe injuries Medical treatment with an invasive device or presence of invasive line/device Are very young (e.g., premature babies) or very old Have a weakened ("compromised") immune system, often because of treatments such as chemotherapy for cancer, steroids (e.g., cortisone) for inflammatory conditions, etc. Have wounds or injuries, such as those from burns, a car crash, or a bullet Have certain addictive habits, such as alcohol or drugs Are receiving certain treatments or examinations (e.g., intravenous catheters [a small tube for dripping fluids into the vein], wound drainage, urinary catheters [a small tube inserted into the bladder] Are more prone to develop sepsis than others because of genetic factors (or their "genes")

What should you do? What Do You Notice? Every patient in the hospital is at risk! What should you do? Be vigilant, Suspect sepsis

CMS Sepsis Bundle Guidelines Lactate measurement Blood cultures Antibiotic administration Fluids Vasopressors Reassessment Repeat lactate level

Look for Sepsis in All the Right Places ED Screen the following patients Pneumonia (Respiratory infections) UTI Abdominal Infections Screen the elderly 83% of patients with sepsis are already septic in the ED Elderly are 13X more likely to develop sepsis and mortality is 40%

Suspect Infections Pneumonia Urinary Tract Infection Diarrhea Meningitis Cellulitis Septic Arthritis Wound Infections Endocarditis Catheter Related Infections Usual suspects

4 Stages of Sepsis Systemic Inflammatory Response (SIRS) Sepsis Severe Sepsis Septic Shock

2 or more of the following Stage 1 SIRS 2 or more of the following Temperature above 100.4 (38 C) or below 96.8 (36 C) Heart rate greater than 90/minute Respiratory rate greater than 20/minute or PaCO2 less than 32 mmHg WBC higher than 12,000 or lower than 4,000 or more than 10% bands Nursing Role: stay alert! monitor the patient, alert the provider, check labs Maintain a high level of suspicion

2 SIRS criteria + Known or Suspected Infection Stage 2 Sepsis 2 SIRS criteria + Known or Suspected Infection Other inclusion factors: receiving antibiotics, recent procedure Nursing Role: Increase frequency of monitoring (√ bowel sounds, notify provider, watch for signs of deterioration; initiate therapies, lactate) Therapies: labs/cultures, fluids, antibiotics, frequent monitoring, evaluate response to fluids – watch BP, HR and RR carefully – monitor trends

What Should I Monitor? Vital signs Intake & output Urine output at least 0.5 mL/kg/hr Level of consciousness new onset anxiety, restlessness Heart & lung sounds Peripheral pulses & capillary refill Watch lab values (↑ wbc, creatinine, bilirubin; ↓ platelets)

Trending Heart rate changes over a period of 36 hours. Monitoring trends is essential. Watch for increasing HR, increasing RR and decreasing BP. Patients generally do not “crash” instead they slip down the cliff Heart rate changes over a period of 36 hours.

Stage 3 Severe Sepsis/Organ Dysfunction Sepsis + One Sign of Organ Failure Other clinical s/s: lactic acidosis, oliguria, thrombocytopenia and altered LOC Patient requires aggressive treatment Nursing Role: immediate notification provider (RRT), oxygen

Signs of Organ Dysfunction Tachycardia Dysrhythmias RR greater than 24 BP less than 90 systolic (decrease > 40) MAP less than 65 Urine output less than 0.5 mL/kg GCS less than 15; new onset altered mental status O2 sat less than 90% RA (or needs O2 to keep sat ≥ 90%) Ileus Labs: Hypoxemia Bilirubin > 2 mg/dL Creatinine > 2mg/dL Elevated liver enzymes Decreased albumin Coagulopathy (Platelets < 100,000; INR > 1.5; aPTT >60 sec) ↓ Protein C levels Elevated serum lactate >2)

Determining Response to Fluid A focused exam including: * Vital Signs Cardiopulmonary Exam Capillary Refill Peripheral Pulse Evaluation Skin Examination OR Any 2 of the following: * Central Venous Pressure Measurement Central Venous Oxygen Measurement Bedside Cardiovascular Ultrasound Passive Leg Raise or Fluid Challenge *Provider documentation required*

Severe Sepsis + Hypotension (unresponsive to fluid resuscitation) Stage 4 Septic Shock Severe Sepsis + Hypotension (unresponsive to fluid resuscitation) Requires advanced monitoring and drug therapy High morbidity and mortality

Indicators of Septic Shock Hypoperfusion persists after fluid administration Systolic BP < 90 MAP < 65 Decrease in systolic BP from baseline > 40 mmHg Lactate level > 4 mmol/L

Key Therapies to Initiate Early Lab tests (blood cultures X 2 -- different sites), source infection cultures, lactate) Oxygen Antibiotics Fluids (Normal Saline) Strict I&O Frequent assessments Infection control Fluids – some patients require as much as 4-8 liters, fluid boluses 500 mL over 30 minutes, watch BP and MAP; fluid overload a problem with patients who have co-morbid cardiac problems

Case Study Elvira Adams

81 year old female (from assisted living) is admitted to the unit with progressive weakness and diarrhea X 3 weeks. Admitting Dx: Dehydration Worrisome s/s: temp = 97 does not meet SIRS/Sepsis guidelines HR = 99 – tachycardia (1 sign of SIRS) + meets criteria for up - triaging to Level 2 RR = 20 – this is a warning sign (SIRS rr > 20)

Initial Assessment Assessment: ABCs intact, alert/oriented X3, skin warm and dry, IV (22 g) infusing slowly in left hand History: skin rash X 2 weeks, treated with prednisone, type 1 DM, UTI 2 weeks ago treated with antibiotics VS: 97ºF, 124/58, 99, 20, 97% RA Does she have any “possible” SIRS s/s? Does she have any sepsis risk factors?

Ms Adams Sepsis Risk Factors S/S SIRS Age > 65 Poorly functioning or weakened immune system (diabetes) Taking immune-suppressing drugs Hospitalized S/S SIRS Heart Rate > 90/minute RR 20 (could be a warning sign) Check her labs for wbc count & bands

A few hours later: Vital signs: 101° F, 107/60, 106, 20, SaO2 96% Labs are resulted. What lab work will you track? WBC and bands 11:45 AM Labs resulted WBC: 26.5 (N 3.9-11.3) Bands 24% (N 0-8) SIRS

What does this mean? Ms Adams now meets the criteria for SIRS. Appropriate Nursing Action: Recheck vital signs (temp, HR, RR) 100.4°F, 95/41, 109, 24, O2 sat 92% 2. Does she also meet the criteria for Sepsis? Assess for any signs of obvious infection “UTI 2 weeks ago” u/a results: 1+ protein, trace blood, nitrate +, trace leuk ester, 4 + bacteria Is she Septic? Urine results = possible infection Meets the criteria for Sepsis – 2 SIRS criteria + known or suspected infection (UTI)

Ms Adams meets the criteria for Sepsis Orders to Obtain/Initiate Oxygen Additional Labs (Blood cultures, lactate, urine c/s) Antibiotics Fluids 2 good lines (18-20 g) Frequent vital sign monitoring and trending to watch for Severe Sepsis Watch for increases in HR, RR, decreases in BP, urine output Change in mental status, signs of organ failure

Later that day Ms Adams rings for the nurse and states: “I don’t feel well.” She is oriented only to self and is confused & restless. Vital signs: 86/25, 125, 28, 91% (2 L n/c), 96.6° F Does she have any signs of organ failure (Severe Sepsis)? Systolic BP < 90 Change in mental status RR > 24

RRT (Institution Specific) Please update RRT Policy NUR R-4 5151 Team ICU Nurse Hospitalist Respiratory Practitioner Nurse assigned to patient Documentation in the RRT Narrator

What RRT Criteria Does She Meet? Respiratory O2 sat <90 despite O2 Increased WOB SBP < 90 Neurological Status New onset decrease in LOC

Ms Adams meets the criteria for Severe Sepsis Orders to Obtain/Initiate Alert physician Evaluate intake and output Frequent vital signs Fluid Boluses (500 over 30 min, repeated until SBP > 90)

Ms Adams Deteriorates Blood pressures 60-70s systolic Heart rate 120+ Respiratory Rate 24-28 Cool clammy skin No urine output Not responding to Dopamine Change in mental status

What has happened? Severe Sepsis Septic Shock Outcome: Septic Shock with renal failure 10 day hospital stay Discharged to long term care

Lessons Learned Suspect sepsis early Reassess for SIRS, sepsis after labs reported Trend the vital signs – increase frequency of assessments Initiate nursing interventions while waiting Document complete and measurable assessments

Don’t forget the antibiotics Do evaluate for appropriate level of care 4 Ds for Sepsis Draw labs Discover the source Don’t forget the antibiotics Do evaluate for appropriate level of care

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