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• Septic Shock – a subset of Sepsis with circulatory and cellular/metabolic dysfunction associated with a higher risk of mortality.. This is a clinical diagnosis.[r]
(1)Heed the Warning:
Early Warning Scores for Sepsis Identification
Vietnam 2019: Sepsis
Barbara McLean, MN, CCNS-BC, NP-BC, FCCM Grady Health Systems
(2)OBJECTIVES
• To understand and be able to identify the
differences between Sepsis and Shock
• To appreciate the role of SIRS in identifying
patients at risk
• 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
(3)(4).http://www.cdc.gov/nchs/data/databriefs/db62.pdf accessed August 7, 2015
(5)(6)Sepsis 2016 • Infected: Use SIRS + suspicion
• Sepsis (with organ dysfunction) – now defined as life-threatening organ dysfunction caused by a
dysregulated host response to infection This is a clinical diagnosis.
o Identify with modified SIRS and Change in LOC
• Septic Shock – a subset of Sepsis with circulatory and cellular/metabolic dysfunction associated with a higher risk of mortality This is a clinical diagnosis.
(7)(8)JAMA 2016;315(8):762-774 doi:10.1001/jama.2016.0288
Suggested Clinical Criteria for Sepsis (if in ICU?)
Infection + or more SOFA points (above baseline)
Consider Sepsis outside ICU if
(9)QUICK SOFA / QSOFA
> 22/ min SBP
≤100mmHg
In patients with infection a qSOFA score > is associated with higher
mortality and prolonged ICU stay
SEPSIS Scoring Tool: Adding Organ Dysfunction
(10)MEWS Scoring Algorithm: Making it Simple
• Uses vital signs to generate an acuity score
• No process change or manual entry
(11)(12)5-6 7+
MEWS SCORING ALGORITHM: MAKING IT SIMPLE
1-4
(13)(14)3
hr 6 h
r.
StEP-1: EARLY MANAGEMENT BUNDLE
Measures & Intervention Required:
Blood culture before
antibiotics
Antibiotics
Fluid resuscitation
Lactate level
Set Measure ID # SEP-1-8; Early Management Bundle, Severe Sepsis/Septic Shock
Interventions Required:
Lactate level repeated (If
elevated)
Vasopressors if necessary
Optimize fluid
Severe Sepsis
Time Zero
StEP-1 By 3 Hours
(15)BEFORE HOURS ARE UP!
To Be Completed by Hours Of Time Of Presentation:
1 Obtain blood cultures prior to administration of antibiotics
2 Measure lactate level
3 Administer broad spectrum antibiotics
4 Administer 30ml/kg crystalloid for hypotension,
(16)StEP-1 By 3 Hours
“Delays in administering all four
guidelines recommendations, even when they did not exceed hours,
were associated with a significant increase in in-hospital mortality.”
(17)3
hr
SEP-1: EARLY MANAGEMENT BUNDLE
Measures & Intervention Required:
Blood culture before
antibiotics
Antibiotics
Fluid resuscitation
Lactate level
Grady RRT protocol
Severe Sepsis
Time Zero
Our Clock Is One Hour!
1 h
(18)Guidelines For Initial Resuscitation In Patients With Sepsis Or Septic Shock
Rhodes A et al Intensive Care Med 2017;43:304-377
Initial resuscitation guidelines
• At least 30 mL/kg of IV crystalloid fluid recommended within the first hours
(19)Study Year Mortality Before (%) Mortality After (%)
(20)3 Recent Large Randomized Control Trials:
Although advanced severe sepsis therapies (such as central line placement, SVO2 goals, etc) did not show improved
outcomes, all were randomized after early recognition and
standard therapies including antibiotics and fluid
(21)Combo Therapy
• Choose
o Aminoglycosides or Aztreonam or
Ciprofloxacin
o Cephalosporins, (1st and 2nd Generation) - or –
o Clindamycin - or - Daptomycin - or
-Glycopeptides - or - Linezolid - or - Macrolides
- or – Penicillins
(22)3
hr 6 h
r.
SEP-1: EARLY MANAGEMENT BUNDLE
Measures & Intervention Required:
Blood culture before
antibiotics
Antibiotics
Fluid resuscitation
Lactate level
Set Measure ID # SEP-1-8; Early Management Bundle, Severe Sepsis/Septic Shock
Interventions Required:
Lactate level repeated (If
elevated)
Vasopressors if necessary
Optimize fluid
Severe Sepsis
Time Zero
StEP-2 By 6 Hours
1 h
r
(23)3
hr 6 h
r.
Severe Sepsis
Time Zero
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
Interventions Required: Persistent Hypotension
Within hour of fluid add VASOPRESSOR
Persistent Hypoperfusion OR Lactate > 4
Shock Assessment (1 of 2)
(24)COMMON ISSUES IN SHOCK
• Inadequate oxygen delivery to meet metabolic
demands
• Results in global tissue hypoperfusion and
metabolic acidosis
• Most important, evidence of hypoperfusion: All
shocks
o hypotension
o Lactic acid
o Base deficit
o SvO2 or ScV02
o pH
Focus on tissue acidosis and
(25)COMPENSATORY RESPONSE IN SHOCK
• Inadequate systemic oxygen delivery
activates autonomic responses to maintain systemic oxygen delivery
• Sympathetic nervous system
• NE, epinephrine, dopamine, and cortisol release
• Causes vasoconstriction, increase in HR, and increase of cardiac contractility (cardiac output)
• Renin-angiotensin axis
• Water and sodium conservation and vasoconstriction • Increase in blood volume and blood pressure
(26)Acute kidney injury Myocardial injury
LOW MAP IS ASSOCIATED WITH SERIOUS ADVERSE EVENTS
Risk of both kidney and cardiac injury increases with decreasing MAP
Adapted from Walsh M et al Anesthesiology 2013;119:507-515.
0.12
30 40 50 60 70 80 Lowest MAP (mm Hg)
P rob ab ili ty o f ac ut e k idn ey inj ury 0.04 0.06 0.08 0.10 0.08
30 40 50 60 70 80 Lowest MAP (mm Hg)
(27)DURATION OF LOW MAP AND ADVERSE EVENTS
Adapted from Walsh M et al Anesthesiology 2013;119:507-515.
0 minutes to minutes to 10 minutes 11 to 20 minutes >20 minutes
A
dj
usted
od
ds
ratio
1 1.5 2.5
Acute kidney injury Cardiac complication Myocardial injury
(28)TAKE HOME POINTS
• Suspect Sepsis Early
• Quantify patients at risk with MEWS
• Make it automatic
• Re-Evaluate Patients Promptly
• Treat as a team event and if determine
patient is septic treat as a “code sepsis”
• Apply antibiotics as STAT drugs
• Use your clinical judgment as you fluid
(29)To Save Lives
Early fluid resuscitation
Early identification
(30)And STOP SEPSIS!
Barbara McLean, MN, CCNS-BC, NP-BC, FCCM Grady Health Systems
.http://www.cdc.gov/nchs/data/databriefs/db62.pdf accessed August 7