4/10/2015

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Joseph Clement, MS, RN, CCNSClinical Nurse Specialist

San Francisco General Hospital and Trauma Center

Evidence-Based Care for Sepsis: What’s new in 2015

A case• 77 year old M admitted 5

wks prior for CVA.

– PMH: HTN, DM, CAD

– Non-verbal, PEG, Foley

– Unstageable sacral PU

• Baseline VS:

T: 37.4 HR: 85 RR: 20 BP: 115/65 SpO2 99 on RA

• Awaiting SNF

Thursday

• Morning Report

– WBC 13.5

• 8 am: T: 37 HR: 88 RR: 38 BP: 100/54 SpO2 97 on RA

– CXR ordered

• 12 pm: T: 37.7 HR: 90 RR: 20 BP: 130/65 SpO2 98 on RA

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Thursday cont.

• 4 pm: T: 37.4 HR: 91 RR: 26 BP: 124/61 96% RA

• 8 pm: T: 37.1 HR: 93 RR: 24 BP: 126/63 94% RA

• 12 am: T: 38.8 HR: 96 RR: 28 BP: 128/62 95% RA

– Cultures Drawn

• 4 am (Fri): T: 37 HR: 94 RR: 40 BP: 102/61 96% 4L

– Lacate drawn 5am -> 2.5 mmol/L

Friday• 8:30 am T:38.6 HR:92 RR:45 BP:106/57 96% 2L

– Rapid Response Team Activated, To ICU

• 10 am: T:38.6 HR:92 RR:45 BP:78/45 100% FiO2 1.0– Intubated, Central and Arterial lines placed

– On Phenylephrine, norepinephrine

– Ertapenem and Vancomycin started

– 1 L bolus started over 1 hour

• 12 – 2pm: 2 additional L infused

– BP Stablized on pressors

• 5pm: PEA arrest. Expired

SS Campaign, INLP

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Objectives

• Review Sepsis 101

• Explain Early Goal Directed Therapy – the good and the bad

• New Research in 2014-2015

• New Standards of Care

Why is Sepsis Important?• Incidence is rising

– 2000: 11.6 per 10k hospitalization rate

– 2008: 24 per 10k hospitalization rate

• Tenth leading cause of death in US per CDC

• Mortality rate with severe sepsis: 25-35%

• Rapid identification and treatment can decrease mortality

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Relationship Of SIRS, Sepsis, and Infection

The ACCP/SCCM Consensus Conference Committee. Chest. 1992;101:1644-1655.

Bacterial

SIRS

PANCREATITIS

TRAUMA

BURNS

OTHER

Fungal

Parasitic

Viral

Other

INFECTION

SEVERE

SEPSIS SEPSISSEPSIS

SEPTICSHOCK

SIRS: Systemic Inflammatory Response Syndrome:

2 or more of:• HR > 90• RR > 20• WBC >12 or <4• Temp >38 or <36

SEPSIS: SIRS + Infection

SEVERE SEPSIS: Sepsis + End-Organ DamageSEPTIC SHOCK: Sepsis + Persistent Hypotension

Examples of End-Organ Damage:• Hypotension• Delirium• Low Urine Output• Hypoxia (low SpO2)• Lactate >2• Elevated INR, Troponin,

Creatinine, Liver Function Tests

A Spectrum of Illness

Why would an infection in a patient’s foot cause her kidneys to

fail?

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Tissue Damage(Infection)

Pro-Inflammatory Cytokine release

e.g. TNF-α

Vasodilation Capillary Leak ↑ Thrombus Formation

↓ Blood Pressure

↓ Blood Volume

↑ Blood Viscosity

↑ Tissue Pressure

↓ Capillary Flow

↑ Lactate Production,

AcidemiaOrgan Failure Death

↓ Blood Flow

Video of circulation

• Link

• It’s not the infection, it’s the body’s responseto infection that kills you

Treatment: The Sepsis Bundles

6 Hour Bundle

Early Goal Directed Therapy

6 Hour Bundle (EGDT)

3 Hour Bundle

24 Hour

Bundle

2004, 2008 Guidelines 2012 Guidelines

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Treatment: The 3 Hr Bundle

Treatment RationaleMeasure Lactate Lactate indicates severity; Can guide

treatment later

Give Fluid Bolus30 ml/kg crystalloid

Replace lost fluidsRestore/Maintain perfusion to end organsMaintain blood pressure

Draw Blood CulturesBefore Antibiotics

ID pathogens to guide antibiotic therapy

Give Broad SpectrumAntibiotics

Treat infections

Non-Shock Shock

Low 8.7 15.4

Intermediate 16.4 37.3

High 31.8 46.9

0

10

20

30

40

50

28-d

ay m

ort

alit

y (%

)

Impact of Lactate Level and BP on Mortality Rate

Lactate – draw immediately

Mikkelsen et al. Crit Care Med 2009 Vol. 37, No. 5, p. 1670-1678

• Give Fast (1 hr)

• Give AFTER blood cultures (unless that will delay abx

• After fluids, the single most important intervention

Antibiotics

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Treatment: The 6 Hr Bundle

Treatment RationaleStabilize Blood Pressure with vasopressors (if low BP after 1 L IVF)

Improve cardiac output -> oxygen delivery

Normalize Central Venous Pressure (if low BP or Lactate >4)

Normalize Central Venous Oxygen Saturation with Blood Transfusions and/or Dobutamine(if low BP or Lactate >4)

Recheck Lactate (If initially >4)

Early Goal Directed Therapy

Early Goal Directed Therapy (EGDT)

www.Edwards.com

Requires Immediate Central Line if Lactate > 4.0 or persistently hypotensive.

46.5%

30.5%

0%

10%

20%

30%

40%

50%

Control EGDT

Effect of EGDT on In Hospital Mortality

n=133 n=130

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Controversies with EGDT and Early SSC Guidelines

• Mortality Rate higher than other trials/centers

• Single Center Trial, Single Investigator

• Bundled approach – what was the cause of benefit

• Influence of industry

• Later research questioning individual elements of bundle

• Multi-center/International

• Randomized Controlled Trials

• Testing EGDT against usual care

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ProCESS

1,351 patientsSevere Sepsis, Lactate >4 or

hypotensive

EGDT ProtocolizedTherapy

Usual Care

Early Fluid BolusEarly AntibioticsOther supportive therapy prn

21% 18.2% 18.9%Outcome

60 day Mortality

Intervention

Enrollment

Not Significant

ARISE

1,600 patientsSevere Sepsis, Lactate >4 or

hypotensive

EGDT Usual Care

Early Fluid BolusEarly AntibioticsOther supportive therapy prn

18.6% 18.8%Outcome

90 day Mortality

Intervention

Enrollment

Not Significant

ProMISE

1,260 patientsSevere Sepsis, Lactate >4 or

hypotensive

EGDT Usual Care

Early Fluid BolusEarly AntibioticsOther supportive therapy prn

29.5% 29.2%Outcome

90 day Mortality

Intervention

Enrollment

Not Significant

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So are Sepsis Protocols Dead?

• Sepsis Bundles vs EGDT

If you:

• Identify Promptly

• Early Antibiotics

• Early, aggressive Fluids

You don’t have to:

• Place CVL necessarily

• Optimized CVP

• Optimize ScVO2

SS Campaign, INLPUsual care has improved

Treatment: The Sepsis Bundles

6 Hour Bundle (EGDT)• Vasopressors• CVP• ScVO2• Re-check Lactate

3 Hour Bundle

2015 Guideline Revision2012 Guidelines

3 Hour Bundle

6 Hour Bundle• Vasopressors• Either

– MD focused exam, or– 2 of 4:

• CVP• ScVO2• Ultrasound• Passive Leg Raise

• Re-check Lactate

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The Role of the MedSurg Nurse in Sepsis Care

More important than ever

The Role of the MedSurg Nurse in Sepsis Care

Prevent

• Wash hands

• CVL Care

• Remove Lines/tubes

Recognize• High Suspicion

• Look for SIRS & Infection

• Use proper terms

Activate

• Communicate new SIRS

• Advocate for Lactate

• Use RRT

Treat

• Blood cultures first

• Antibiotics Immediately

• Fluids Fast

Monitor

• VS should normalize

• UOP should be adequate

• Lactate should ↓

• If not, higher Level of Care needed

More important than ever!

Questions?

Joe Clement

Joseph.clement@sfdph.org