1. Sepsis: Identification and Management in an Acute Care Setting
Dr. Barbara M. Mills DNP
Director Rapid Response Team/
Code Resuscitation
Stony Brook University Medical Center
SEPSIS LECTURE NPA 2018

2. oBJECTIVES
To understand and be able to identify the differences between SIRS, Sepsis, Severe Sepsis, and Septic Shock.
To understand the morbidity and mortality of Sepsis in relation to length of stay, current guidelines, cost to health care systems.
To understand modalities of treatment which include management, such as fluid resuscitation and pharmacological interventions.

4. In-hospital death 8X higher compared to other diagnoses
Data from the National hospital discharge survey, NCHS data brief June The number of sepsis cases more than doubled from In hospital deaths were more than 8x as likely among hospitalized for septicemia or sepsis (17%) compared with other diagnoses (2%). In addition, those hospialized for septicemia or sepsis were ½ as likely to be discharged home, twice as likely to be transferred to another short-term facility and 3x as likely to be discharged to a long-term care institutions, as those with other diagnoses.
. accessed August 7, 2015

6. Sepsis Bundle Project (SEP) National Hospital Inpatient Quality Measures SEP-1 Early Management Bundle, Severe Sepsis/Septic Shock
Discharges (4Q15) through (2Q16)

8. Sepsis ECONOMICS
Sepsis is a major and economically significant disease in the ICU, costing over $20 billion in the United States in 2011 (5.2% of all U.S. hospital costs) with costs growing to over $23 billion in 2013 (6.2% of all U.S. hospital costs)

9. Sepsis ECONOMICS
Sepsis: major health problem with increasing prevalence, high costs, and poor outcomes.

10. Increased hospitalizations for more than 1 million people in 2008
Sepsis ECONOMICS
Increased hospitalizations for more than 1 million people in 2008

11. Sepsis ECONOMICS
Between 1999 and 2014: 2,470,666 deaths with sepsis on the death certificate with increase annual sepsis related deaths by 31%

12. Sepsis ECONOMICS
Severe Sepsis and Septic Shock are subsets of sepsis conditions with at least one organ dysfunction, which accounts for 25-50% of in-hospital mortality…

13. …that can range with a 45%-65% mortality within 6 months of discharge.
Sepsis ECONOMICS
…that can range with a 45%-65% mortality within 6 months of discharge.

14. INFECTION
INFECTION
SEPSIS
INFECTION
SEVERE
SEPSIS
SEPSIS

15. Those who survive tend to have increasing complications, morbidity, high costs of care, and decreasing quality of life.

16. HISTORICAL PERSPECTIVE
SIRS Criteria ( > 2)
Temperature > 38 C < 36 C
Heart rate > 90 bpm
Respiratory rate > 20 /min or a PaCO2 < 32 mmHg
White blood cell count > 12,000 / cu mm or < 4,000 / cu mm, or > 10 bands
Source: CHEST 1992

17. NEW SEPSIS DEFINITION
Guidelines were revised in 2008, 2012, and most recently updated in 2015.
These guidelines have shaped how hospitals must identify and treat patients who are identified as having sepsis, severe sepsis, and septic shock.

18. NEW SEPSIS DEFINITION
The Surviving Sepsis Campaign (SSC) international guidelines were developed for early detection and treatment of severe sepsis and septic shock

19. NEW SEPSIS DEFINITION
“Sepsis is a life threatening organ dysfunction caused by a dysregulated host response to an infection.”
The European Society of Intensive Care Medicine/Society of Critical Care Medicine Third International Consensus definitions for Sepsis and Septic Shock task force (the Sepsis-3 task force)

20. Serum lactate > 2 mmol/L
New sepsis definition
Persistent hypotension requiring vasopressors to keep MAP > 65 mmHg despite adequate fluid resuscitation
Serum lactate > 2 mmol/L
JAMA 2016

21. SEPSIS Scoring tool
Quick SOFA / qSOFA
SBP ≤100mmHg
> 22/ min
In patients with infection a qSOFA score > 2 is associated with higher mortality and prolonged ICU stay.

22. ProCESS ARISE Enrollment <2 hours from detection of shock
Research trials
ProCESS
ARISE
Enrollment
<2 hours from detection of shock
2.8 hours (median) from presentation to ED
Antibiotics
75% received prior to enrollment
70 minutes (median) from presentation to ED
Fluids
>2 liters prior ot enrollment
2515ml (mean) prior to enrollment
Research trials in the emergency room.

23. SEP-1 Two Clocks
3 hour

24. SEP-1: EARLY MANAGEMENT BUNDLE
SEP-1 Two Clocks
SEP-1: EARLY MANAGEMENT BUNDLE
Severe Sepsis
Time Zero
3 hr.
6 hr.
Interventions Required:
Blood culture before antibiotics
Antibiotics
Lactate level
Interventions Required:
Lactate level repeated (If elevated)
Set Measure ID # SEP-1-8; Early Management Bundle, Severe Sepsis/Septic Shock

25. TO BE COMPLETED WITHIN 3 HOURS OF TIME OF PRESENTATION:
SEP-1 Two Clocks
TO BE COMPLETED WITHIN 3 HOURS OF TIME OF PRESENTATION:
Obtain blood cultures prior to administration of antibiotics.
Measure lactate level.
Administer broad spectrum antibiotics.
Administer 30ml/kg crystalloid for hypotension, defined as a “mean arterial pressure” MAP<65 or lactate ≥4mmol/L.
2012 NQF: SEPSIS 0500

26. SEP-1 Two Clocks
Focused Exam
Importance of reassessment.

27. SEP-1 Two Clocks
“Delays in administering all four guidelines recommendations, even when they did not exceed 3 hours, were associated with a significant increase in in-hospital mortality.”
Studies done and published in the SCCM journal April Volume 46. Number 4 have made some conclusions:
SCCM journal April Volume 46. Number 4

28. SEPTIC SHOCK ONLY Severe Sepsis Time Zero 3 hr. 6 hr.
Interventions Required:
Persistent Hypotension
Within 1 hour of fluid add VASOPRESSOR
OR Lactate > 4
Shock Assessment (1 of 2)
Interventions Required:
ALL of Severe Sepsis +
Fluid 30 ml/kg
(NO exclusionary criteria)
Physical Exam (ALL)
Vital Signs (T, HR, RR, BP)
Cardiopulmonary exam
Capillary refill evaluation
Peripheral Pulse evaluation
Skin evaluation
Hemodynamics (2 of 4)
CVP
SVO2
Bedside cardiovascular ultrasound
Passive leg raise / fluid challenge
Shock Assessment

29. SEP-1 Two Clocks
TO BE COMPLETED WITHIN 6 HOURS OF
TIME OF PRESENTATION:
Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure (MAP) ≥65mmHg)
2012 NQF: SEPSIS 0500

30. Mean arterial pressure
65 mm Hg
75 mm Hg
85 mm Hg
F/LT
Urinary
output (mL)
49 +18
43 +13
.60/.71
Capillary blood flow (mL/min/100 g)
.59/.55
Red Cell
Velocity (au)
.74/.97
Pico2 (mm Hg)
41 + 2
47 + 2
46 + 2
.11/.12
Pa-Pico2 (mm Hg)
13 + 3
17 + 3
16 + 3
.27/.40
Adapted from Table 4, page 2731, from LeDoux, Astiz ME, Carpati CM, Rackow ED. Effects of perfusion pressure on tissue perfusion in septic shock. Crit Care Med 2000; 28:

31. TO BE COMPLETED WITHIN 6 HOURS OF TIME OF PRESENTATION:
SEP-1 Two Clocks
TO BE COMPLETED WITHIN 6 HOURS OF TIME OF PRESENTATION:
In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate ≥4 mmol/L (36mg/dl):
Measure central venous pressure (CVP)
Measure central venous oxygen saturation (ScvO2)
Remeasure lactate if elevated
2012 NQF: SEPSIS 0500

32. FLUID RESUSCITATION

33. RESEARCH SUPPORTING FLUID RESUSCITATION BUNDLE

34. Choice of Fluids Crystalloids Colloids Ringers Lactate Normal Saline
Gelatins
Hetastarch
Albumin

35. IV FLUID COMPOSITIONS

36. FLUID REPLACEMENT CHALLENGES
End Stage Renal
Disease on Dialysis
Compensated
Congestive
Heart Failure

37. HEMODYNAMIC CHANGES IN SEPTIC SHOCK
Interstitial Edema in Septic Shock
Lungs
Brain
Kidney

38. Dellinger RP. Cardiovascular management of septic shock
Dellinger RP. Cardiovascular management of septic shock. Crit Care Med 2003;31:

39. During Septic Shock End Diastole Systole 10 Days Post Shock
This slide demonstrates radionuclide angiography in a patient during septic shock and following recovery. The top left panel shows end-diastole and demonstrates increased diastolic size of the ventricles (increased compliance), which is thought to be an adaptive mechanism. The top right image shows end-systole in this patient demonstrating a very low ejection fraction (little change in chamber size compared to end-diastole). The bottom two frames following recovery demonstrate a decrease in end-diastole volume, smaller ventricle at end systole and therefore significant improvement in ejection fraction.
Courtesy of Joe Parrillo Hackensack NJ

40. RESEARCH RECOMMENDATION
SCCM recommends that, in the resuscitation of sepsis-induced hypoperfusion, at least 30 ml/kg of IV crystalloid fluid be given within the first 3 hours (strong recommendation, low quality of evidence).

41. Started within 3 hrs after severe sepsis presentation
ANTIBIOTIC THERAPY
Started within 3 hrs after severe sepsis presentation
Monotherapy vs. Combination Therapy

42. Choose Aminoglycosides or Aztreonam or Ciprofloxacin
COMBINATION THERAPY
Choose Aminoglycosides or Aztreonam or Ciprofloxacin
Cephalosporins, (1st and 2nd Generation) - or – Clindamycin - or - Daptomycin - or - Glycopeptides - or - Linezolid - or - Macrolides - or - Penicillins

43. Choice of vASOPRESSERS
Norepinephrine
First Line
Low Dose Vasopressin
( units/min)
Epinephrine
Second Line
Dopamine (sinus bradycardia)
Niche Drugs
Phenylephrine
(high cardiac output or serious tachyarrhythmias and salvage)

45. Surviving sepsis campaign 2016
We suggest against using IV hydrocortisone to treat septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability. If this is not achievable, we suggest IV hydrocortisone at a dose of 200 mg per day

46. Surviving sepsis campaign 2016
No ACTH stimulation tests or serum cortisol testing
No additional mineralocorticoid
7 days
Taper

47. Tapering of steroids is recommended.
WHAT DO WE KNOW?
Hydrocortisone provides adequate glucocorticoid and mineralocorticoid effects so fludrocortisone is not needed.
Tapering of steroids is recommended.
Although the current hypothesis for the use of steroids in septic shock is to treat relative adrenal insufficiency, current evidence suggests no value in measuring this with a corticotropin response test.

48. Low dose steroid therapy reduces time to reversal of septic shock
WHAT DO WE KNOW?
Steroids are of no benefit in the treatment of severe sepsis in the absence of shock.
Low dose steroid therapy reduces time to reversal of septic shock
Still controversial as to whether or not there is a meaningful reduction in mortality.
The more severely ill and hemodynamically unstable the patient is the more likely to benefit from stress-dose steroids.

50. To Save Lives..... Early identification Early antibiotics
Insert vent, kumar article EGDT article sedation vacation bundles scattered
Early fluid resuscitation

51. Thank You!