December 17, 2014 - WSHA
Transcript of December 17, 2014 - WSHA
Patient SafetySafe Table Webcast: Sepsis (Part III and IV)December 17, 2014
Presented at the WSHA Safe Table Webcast on December 17, 2014
Presenters
Mark Blaney, RNRegional Nurse EducatorCHI Franciscan Health
Karen LautermilchDirector, Quality & Performance ImprovementWashington State Hospital Association
Presented at the WSHA Safe Table Webcast on December 17, 2014
35.2% decrease in mortality rate.
13 fewer deaths per week due to severe sepsis or septic shock, saving $96.8million.
Presented at the WSHA Safe Table Webcast on December 17, 2014
Friday, December 5th (Sessions 1 & 2)
Session 1: Recognition & Pathophysiology• Describe the importance of the early identification of Sepsis. • Differentiate between SIRS, Sepsis, Severe Sepsis, and Septic Shock. • Recognize the progression of the inflammatory response in Sepsis. • Identify three signs and symptoms that can help with the early identification of Sepsis.
Session 2: Initial Treatment• Define your role in the care of the Septic patient. • Explain the rationale for each element in the Surviving Sepsis Campaign 3‐hour bundle.
• Apply the steps of Sepsis care into your practice.
Presented at the WSHA Safe Table Webcast on December 17, 2014
Friday, December 17th 10:00 a.m. –11:30 a.m. (Sessions 3 & 4)Session 2: Initial Treatment
Session 3: Septic shock Treatment • Define your role in the care of the Septic patient.• Explain the rationale for each element in the Surviving Sepsis bundle.
• Apply the steps of Septic Shock care into your practice.
Session 4: Sepsis Recognition for Nursing Assistantsand ER Techs
• Recognize the importance of the early identification of Sepsis. • Define your role as a member of the Sepsis care team. • Identify three signs and symptoms that patients could display during the progression of Sepsis.
Presented at the WSHA Safe Table Webcast on December 17, 2014
SEPSISWhat is it? How do we find it? How do we fix it?
Mark Blaney RN, BSN, CENWSHA Training - 2014
P
Presented at the WSHA Safe Table Webcast on December 17, 2014
SEPSISSession 3: 6-Hour Bundle
Mark Blaney RN, BSN, CENWSHA Training - 2014Presented at the WSHA Safe Table Webcast on December 17, 2014
Session 3 Objectives
• Define your role in the care of the Septic patient
• Explain the rationale for each element in the Surviving Sepsis Campaign 6-hour bundle
• Apply the steps of Septic Shock care into your practice
Presented at the WSHA Safe Table Webcast on December 17, 2014
CARE OF THE SEPTIC PATIENT
Presented at the WSHA Safe Table Webcast on December 17, 2014
Role in Sepsis Care• Prevention• Assessment and recognition• Advocating for your patient• Team work
Consider calling a Code Rapid Response early
Presented at the WSHA Safe Table Webcast on December 17, 2014
Role in Sepsis Care• RNs must be severe sepsis experts:
Have knowledge of risk factorsRecognize classic & atypical signs and symptomsUnderstand potential diagnostic tests and their useKnow potential differential diagnoses and include sepsis as one of themUnderstand evidence-based standards of care for sepsis
Presented at the WSHA Safe Table Webcast on December 17, 2014
3-Hour Bundle ReviewMeasure lactate levelObtain blood cultures prior to antibioticAdminister broad-spectrum antibioticAdminister 30ml/kg crystalloid for hypotension or lactate ≥4 mmol/L
Surviving Sepsis Campaign, 2012Presented at the WSHA Safe Table Webcast on December 17, 2014
Sepsis Care Overview• Step 1: SIRS + Infection (Sepsis)
Notify Provider nowRequest labs: lactate, CBC, blood cultures x2, etc.Ask: “Do you want to start an antibiotic now?”
• Step 2: MAP <65, SBP <90, lactate > 2?Ask: “Do you want a 30ml/kg fluid challenge?”
• Step 3: Fluid challenge ineffective? (MAP <65, lactate ≥4)
Request transfer to ICU if not done already (6-Hour Bundle)Presented at the WSHA Safe Table Webcast on December 17, 2014
6-Hour BundleIf hypotension persists despite volume
Utilize vasopressors to maintain MAP ≥65If hypotension persists or initial lactate ≥4
Measure CVPMeasure ScvO2
Remeasure lactate
Surviving Sepsis Campaign, 2012
Presented at the WSHA Safe Table Webcast on December 17, 2014
6-Hour Bundle
Target: CVP ≥8 mm Hg, ScvO2 ≥70%, normalization of lactate
Surviving Sepsis Campaign, 2012
Presented at the WSHA Safe Table Webcast on December 17, 2014
Sepsis Care Overview• Step 1: Continue fluid administration
• Step 2: If MAP <65 mmHg despite adequate fluid administration:
Initiate vasopressors to target MAP ≥65 mmHg
• Step 3: If hypoperfusion persists:Initiate inotropic therapy
Presented at the WSHA Safe Table Webcast on December 17, 2014
Sepsis Care Overview• Step 4: Consider mechanical ventilation
• Step 5: Consider blood product administration
Presented at the WSHA Safe Table Webcast on December 17, 2014
Sepsis Care• Step 1: Continue fluid administration if there is
continued hemodynamic improvementCentral Venous Pressure (CVP)**Pulse PressureStroke Volume Variation (SVV) or Pulse Pressure Variation (PPV)Arterial Blood Pressure (ABP)Heart rate
Presented at the WSHA Safe Table Webcast on December 17, 2014
Sepsis Care – Step 1• Central Venous Pressure (CVP)**
Static preload assessmentLimited use as a marker for intravascular volume status and potential fluid responsiveness
Right ventricle is very compliant and adjusts to meet cardiovascular needs
Dellinger, et al., Critical Care Medicine, 2013; 588
Presented at the WSHA Safe Table Webcast on December 17, 2014
Sepsis Care – Step 1• Central Venous Pressure (CVP)**
A low CVP can be relied on to support continued volume resuscitationWill not give us an effective endpoint for fluid resuscitation
Dellinger, et al., Critical Care Medicine, 2013; 588
Presented at the WSHA Safe Table Webcast on December 17, 2014
Sepsis Care – Step 1• SVV & PPV
Dynamic assessmentCan be used to assess fluid responsivenessRequires patient to be mechanically ventilated with controlled tidal volumesEquipment:
PPV: arterial lineSVV: special monitor (FloTrac, Vigileo) and an arterial line
Dellinger, et al., Critical Care Medicine, 2013; 597Enomoto TM, Harder L. Crit Care Clin. 2010;26(2): 307-21
Presented at the WSHA Safe Table Webcast on December 17, 2014
Sepsis Care – Step 1• Fluid responsiveness:
PPV: >13% difference in systolic peak between inspiration and expiration
SVV: >13% difference in SVV
Dellinger, et al., Critical Care Medicine, 2013; 597Enomoto TM, Harder L. Crit Care Clin. 2010;26(2): 307-21
Presented at the WSHA Safe Table Webcast on December 17, 2014
Sepsis Care – Step 1• SVV & PPV
Utility is limited:Atrial fibrillationRight heart failureSpontaneous breathing (modern ventilation techniques)Low pressure support ventilationLow tidal volumes (<10 ml/kg)
Dellinger, et al., Critical Care Medicine, 2013; 597Enomoto TM, Harder L. Crit Care Clin. 2010;26(2): 307-21
Presented at the WSHA Safe Table Webcast on December 17, 2014
Sepsis Care – Step 1• What if your patient is spontaneously
breathing?Inferior vena cava ultrasound
Looks at collapsibility of the vesselPassive leg raise
Bolus the patient from their own systemic circulation
Enomoto TM, Harder L. Crit Care Clin. 2010;26(2): 307-21
Presented at the WSHA Safe Table Webcast on December 17, 2014
Sepsis Care – Step 1• Passive leg raise
Raise legs to 45˚ for 2 minutesBoluses 100-300 ml into central circulation
Presented at the WSHA Safe Table Webcast on December 17, 2014
Sepsis Care – Step 1• Passive leg raise
Does the stroke volume or MAP improve?9% increase in stroke volume10% increase in pulse pressure10% increase in mean arterial pressure (MAP)
If yes, patient is likely fluid responsive
Enomoto TM, Harder L. Crit Care Clin. 2010;26(2): 307-21
Presented at the WSHA Safe Table Webcast on December 17, 2014
Sepsis Care – Step 1• Goals of fluid administration
MAP >65 mmHgCVP ≥8 mmHg
Surviving Sepsis Campaign, 2012
Presented at the WSHA Safe Table Webcast on December 17, 2014
Sepsis Care• Step 2: If MAP <65 mmHg despite
adequate fluid administration:Initiate vasopressors to target MAP ≥65 mmHg
1st choice: Norepinephrine2nd choice: Norepinephrine + epinephrine
orNorepinephrine + vasopressin
Surviving Sepsis Campaign, 2012
Sepsis Care – Step 2• Norepinephrine
Initial vasopressor of choicePrimarily α1 with few β1 effects
Vasoconstriction increasing SVR & MAPMinimal impact on heart rate
Titrate every 5-15 minutes to reach a target MAP of ≥65 mmHg
Allen, Journal of Infusion Nursing, 2014; 82-86
Presented at the WSHA Safe Table Webcast on December 17, 2014
Sepsis Care – Step 2• Vasopressin
Given in combination with norepinephrineVasopressin levels may be lower in Septic ShockV1 receptor agonist causing vasoconstriction in high doses
Recommended dose: 0.03 units/minTarget MAP ≥65 mmHg
Allen, Journal of Infusion Nursing, 2014; 82-86Dellinger, et al., Critical Care Medicine, 2013; 597
Presented at the WSHA Safe Table Webcast on December 17, 2014
Sepsis Care• Step 3: If hypoperfusion persists despite
adequate fluid volume & adequate MAP:Initiate inotropic therapy
• Dobutamine
Surviving Sepsis Campaign, 2012
Presented at the WSHA Safe Table Webcast on December 17, 2014
Sepsis Care – Step 3• Dobutamine
Inotropic agent of choiceβ1 adrenergic agonist
Increases cardiac contractilityTitrate up to 20 mcg/kg/minTitrate every 5-15 minutes to reach target ScvO2 of ≥70%
Allen, Journal of Infusion Nursing, 2014; 82-86Dellinger, et al., Critical Care Medicine, 2013; 597
Presented at the WSHA Safe Table Webcast on December 17, 2014
Sepsis Care – Step 3• ScvO2
Mixed venous oxygen saturationMeasurement of the relationship between O2consumption & deliveryMeasured in the superior vena cava or right atriumA decrease in O2 supply or increase in O2demand will lead to a deviation of ScvO2 from the normal range
Presented at the WSHA Safe Table Webcast on December 17, 2014
Sepsis Care – Step 3
Normal: 65-80%Goal in Septic Shock: ≥70%
Surviving Sepsis Campaign, 2012
• ScvO2
Presented at the WSHA Safe Table Webcast on December 17, 2014
Sepsis Care• Step 4: Consider mechanical ventilation
Especially in patients with Sepsis-Induced Acute Respiratory Distress Syndrome (ARDS)Recommended tidal volume of 6 ml/kgRecommended to utilize PEEP to avoid alveolar collapse
Surviving Sepsis Campaign, 2012
Presented at the WSHA Safe Table Webcast on December 17, 2014
Sepsis Care• Step 5: Consider blood product
administrationOnce tissue hypoperfusion is resolved, transfuse for Hgb <7 g/dLGoal Hgb = 7-9 g/dL or Hct ≥30%
Surviving Sepsis Campaign, 2012
Presented at the WSHA Safe Table Webcast on December 17, 2014
Endpoints of Resuscitation• Lactate normalization• ScvO2
• Base Deficit
• The use of a combination of endpoints is likely the goal
Presented at the WSHA Safe Table Webcast on December 17, 2014
Endpoints of Resuscitation• Lactate normalization
Measure of cellular level hypoperfusion**Recommended when ScvO2 is not availableProlongation of lactate clearance is associated with increased mortalityExample:
<24 hours – Survival24-48 hours – 25% mortality>48 hours – 86% mortality
Surviving Sepsis Campaign, 2012Abramson, D. J Trauma, 1993, 35, 584-599
Presented at the WSHA Safe Table Webcast on December 17, 2014
Endpoints of Resuscitation• Lactate normalization
Cautions**:Lactate is also a marker of metabolic stress and not only related to tissue hypoxiaIncreased lactate may be an important adaptive survival response in sepsisMay be a better marker of disease severity rather than a treatment endpoint
Marik PE, Bellomo R. OA Critical Care, 2013, Mar 01; 1(1):3
Endpoints of Resuscitation
Normal: 65-80%Goal in Septic Shock: ≥70%
Surviving Sepsis Campaign, 2012
• ScvO2
Presented at the WSHA Safe Table Webcast on December 17, 2014
Endpoints of Resuscitation• Achieving a reduction in lactate with an
ScvO2 ≥70% is associated with improved outcomes
Surviving Sepsis Campaign, 2012
Presented at the WSHA Safe Table Webcast on December 17, 2014
Endpoints of Resuscitation• Base Deficit
Indicator of anaerobic metabolismReflective of serum bicarb utilization to buffer acidosis (amount required to titrate 1L of blood to normal pH)
Resuscitation measures to restore tissue perfusion and cellular oxygenation should produce a reduction in base deficit as acidosis resolves
Presented at the WSHA Safe Table Webcast on December 17, 2014
Endpoints of Resuscitation• Base Deficit
Normal: +2 to -2Mild: -3 to -5Severe: >-10
Base deficit >-6 mmol/L is associated with severe injury and potential higher mortality
Davis, JW et al. J Trauma, 1998, 45, 873-877
Presented at the WSHA Safe Table Webcast on December 17, 2014
Resources• International Guidelines for Management of Severe Sepsis and Septic Shock: 2012
(Surviving Sepsis Campaign)Dellinger et. al, Crit Care Med. 2013, 41(2): 580-637
• Understanding Vasoactive MedicationsAllen, JM. Journal of Infusion Nursing, 2014, 37(2): 82-86
• Lactate clearance as a target of therapy in sepsis: A flawed paradigm.Marik PE, Bellomo R. OA Critical Care, 2013, Mar 01; 1(1):3
• Lactate clearances and survival following injuryAbramson, D. J Trauma, 1993, 35, 584-589
• Base deficit in the elderly: a marker of severe injury and death.Davis et. al, J Trauma, 1998, 45, 873-877
• AACN Advanced Critical Care Nursing, 2009
Presented at the WSHA Safe Table Webcast on December 17, 2014
SEPSISWhat is it? How do we find it? How do we fix it?
Mark Blaney RN, BSN, CENWSHA Training - 2014
Presented at the WSHA Safe Table Webcast on December 17, 2014
SEPSISSession 4: Sepsis Recognition for
Ancillary Staff
Mark Blaney RN, BSN, CENWSHA Training - 2014
Presented at the WSHA Safe Table Webcast on December 17, 2014
Session 4 Objectives• Recognize the importance of the early
identification of Sepsis
• Define your role as a member of the Sepsis care team
• Identify 3 signs and symptoms that patients can display during the progression of Sepsis
Presented at the WSHA Safe Table Webcast on December 17, 2014
• You are caring for a 84 y/o female admitted to Med-Surg with a urinary tract infection. She’s been in the unit for 2 days.
• You go in to take a set of vitals and notice that she’s acting more confused than she was a few hours ago.
• Vitals: HR 98, RR 22, BP 98/55, T 38.4˚C
Presented at the WSHA Safe Table Webcast on December 17, 2014
• You inform the RN who then calls the provider. Before you know it, labs are being drawn, and IV fluid is being hung.
• After the IV fluids are completed, you are asked to complete a few more sets of vital signs.
• Shortly after, your patient is transferred up to the Critical Care Unit.
Presented at the WSHA Safe Table Webcast on December 17, 2014
• What happened?
Presented at the WSHA Safe Table Webcast on December 17, 2014
WHY SHOULD WE CARE ABOUT SEPSIS?
Presented at the WSHA Safe Table Webcast on December 17, 2014
Sepsis
• 6th leading reason for hospitalization in the USA (2009)
836,000 cases annually (primary diagnosis)
829,500 cases annually (secondary diagnosis)
• 210,000 deaths per year
Why do we care?
$15.4B per year
Agency for Healthcare Research
& Quality, 2011
Presented at the WSHA Safe Table Webcast on December 17, 2014
Sepsis
• Mortality:Severe Sepsis: 30-50%Septic Shock: 50-60%
• Mortality has changed little since the 1960s (until recently).
Why do we care?
Presented at the WSHA Safe Table Webcast on December 17, 2014
Sepsis• Every hour of delay in antibiotic
administration reduces survival by 7.6%
Recommendation is to give antibiotics within 1 hour of sepsis recognition Must be given within 3 hours to be compliant with the 3-hour bundle
Why do we care?
Surviving Sepsis Campaign, 2012
Dellinger, 2004; Kumar, 2006
Presented at the WSHA Safe Table Webcast on December 17, 2014
SepsisWhy do we care?
• Takeaways:Early recognition is critical to patient outcomeVital sign abnormalities and changes in patient condition can be useful to help identify Sepsis early
Presented at the WSHA Safe Table Webcast on December 17, 2014
WHAT IS SEPSIS?
Presented at the WSHA Safe Table Webcast on December 17, 2014
Sepsis• “a systemic, deleterious host response to an
infection.” (Dellinger, et al., Critical Care Medicine, 2013, 583)
• Must be treated like a medical emergencyCan progress rapidly to severe sepsis & septic shock within 24 hours (AACN Practice Alert, 2010)
• Healthcare workers have just hours to deliver the right care
Presented at the WSHA Safe Table Webcast on December 17, 2014
Sepsis• Sepsis is a disease state continuum :
SIRS (as a result of an infection)SepsisSevere SepsisSeptic ShockDeath
Presented at the WSHA Safe Table Webcast on December 17, 2014
Condition Definition
Systemic Inflammatory
Response Syndrome(SIRS)
Temp < 36°C (97°F) or > 38.3°C (101°F)HR > 90 beats/minRR > 20 breaths/min or PaCO2 < 32 mm HgWBC > 12,000 cells/mm3 (leukocytosis) or < 4,000 cells/mm3 (leukopenia) or Bands > 10% immature (band) forms
Sepsis Infection + ≥ 2 SIRS criteria
Severe Sepsis Sepsis + organ dysfunction, hypoperfusion, or hypotension
Septic ShockSevere Sepsis + hypotension despite adequate fluid
resuscitation, + presence of perfusion abnormalities that requires pharmacological intervention (vasopressors and/or inotropic agents)
Presented at the WSHA Safe Table Webcast on December 17, 2014
Sepsis• Risk Factors for Severe Sepsis or Septic Shock:
<1 and >65 years oldPost surgeryMalnourishmentBroad spectrum antibiotic useChronic illnessDiabetesImmunodeficiency (AIDS, immunosuppressive agents, etc)CancerChronic Renal FailureEtc…
Presented at the WSHA Safe Table Webcast on December 17, 2014
Pathophysiology1. A bacterial infection releases endotoxins which initiate an
inflammatory response (pneumonia, UTI, etc)
2. The inflammatory response triggers the:a) Release of white blood cellsb) Injury and vasodilation of the blood vessels c) Amplification of the immune response d) Creation of fibrin strands and the development of clots
Presented at the WSHA Safe Table Webcast on December 17, 2014
Pathophysiology3. This systemic inflammatory response can lead to
maladaptive SIRS (usually in patients with risk factors)
4. These components act on vascular endothelium causing:a) Blood vessel injuryb) Capillary leakagec) Microthrombi formationd) Impaired fibrinolysis
Presented at the WSHA Safe Table Webcast on December 17, 2014
Pathophysiology5. This damage results in a systemic imbalance between
cellular O2 supply and demand leading to global tissue hypoxia
Global Tissue Hypoxia is a central concept in the understanding of the
sepsis continuum.
Presented at the WSHA Safe Table Webcast on December 17, 2014
SEPSIS SIGNS & SYMPTOMS
Presented at the WSHA Safe Table Webcast on December 17, 2014
Signs & Symptoms• Sepsis:
SIRS symptoms• Temperature alterations (T <36 or >38.3˚C)• Tachypnea (RR >20)• Tachycardia (HR >90)• ↑ or ↓ white count
WeaknessInfection source-specific signs and symptoms
Most common: Urinary Tract Infection & PneumoniaPresented at the WSHA Safe Table Webcast on December 17, 2014
Signs & Symptoms• Severe Sepsis & Septic Shock:
Vital signs alterationsTachycardia (HR >90)Tachypnea (RR >20)Hypotension (SBP <90)Hypoperfusion (MAP <65)
Presented at the WSHA Safe Table Webcast on December 17, 2014
Signs & Symptoms• Severe Sepsis & Septic Shock cont.:
Skin signs Color: Pale or mottledTemperature: Cool or coldMoisture: Clammy or wet
Organ dysfunctionConfusionDecreasing urine output
Presented at the WSHA Safe Table Webcast on December 17, 2014
SEPSIS TREATMENTS
Presented at the WSHA Safe Table Webcast on December 17, 2014
Sepsis Treatments• Sepsis
Lab draws (CBC, blood cultures, lactate)AntibioticsFrequent vital signs
Presented at the WSHA Safe Table Webcast on December 17, 2014
Sepsis Treatments• Severe Sepsis
Frequent vital signsVolume resuscitation
“Fluid Challenge” – Normal saline 30 ml/kg @ 2L/hr
Presented at the WSHA Safe Table Webcast on December 17, 2014
Sepsis Treatments• Septic Shock
Transfer to Critical CareFrequent vital signsContinued IV fluid administrationIV medications to improve blood pressure and perfusion statusPotential intubationPotential blood product administration
Presented at the WSHA Safe Table Webcast on December 17, 2014
ROLE IN SEPSIS CARE
Presented at the WSHA Safe Table Webcast on December 17, 2014
Role in Sepsis Care• Sepsis
Frequent vital signsFacilitate lab draws
• Severe SepsisFrequent vital signsObtain IV tubing, IV pumps, pressure bags, or rapid infuserAssist with other patients in your assignment
Presented at the WSHA Safe Table Webcast on December 17, 2014
Role in Sepsis Care• Septic Shock
Frequent vital signsAssist with other patientsFacilitate transport to Critical Care Unit
Presented at the WSHA Safe Table Webcast on December 17, 2014
Resources• International Guidelines for Management of Severe Sepsis and Septic Shock: 2012
(Surviving Sepsis Campaign)Dellinger et. al, Crit Care Med. 2013, 41(2): 580-637
• Understanding Vasoactive MedicationsAllen, JM. Journal of Infusion Nursing, 2014, 37(2): 82-86
• Lactate clearance as a target of therapy in sepsis: A flawed paradigm.Marik PE, Bellomo R. OA Critical Care, 2013, Mar 01; 1(1):3
• Lactate clearances and survival following injuryAbramson, D. J Trauma, 1993, 35, 584-589
• Base deficit in the elderly: a marker of severe injury and death.Davis et. al, J Trauma, 1998, 45, 873-877
• AACN Advanced Critical Care Nursing, 2009Presented at the WSHA Safe Table Webcast on December 17, 2014
Upcoming Safe Table Events
• January 28, 2015: Safe Table Web Conference ‐ Radiology
• February 10, 2015: Safe Table – Obstetrics
• February 17, 2015: Safe Table Web Conference – Infections
• February 25, 2015: Safe Table ‐ Radiology
• http://www.wsha.org/events.cfm
Presented at the WSHA Safe Table Webcast on December 17, 2014