Nancy Hunt, RN, BSN

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Sepsis!!!What you really need to know!!!

• Nancy Hunt, RN, BSN
• Beaumont hospital
• Grosse Pointe, MI

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Objectives

• Understand the causes and risk factors of sepsis.
• Be able to indentify a septic patient.
• Be able to treat a septic shock patient
  appropriately.

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Why is this important?

• Mortality?
• Severe Sepsis Septic Shock
• Up to 40-60 mortality
• Severe Sepsis Septic Shock (Immunocompromised)
• Up to 80 mortality

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Why is this important?

• Sepsis
• Estimated 750,000 cases per year.
• Estimated 215,000 deaths per year.
• 16,800 in Texas
• During this Presentation
• 84 Cases will develop.
• 24 People will die in the US.

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Why is this important?

• AMI (2006 CDC Death rates)
• 141,462

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Cost!

• The present annual cost is estimated at 16.7
  billion

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SIRS

• Systemic Inflammatory Response Syndrome
• Causes
• Trauma
• Severe Burns
• Pancreatitis
• Ischemia
• Infection (Can Lead to Sepsis)

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SIRS Signs Symptoms

• Two or More
• White Blood Cell (Leukocyte) Count
• gt 12,000 or lt 4,000
• Respiratory Rate
• gt 20 breaths.min or mechanically ventilated
• Heart Rate
• gt 90 beats/min
• Temperature
• gt 38 C (100.4 F) or lt 36 C (96.8 F)

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Sepsis

• SIRS with documented or suspected infection.
• Bacterial
• Viral
• Fungal
• Protozoa

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Sepsis

• Common Causes
• Pneumonia
• Urinary Tract Infection
• Abdominal Surgery
• Cellulitis
• IV Drug Users
• Ear Infections

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Sepsis High Risk Factors

• Higher Risk
• Extremes of Age
• Multiple Co-morbidities
• Recent Hospitalization
• 2 million Hospital Acquired Infections per year.

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Sepsis High Risk Factors

• Cough Present
• Indwelling Foley/IV
• Wounds/Injuries
• Para/Quadriplegic
• Bedridden
• Recent Antibiotic Use

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Sepsis High Risk Factors

• Immune Compromise
• Diabetic
• Cancer
• HIV
• Systemic Steroids
• Anti-rejection Medications
• Powerful Anti-inflammatory Medications

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Severe Sepsis/Septic Shock

• Septic Shock Sepsis Hypoperfusion
• Systolic
• Less than 90 mm Hg

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Septic Shock

• Mean Arterial Pressure (MAP)
• Less than 65 mm Hg
• MAP (2 X DBP) SBP
• 3

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EMS Lactate Levels

• Pre-Hospital Lactate Meters
• Developed for Endurance Athletes
• Works just like a Glucometer

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Septic Shock

• Classic Distributive Shock Example
• - ALSO
• Cardiac Function Compromised (Cardiogenic Shock)
• Massive Fluid Shift (Hypovolemic Shock)

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MODS

• Multiple Organ Dysfunction Syndrome (MODS)
• Presence of altered organ dysfunction in the
  septic patient.
• Last stop before death.

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Pathophysiology

• Bacterial Infection
• Capillary Vasodilatation Increased Vascular
  Permeability
• Leukocytes (White Blood Cells) Combat Infection
• Chemotaxis
• Secreted Chemical Signal

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Pathophysiology

• Systemic Infection?
• Cant maintain perfusing pressures
• Release of Pro-Inflammatory Cytokines
• Powerful Vasodilators
• Release of Anti-inflammatory Mediators
• Inhibit production of inflammatory components

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Pathophysiology

• Coagulation
• Pro-Inflammatory Cytokines causes endothelium to
  loose anti-coagulation properties.
• Exacerbated by venous blood pooling properties
• Takes blood out of circulation
• Micro Thrombi Form
• Organ System Dysfunction/Failure

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Pathophysiology

• Remaining Blood
• No Coagulation Properties
• Flows Sluggishly
• Vessels Permeated Dilated
• Leaks out

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Pathophysiology

• Respiratory System
• Acute Respiratory distress Syndrome (ARDS)
• 40 Mortality Rate
• Surfactant Production Decreases
• Maintains Alveolar Tension
• Lungs are extremely
• susceptible to ventilation
• induced injury

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EMS Treatment

• Early Recognition Key
• History
• Physical exam
• Look for Infection
• Strict Aseptic Practices
• Patient already compromised

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EMS Treatment

• Fluid Resuscitation
• Large Bore IVs
• 20 ml/kg bolus (500 ml increments)
• Follow local protocol for max dose
• Pulmonary Edema
• Move to Vasopressors

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EMS Treatment

• Increased Oxygen Demand
• Hypermetabolism
• Impaired Oxygen Extraction
• Respiratory Failure Occurs Rapidly

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EMS Treatment

• Lung Protective Ventilation
• Lower tidal Volumes
• Slightly Increased Rate
• O2 Sat between 88 92

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EMS Treatment

• Pharmacological Support
• Dopamine 2-20 mcg/kg/min
• Maintain SBP of 90 mm Hg or MAP of 65-70 mm Hg
• May need higher doses

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EMS Treatment

• Place supine with feet elevated.
• NOT Trendelenberg
• May Impede Breathing
• Rapid Transport

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ER Treatment

• Early Goal Directed Therapy (EGDT)
• Goal Oriented Manipulation of
• Cardiac Preload
• Cardiac Afterload
• Contractility
• Balanced between oxygen delivery and oxygen demand

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EGDT - Goals

• Resuscitation Bundle (lt 6 hours)
• Serum Lactate Levels
• Blood Cultures Prior to Antibiotics
• Antibiotic therapy within 1 hour of diagnosis
• Each hour of delay during the first 6 hours of
  hypotension was associated with a 7.6 increase
  in mortality

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6 Hour Resuscitation Bundle

• Early Identification
• Early Antibiotics and Cultures
• Early Goal Directed Therapy

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EGDT - Treatment

• Central Venous Pressure (CVP)
• Maintain between 8 and 12 mm Hg
• Measure of Intravascular Volume (Preload)

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EGDT - Treatment

• Mean Arterial Pressure (MAP)
• Maintain at 65-70 mm Hg
• Vasoactive Agents
• Norepinephrine
• Dopamine

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EGDT - Treatment

• Central Venous Oxygen Content (ScvO2)
• If ScvO2 lt 70
• Packed Red Blood Cells
• Hematocrit gt 30

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EGDT - Treatment

• Activated Protein C
• Reduced Production of Thrombin
• Major Physiological Anticoagulant
• Increased risk of serious bleeding

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EGDT - Treatment

• Protective Lung Strategies
• Reduce volume to 6 ml/kg verses 12 ml/kg
• 9.9 reduction in mortality.
• ARDS Patients

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EGDT - Treatment

• Tight Glycemic Control
• Blood Sugar between 80 110 mg/dl

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EGDT - Results

• Severe Sepsis or Septic Shock after 72 hours
• EGDT Standard Therapy
• Mortality 30.5 46.5
• ScvO2 70.4 65.3
• Lactate 3.0 mmol/L 4.4 mmol/L
• Rivers, E, Et Al. Early Goal directed Therapy in
  the treatment of Severe Sepsis and Septic Shock.
  N Engl J Med 2001 191368-1377.

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EGDT - Results

• (Hours) 0-7 7-72 0-72
• Vasopressors ()
• Standard 30.3 42.9 51.3
• EGDT 27.4 29.1 36.8
• Mechanical Vent ()
• Standard 53.8 16.8 70.6
• EGDT 53.0 2.6 55.6
• Rivers, E, Et Al. Early Goal directed Therapy in
  the treatment of Severe Sepsis and Septic Shock.
  N Engl J Med 2001 191368-1377.

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EGDT - Results

• EGDT save lives
• Meeting all EGDT goals in less than 6 hours
  decreases mortality
• Studies support even better results with earlier
  intervention

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EMS Sepsis alert

• Goal
• Identify Septic Shock Patients
• Alert Hospital
• Start Fluid Resuscitation
• Start Pressors (if needed)
• Transfer to closest appropriate facility
• Consider emergent Transport

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EMS Sepsis Alert Criteria

• Initiate sepsis alert for patients
• 18 years and older
• NOT Pregnant
• TWO or more of the below SIRS Criteria (Systemic
  Inflammatory Response Syndrome)
• Temperature gt38 C (100.4 F) or lt36 C (96.8 F)
• Pulse gt90
• Respiratory rate gt 20
• AND

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EMS Sepsis Alert Criteria

• Suspected or Documented Infection
• AND
• One of the following
• Hypoperfusion evidenced by SBP lt 90 and/or MAP
  lt65
• Lactate 4

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Case 1 EMS Findings

• 56 y/o Female
• Responsive to painful stimuli
• Witnessed Seizure
• HR 135
• Temp 103.5 F
• BP No Radial Pulse
• Glucose High

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Case 1 EMS Findings

• History
• Flu-like Symptoms
• Weakness X 2 Days
• Diabetes
• Headaches

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Case 1 EMS Findings

• Allergy
• Codeine
• Medications
• Oral hypoglycemic (prescribed to husband)
  occasionally.

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ER Findings

• Pulse 134
• BP 75/39
• Resp 8
• Temp 39.8 C (103.6 F)
• Lactate 7.7
• Glucose gt1,600

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ER Findings

• WBC 6.4
• Jumped to gt20 in 24 hours
• Infection Sites
• Urinary tract Infection
• Bacteria in blood
• Fungus is Blood

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ER Treatment

• Intubated
• Central Line Placement (CVP)
• Dopamine
• Normal Saline
• 6 liters!!!!

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ER Treatment

• Antibiotics
• Insulin
• Admitted to ICU
• Diagnosis Sepsis, DKA and
• Bleeding Gastric Ulcer

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Hospital Treatment

• Nor-epi Infusion
• Vecuronim
• And 30 others
• Electrolyte Balance
• pH Balance
• Pain Control
• 2,400 ml Blood Products

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Hospital Treatment

• Normal Saline
• First 72 Hours 37 liters!!!
• Total stay 76 liters!!!
• Intubated 9 days
• Total stay 28 Days
• Discharged Alert to Rehab

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Case 2 EMS Findings

• 59 y/o Female
• Chief Complaint
• Altered LOC and Breathing Problems
• Temp 105.5 F
• Pulse 180 bpm
• Resp 32

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Case 2 EMS Findings

• Diagnosed with
• Upper Respiratory Infections
• Sinus Infection
• BP 102/74
• MAP 83

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Case 2 EMS Findings

• Lactate 4.0
• Cryptic Sepsis

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ER Findings

• Temp 105 F
• Resp 24
• Pulse 148
• BP 79/40
• MAP 53

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Hospital Treatment

• Intubation
• Central line
• Normal Saline
• First 72 hours 22 Liters!!!
• Total 51 Liters!!!!
• Antibiotics

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Cryptic Sepsis

• Patients with severe sepsis accompanied by lactic
  acidosis may display global tissue hypoxia in the
  absence of hypotension.
• Early identification and goal-directed therapy of
  this subgroup leads to a reduction in morbidity
  and mortality.

Donnino, M, Et. Al. Cryptic Septic Shock A
Sub-analysis of Early, Goal-Directed Therapy.
Chest 2003 124 (4) 90 Henry Ford Hospital,
Detroit, MI
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Outcome

• Spent 17 days in hospital.
• Discharged home

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Questions?
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Thank you!!!!

• Nancy.hunt_at_beaumont.edu