1. Judy Bedard RN, MSN/ED

2. I do not have any affiliation with Laerdal Corporation that offers financial support for this educational activity.

3. Review of Sepsis, Severe Sepsis and Septic Shock SIRC Surviving Sepsis Campaign Application of Simulation and Use of Software

4. Describe the difference between sepsis, severe sepsis and septic shock Identify the signs and symptoms of SIRS Discuss assessment finding correlated with patients who are at increased risk for sepsis (index of suspicion) Identify signs and symptoms of tissue hypoxia Identify signs and symptoms of organ dysfunction Discuss fluid resuscitation recommendations and goals according to the surviving sepsis campaign guidelines Identify correct early identification and treatment according to the surviving sepsis campaign guidelines

5. Sepsis: Type of blood infection – When the body is unable to contain the infection within the original site and spreads into the blood – Primarily bacterial, can be fungi or viruses – Only 30 to 50% of patients have + blood cultures (Chamberlain) Severe Sepsis: Infection induced organ dysfunction, can be due to hypoperfusion – Most common type: Nosocomial pheumonia Septic Shock: Hypotensive condition resulting from uncontrolled sepsis despite fluid resuscitation, including hypoperfusion abnormalities. – Signs and Symptoms: Hypotension, tachycardia, confusion or decreased mental awareness, requires respiratory support – Shock develops in 40% of septic patients

6. Sepsis Most common form of shock treated by Intensivists in ICU Most common cause of morality in ICU It is the 10th most common cause of death overall Average Mortality: – 20% for sepsis – 40% for severe sepsis – Greater than 60% for septic shock

7. Systemic Inflammatory Response Syndrome. A physiologic response of the endocrine axis and immune systems Sepsis SIRS + a documented infection site Severe Sepsis Sepsis with organ dysfunction, hypoperfusion abnormalities OR hypotension Septic Shock Sepsis induced hypotension despite fluid resuscitation plus hypoperfusion abnormalities SIRC Critical Care Medicine

8. Patient presents with two or more of the following criteria: Temperature > 38 º C or < 36 º C Heart Rate > 90 bbm Respiration: – > 20/min – PaCO2 < 32 mm Hg Leukocyte Count > 12,000/mm3, 10% immature (band) cells

9. Extremes of age ( 70 years ) Primary diseases – Liver cirrhosis – Alcoholism – Diabetes mellitus – Cardiopulmonary diseases – Solid malignancy – Hematologic malignancy – Major surgery, trauma, burns – Invasive procedures – Recent or prolonged hospitalization – Prior antibiotic therapy

10. – Other factors such as childbirth, abortion, and malnutrition – Neutropenia – Immunosuppressive therapy – Corticosteroid therapy – Intravenous drug abuse – Compliment deficiencies – Absence of spleen

11. Hypoxia – results in organ dysfunction, due to tissue hypoperfusion Clinical Manifestations: PaO 2 /FiO 2 < 80 lactates (> or equal to 4 mmol/l) Urine output < 0.5 ml/kg/hr post fluid resuscitation Acute mental status alteration - confusion Hypotension as demonstrated by systolic BP < 90mmHg or a reduction in systolic BP of at least 40mmHg from baseline Treatment: – Fluid boluses – 2 liters initially – Pressors » Norepi and vasopressin » Keep CVP > 8-12 nonventilated patient » Ventilate patient if support needed. Keep CVP 12 – 15 – Volume Expanders

12. Treat hypoxia Treat hypotension Identify source of infection – Antibiotics Fluid resuscitation, volume expanders Check blood panels – esp for glucose control and lactate Ventilation support - ARDS Consider steroids Sedate if needed

13. Early Identification and Treatment Rapid Screening: Criteria – Sepsis Timeline Goal Directed Therapy Protocols and Bundles Therapy Antibiotics Fluid Therapy Lactate / hypotension Steroids Glucose Control Human Activated Protein C Blood / volume expanders Ventilation Sedation Renal protection Stress Ulcers DVT

14. Previously in Nursing: See One–Do One–Teach One Application of Adult Learning Theories Simulation Advantages – Familiarity – Hands – on – Retention – Confidence – No risk Is this applicable for hospitals? What type of simulation is available? What type of impact should I expect? Is it “real”? Where do I start?

15. Let’s Get Started!!! Hands-on Time & Demonstration With Discussion!!

16. American College of Chest Physicians (200) Society of Critical Care Medicine Conference. Critical Care Medicine, 20, 864-875. Chamberlain, N. (2004). From Systemic Inflammatory Response Syndrome (SIRC) to Bacterial Sepsis with Shock. ATSU website. Dellinger, R., Carlet, J., Masur, H., Gerlach, H., Calandra, T., Cohen, J., Gea-Banaclothe, J., Keh, D., Marshall, J., Parker, M., Ramsay, G., Zimmerman, J., Vincent, J., Levy, M. (2004). Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Critical Care Medicine, 32 (3), 858- 873. Golden, Jr., E. (2007). Sepsis: Putting the Pieces Together. Institute for Healthcare Improvement (IHI) website. Lindquist, F., Berry, D., Weiche, R., Brooks, S., Meyer, D., Campbell, M., Stermer, B., Bufton, M. (2009). Early Goal Directed Therapy Reduces Sepsis Complication and Mortality. Institute for Healthcare Improvement (IHI) website. SimSuite Presentation. (2010) Take the Shock out of Sepsis. Laerdal website.