Transcript Surviving sepsis in the emergency department

Surviving Sepsis in the
Emergency Department
Clinical Project
Erin Vitale RN, BSN
NUR 7203
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Sepsis and septic
shock are major
healthcare problems
In the ED, symptoms
may be vague and
unclear
Older, younger, or
immunocompromised
individuals may
present with subtle
signs
Missing or delayed
diagnosis results in
greater mortality and
morbidity
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Timeliness and
appropriateness of
treatment is crucial
The need is to have
staff recognize the
time sensitive nature
of diagnosis and
treatment
Review of the
Surviving Sepsis
Guidelines by Society
of Critical Care
Medicine
Needs Assessment
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Recognize importance
of obtaining regular
vital signs
Thorough triage note
Notification of
physician, physician
assistant, or nurse
practitioner of any
indwelling lines,
catheters, or wounds
Purpose
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Update medical
history including comorbidities,
immunocompromised
state, vaccination
status, and current
medications
Thorough skin
assessment noting
wounds or rash
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Entire healthcare team
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Physician
Nurse Practitioner/Physician Assistant
Residents, medical interns
Nurse
Respiratory therapy
Patient care technician
To appropriately diagnose, treat, and
improve outcomes= team effort!
Audience
Review the Surviving Sepsis Campaign:
International Guidelines for Management
of Severe Sepsis and Septic Shock: 2012
specific to the ED environment
 Discuss the differences between sepsis,
severe sepsis, and septic shock
 Describe the different tests that will assist
in guiding treatment
 Review recommended treatments for ED
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Overview
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Sepsis: confirmed or suspected infection with 2 or more of the following
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General variables
Fever (> 38.3°C)
Hypothermia (core temperature < 36°C)
Heart rate > 90/min
Tachypnea
Altered mental status
Significant edema or positive fluid balance (> 20 mL/kg over 24 hr)
Hyperglycemia (plasma glucose > 140 mg/dL or 7.7 mmol/L) in the absence of diabetes
Inflammatory variables
Leukocytosis (WBC count > 12,000 µL–1)
Leukopenia (WBC count < 4000 µL–1)
Normal WBC count with greater than 10% immature forms
Plasma C-reactive protein more than two sd above the normal value
Plasma procalcitonin more than two sd above the normal value
Hemodynamic variables
Arterial hypotension (SBP < 90 mm Hg, MAP < 70 mm Hg, or an SBP decrease > 40 mm Hg in adults
Organ dysfunction variables
Arterial hypoxemia (Pao2/Fio2 < 300)
Acute oliguria (urine output < 0.5 mL/kg/hr for at least 2 hrs despite adequate fluid resuscitation)
Creatinine increase > 0.5 mg/dL or 44.2 µmol/L
Coagulation abnormalities (INR > 1.5 or aPTT > 60 s)
Ileus (absent bowel sounds)
Thrombocytopenia (platelet count < 100,000 µL–1)
Hyperbilirubinemia (plasma total bilirubin > 4 mg/dL or 70 µmol/L)
Tissue perfusion variables
Hyperlactatemia (> 1 mmol/L)
Decreased capillary refill or mottling
Definitions
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Severe sepsis
◦ Sepsis-induced hypotension
◦ Lactate above upper limits laboratory normal
◦ Urine output < 0.5 mL/kg/hr for more than 2 hrs despite adequate
fluid resuscitation
◦ Acute lung injury with PaO2/FIO2 < 250 in the absence of pneumonia
as infection source
◦ Acute lung injury with PaO2/FIO2 < 200 in the presence of pneumonia
as infection source
◦ Creatinine > 2.0 mg/dL (176.8 µmol/L)
◦ Bilirubin > 2 mg/dL (34.2 µmol/L)
◦ Platelet count < 100,000 µL
◦ Coagulopathy (international normalized ratio > 1.5)
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Septic Shock
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Sepsis unresponsive to fluid resuscitation
Definitions
Differential Diagnosis of Shock
Vasodilatory shock
Low-output shock states
Sepsis
Anaphylaxis
Adrenal insufficiency
Neurogenic
Cardiogenic (eg, massive myocardial
infarction, myocarditis, valvular
disease)
Hypovolemic (eg, hemorrhagic,
gastrointestinal losses, burns,
pancreatitis)
Obstructive (eg, massive PE, tension
pneumothorax, auto-PEEP,
tamponade, abdominal compartment
syndrome)
(Adapted from Felner & Smith, 2012)
This is not an all inclusive list. However, important to recognize
the variety of problems that can cause a shock state- not just
sepsis
Differential Diagnosis of Shock
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A patient comes in and has abnormal vital
signs and presentation that fulfil
previously discussed sepsis criteria, now
what? (hypotensive, febrile, etc.)
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2 peripheral IV saline
lock
CBC with differential
stat
BMP stat
Urinalysis and culture
stat
ABG
Oxygen as needed
Place on continuous
heart monitor with 02
sat
Document vitals
frequently including an
initial temperature
Thorough history and
physical
 Imaging if appropriate
(CXR, CT
abdomen/pelvis, CT
head)
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Timely labs, imaging,
and vitals results in a
faster diagnosis and
treatment!
When suspecting sepsis…
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For suspected or confirmed sepsis:
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TO BE COMPLETED WITHIN 3 HOURS: LIKELY TO BE IN ED
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1) Measure lactate level (gray tube on ice)
2) Obtain blood cultures prior to administration of antibiotics (2 sets), if cultures will
take greater than 45 minutes to obtain, administer antibiotics first . Wound cultures
(if present) and send urine samples prior to antibiotic start
3) Administer broad spectrum antibiotics
4) Administer 30 mL/kg crystalloid for hypotension or lactate 4mmol/L
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TO BE COMPLETED WITHIN 6 HOURS: LIKELY TO BE IN ICU SETTING
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5) Initiate vasopressors (for hypotension that does not respond to initial fluid
resuscitation) for a goal of mean arterial pressure (MAP) ≥ 65 mm Hg
6) In the event of persistent arterial hypotension despite volume resuscitation (septic
shock) or initial lactate 4 mmol/L (36 mg/dL):
- Measure central venous pressure (CVP)*
- Measure central venous oxygen saturation (ScvO2)*
7) Re-measure lactate if initial lactate was elevated*
*Targets for quantitative resuscitation included in the guidelines are CVP of ≥8 mm Hg,
ScvO2 of 70%, and normalization of lactate
Surviving Sepsis Bundle
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During the first 6 hours of resuscitation goals should
include
a) CVP 8–12 mm Hg
b) MAP ≥ 65 mm Hg
c) Urine output ≥ 0.5 mL·kg·hr
d) Superior vena cava oxygenation saturation (Scvo2) or
mixed venous oxygen saturation (SvO2) 70% or 65%
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Fluid resuscitation and treatments should be started
in the ED if possible, do not delay until ICU admission
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Routine evaluations of patients that are seriously ill
for severe sepsis can allow earlier initiation of
therapy. This includes re-evaluation of physical exam,
vitals, and laboratory values
Surviving Sepsis
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Administration of effective IV
antibiotics within the first hour
of recognition of septic shock
and severe sepsis without septic
shock as the goal of therapy
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Combination therapy for
neutropenic patients with severe
sepsis and for patients with
difficult-to-treat, multidrug
resistant bacterial pathogens
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Initial empiric antibiotic therapy
of one or more drugs that have
activity against all likely
pathogens (bacterial and/or
fungal or viral) and that
penetrate in adequate
concentrations into tissues
presumed to be the source of
sepsis
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Combination therapy for patients
with severe infections associated
with respiratory failure and
septic shock
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Antiviral therapy initiated as
early as possible in patients with
severe sepsis or septic shock of
viral origin
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Start broad, the admitting team
will narrow down based on
results and patient’s condition.
Base antibiotics on most likely
source (lungs vs urinary etc.)
Antimicrobial Treatment
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Initial fluid resuscitation of
choice: crystalloids
May trial albumin if patient
requiring significant
amount of crystalloids
Norepinephrine (NE) is
first choice vasopressor
Epinephrine is second
agent (adjunct or
replacement to NE)
Vasopressin can be
adjunct to NE
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Dopamine as an alternative
agent to NE only in specific
patients (eg, patients with
low risk of
tachyarrhythmia’s and
absolute or relative
bradycardia)
Dobutamine can be trialed
if myocardial dysfunction
present
Vasopressors should be
going through a central
line. Ideally, the patient will
have an arterial line for BP
monitoring
Hemodynamic Stability
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The primary goal for sepsis in the ED is early
identification and treatment initiation
Transition to the ICU will likely be quick since
septic patient requires obvious admission
Ordering and obtaining the initial appropriate
testing and treatments is crucial to improving
patient outcomes
Sepsis guidelines continue for the inpatient
side and cover additional information
Sepsis in the ED
Organ Failure
Mortality
Table 138-2 Correlation between Organ Failure and Mortality in Sepsis
One lasting more than
one day
20%
Two lasting more than
one day
40%
Three lasting more than 80%
three days
(Adapted from Felner & Smith, 2012)
Sepsis Organ Failure and Mortality
Time from ED triage to
presumptive diagnosis
of severe sepsis is less
than 2 hours
 Time from ED triage to
all patients’ meeting
severe sepsis criteria
having a serum lactate
is less than 3 hours
 Time from ED triage to
appropriate antibiotics
given is less than 1
hour
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If hypotensive or if
lactate > 4.0 mmol,
fluid resuscitation is
started within 1 hour
 If MAP < 65 mmHg and
not responsive to
adequate fluid
resuscitation,
vasopressors are
started immediately
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Measurable Outcomes for the ED
(Adapted from Ely & Goyette, 2005)
Legend:
Sepsis continuum: identifying patients at high risk of death. HR, heart rate; MAP, mean arterial pressure; MODS, multiple organ
dysfunction syndrome; PaO2, arterial partial pressure of O2; RR, respiratory rate
Date of download: 3/24/2014
Copyright © 2012 McGraw-Hill Medical. All rights reserved.
(Adapted from Felner & Smith, 2012)
Summary
(2010).
Chapter 4. I Have a Patient with an Acid-Base Abnormality. How Do I Determine the
Cause?. In Stern S.C., Cifu A.S., Altkorn D (Eds), Symptom to Diagnosis: An Evidence-Based
Guide, 2e. Retrieved March 24,
2014 fromhttp://accessmedicine.mhmedical.com.ezproxy.libraries.wright.edu:2048/content.aspx?
bookid=383&Sectionid=41676333.
(2013). Chapter 57. Critical Care. In Butterworth J.F., IV, Mackey D.C., Wasnick J.D. (Eds), Morgan &
Mikhail's Clinical Anesthesiology, 5e. Retrieved March 24,
2014 fromhttp://accessmedicine.mhmedical.com.ezproxy.libraries.wright.edu:2048/content.aspx?
bookid=564&Sectionid=42800591
Dellinger, R., Levy, M., Rhodes, A., Annane, D., Gerlach, H., Opal, S., & ... Moreno, R. (2013). Surviving
Sepsis Campaign: international guidelines for management of severe sepsis and septic shock,
2012. Intensive Care Medicine, 39(2), 165-228. doi:10.1007/s00134-012-2769-8
Ely E, Goyette R.E. (2005). Chapter 46. Sepsis with Acute Organ Dysfunction. InHall J.B., Schmidt G.A.,
Wood L.H. (Eds), Principles of Critical Care, 3e.Retrieved March 24,
2014 fromhttp://accessmedicine.mhmedical.com.ezproxy.libraries.wright.edu:2048/content.aspx?
bookid=361&Sectionid=39866415.
Felner K, Smith R.L. (2012). Chapter 138. Sepsis. In McKean S.C., Ross J.J., Dressler D.D., Brotman D.J.,
Ginsberg J.S. (Eds), Principles and Practice of Hospital Medicine. Retrieved March 21,
2014 fromhttp://accessmedicine.mhmedical.com.ezproxy.libraries.wright.edu:2048/content.aspx?
bookid=496&Sectionid=41304118
Ferris L, English J.C., III (2012). Chapter 181. The Skin in Infective Endocarditis, Sepsis, Septic Shock,
and Disseminated Intravascular Coagulation. In Goldsmith L.A., Katz S.I., Gilchrest B.A., Paller
A.S., Leffell D.J., Wolff K (Eds), Fitzpatrick's Dermatology in General Medicine, 8e.Retrieved March
24,2014 fromhttp://accessmedicine.mhmedical.com.ezproxy.libraries.wright.edu:2048/content.asp
x?bookid=392&Sectionid=41138908.
Osborn, T., Nguyen, H., & Rivers, E. (2005). Emergency medicine and the surviving sepsis campaign: an
international approach to managing severe sepsis and septic shock [corrected] [published erratum
appears in ANN EMERG MED 2005;46(4):379]. Annals Of Emergency Medicine, 46(3), 228-231.
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