Implementing a Protocol and Interprofessional Education for Early Recognition and Management of Maternal Sepsis

Presented by: Lori Olvera DNP, RNC-OB, EFM-C

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Objectives

At the conclusion of this learning session the participant will be able to: Identify differences between Sepsis, Severe Sepsis, and Septic Shock Identify symptoms for early recognition and how to manage the septic

patient Identify the importance of implementing OB sepsis screening in the

perinatal setting Identify the importance of implementing protocols for early recognition

and management of maternal sepsis Identify the importance of using key stakeholders, RN champions,

Physician champions for implementing sepsis screening and management of maternal sepsis.

Identify the importance of using data collection to develop a program in maternal sepsis.

Identify the importance of training all perinatal staff in early recognition & management of maternal sepsis.

Code Sepsis in OB: Let’s Intervene before it hits!

Maternal Sepsis Video

• http://bcove.me/sd6wl76t

Katie dies of FLU at 26!

Pregnant Patients need to be included in our Sepsis Protocols!

“Pregnancies complicated by severe sepsis and septic shock are associated with increased rates of preterm labor, fetal infection, and preterm delivery. Sepsis onset in pregnancy can be insidious,, and patients may appear deceptively well before rapidly deteriorating with the development of severe shock, multiple organ dysfunction syndrome, or death. The outcome and survivability in severe sepsis and septic shock in pregnancy are improved with early detection, prompt recognition of the source of infection, and targeted therapy” Barton & Sibai, 2012

Acute Pyelonephritis Retained Products of Conception Neglected Chorioamnionitis or endometritis Pneumonia

1. Bacterial2. Viral

Influenza H1N1

Unrecognized or inadequately treated necrotizing fasciitis1. Abdominal incision2. Episiotomy/Perineal Laceration

Intraperitoneal Etiology1. Ruptured Appy2. Acute Cholecystitis3. Bowel Infarction

Urinary Tract Infections Mastitis

CAUSES OF SEVERE SEPSIS & SEPTIC SHOCK IN PREGNANCY & PUERPERIUM

Infectious disease ranks one of the four most common causes of maternal mortality and severe morbidity

Sepsis is one of the leading causes of preventable maternal deaths.

This is an example text. Go ahead and replace it

The lack of recognition of early warning signs of sepsis and guidelines to manage treatment of sepsis contributes to these preventable deaths

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5 Sepsis bundles – even when used incompletely –significantly decrease mortality (SSC 2013)

Septic shock is rare affecting .002-0.01 % of all deliveries

Sepsis Facts

Sepsis is one of the top four causes of maternal mortality Pregnant women are more vulnerable to infection and

susceptible to serious complications Screening protocols are needed for early recognition and

management of maternal sepsis All perinatal staff must be trained on early recognition and

management of maternal sepsis.

What does the literature say…..

Acosta, Kurinczuk, Lucas, Tufnell, Sellers & Knight, 2014

1. More women over 40 becoming pregnant2. Availability of “assisted reproductive technologies” results

in more invasive monitoring due to incidence of multifetal gestation

3. Disorders of pregnancy such as preeclampsia, placental abruption, amniotic fluid embolism, and PPH

4. Increasing rates of Obesity, diabetes, and C/S delivery5. C/S delivery: 3 times more likely to develop sepsis

Maternal Sepsis

Why is maternal sepsis on the rise?

Acosta & Knight, 2013

C/S delivery Emergency C/S Prolonged Rupture of the

Membranes Retained products of Conception Preterm Labor Multiple Vaginal Exams Obesity Diabetes Anemia Low socioeconomic status Winter months Failure to recognize severity

Risk Factors for Sepsis

OB Sepsis Syndrome

OB Specific Criteria

SIRS = Systemic Inflammatory Response Syndrome

Definition A clinical manifestation resulting from an insult,

infection, or trauma, that includes a body-wide activation of immune and inflammatory cascades

Systemic Inflammatory Response

Insult: Can be from anything

• Burn• Trauma• Infection• Surgery• Myocardial Infarction• Pancreatitis• Anesthesia• Allergic reaction

Pathophysiology of Sepsis

https://www.youtube.com/watch?v=o5sYBUarpmI

Inflammatory mediators (histamines, serotonin, cytokines) cause increase vascular permeability and vasodilation

Vascular Permeability: Increase permeability of blood vessels; leaky vessels • Migration of leukocytes to site of injury

Vasodilation: widening of blood vessels, resulting in pooling of blood, causing a relative decrease in intravascular volume; plasma & molecules leak into extravascular space

Pathophysiology

Obstetrical patient with Sepsis

• Small molecules such as Na, H2O leak through leaky vessels

• Some larger molecules such as ALBUMIN will escape as well (loss of osmotic pressure)

• Loss of fluid from intravascular space (tank is dry)

Pathophysiology

Continued

Effects of Increased Vascular Permeability of Capillaries

Reduced Circulating Volume

HypotensionTachycardia

Pathophysiology

Continued

This Results in….

The following symptoms…..

Hypotension Tachycardi

a

Organ Dysfunctio

n

Decreased oxygen to the organs

Accumulation of Extravascular FluidCauses…..

Peripheral Edema

Pulmonary Edema

Renal Edema

Liver Impairment

In Sepsis, there is increase oxygen demand

Increased oxygen demand

Requires increase in

oxygen delivery

Need to increase HR

Metabolic AcidosisIncreased Respiratory Rate

Cardiac depressionConfusion

Anaerobic Respiration OccursLactic Acid is a by-product (serum lactate)

Pathophysiology of Anaerobic RespirationIf Oxygen Demand of the tissues is not met by oxygen delivery

Conversion to Anaerobic Respiration

Lactate Acid production…..

Disseminated Intravascular Clotting

Sepsis causes

widespread clottingThis causes

consumption of platelets, clotting

factors and fibrinogen,

Impaired coagulation

Impaired risk of

bleeding

CONSUMPTIVE COAGULOPATHY

BLEEDINGCLOTTING

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Perinatal Parameters

• Because of the physiology of pregnancy and labor, we adjusted the screening criteria for Perinatal patients

• Increase in blood volume increases maternal heart rate by 10-20 bpm

• Minute volume (RR x Tidal Volume) increases 50% due to an increase in Tidal Volume

• Due to diaphragm position, lung volumes change causing increased respiratory rate

• Increase in WBC in labor and immediate postpartum• Increase in blood flow to the kidneys causes a decrease in

the creatinine level

“Severe Sepsis and septic shock in pregnancy: indications for delivery and maternal and perinatal outcomes”

– Retrospective chart review of OB patients with severe sepsis in the ICU• Severe sepsis N = 20• Septic shock N = 10

– 24 were antepartum– 6 were postpartum

• 11 pylonephritis – responsible for one maternal death• 7 pneumonia• 4 chorio• 2 fatty liver• 1 bacterial meningitis• Mortality rate 33% with septic shock

The Journal of Maternal-Fetal Medicine, 2013. Snyder, Barton, Habli, Sibai

Screening Criteria

Variable Severe Sepsis Septic Shock P value All patientsTemp >38.9 10/20 (50) 7/9 (78) nsSBP <90 6/19 (32) 10/10 (100) <0.001DBP <50 7/19 (37) 10/10 (100) 0.001HR > 110 18/20 (90) 9/9 (100) nsRR > 24 14/18 (78) 8/9 (89) nsWBC > 15, 000 16/20 (80) 9/10 (90) nsLactate >1.0 mmol/L

10/10 (100) 10/10 (100) ns 20/20 (100)

Lactate >4.0 mmol/L

2/10 (20) 2/10 (20) ns 4/20 (20)

Plt > 60s 0/18 (0) 3/9 (33) 0.03 9/30 (30)Mental status 1/20 (5) 8/10 (80) <0.001 9/30 (30)

Sepsis Screening Criteria for Non-OB adults vs. OB Screening Tool - adjusted for the physiological effects of pregnancy

Adult Screening Criteria• Temp > 38°C (100.4°F) or < 36°C

(96.8°F)• HR > 90• Resp Rate> 20• WBC >12,000, < 4,000 or >10%

Bands• New mental status change• Blood glucose > 140 mg/dl in the

absence of diabetes

Perinatal Screening Criteria Adjustments

• Temp > 38°C (100.4°F) or < 36°C (96.8°F)

• HR > 110• Resp Rate > 24• WBC > 15,000 or < 4,000 or

> 10 % immature neutrophils• Altered Mental Status present• Blood glucose > 140 mg/dl in absence

of diabetes

When should I perform the sepsis screening?

• Upon arrival to the unit (triage or direct admit)

• EVERY SHIFT and/or assuming care of patient

• PRN for suspicion/indication of new infection

Sepsis

• Definition:• The presence of 2 or

more SIRS criteria with a presumed or confirmed infectious process

Definition: Sepsis + Organ Dysfunction (resulting from Tissue

Hypo-Perfusion)

Severe Sepsis

Signs of Organ Dysfunction

RespiratoryInadequate oxygenation

Or ventilation

NeurologicChange in LOC

Global Hypoperfusion Lactate > 2mmol/L

CardiovascularHypotension

SBP < 90mmHG or MAP < 65

RenalU/O < 30ml/hr

Elevated Cr. (>1.5) Hematologic

Platelets < 100,000Coagulopathy (INR> 1.5 or aPTT > 60sec)

Organ Dysfunction Criteria

DefinitionPersistent arterial hypotension

despite 30ml/kg volume resuscitation or an Initial lactate > 3.9 mmol/L(Both may be present)

Septic Shock

Sepsis Syndrome

2 SIRS CRITERIA

ANY SIGN OFORGAN DYSFUNCTION

HypotensionDespite FluidResuscitation

SURVIVING SEPSIS CAMPAIGN

Bundles Elements when used together, improve

outcomes more than when used separately!Evidence based

Severe Sepsis Bundle: TO BE COMPLETED WITHIN 3 HOURS

Time zero = time of confirmed positive sepsis screen by RRT

– Measure lactate level– Obtain blood cultures prior to administration of

antibiotics– Administer broad spectrum antibiotic(s)– Administer 30 mL/Kg crystalloid for hypotension or

lactate > 3.9 mmol/L

Delay in diagnosis and treatment of sepsis has been shown to ↑ mortality

Pregnant patients look deceptively well before rapidly deteriorating

Early recognition and treatment of maternal sepsis will improve survival, decrease length of stay, and length of stay in the ICU

WHY DO WE NEED BUNDLES FOR EARLY RECOGNITION?

Barton & Sibai, 2012

Randomly assigned 263 patient who presented to ED with severe sepsis/septic shock

Received either 6 hours of EGDT or conventional care before ICU

Mortality was 30.5% in patients receiving EGDT

Mortality was 46.5% in patients receiving conventional care

Implementation of Sepsis Bundle for Early RecognitionRivers, 2001

Blood Cultures? Why?

Recommended to draw prior to antibiotic administration, but should NOT delay antibiotics.

If antibiotics have been administered, still have cultures drawn

When patient not responding to antibiotic regime, blood culture results are used to narrow antibiotic treatment to most appropriate antibiotic choice

Measure Lactate Level

Why is it important1. Prognostic value of raised lactate levels are well

established in septic shock patients2. Elevated levels in sepsis support aggressive resuscitation3. Mortality is high (46.1 %) in septic patients with both

hypotension and lactate > 3.9 mmol/L4. Mortality in severely septic patients with Lactate >3.9 mmol/L alone is 30%

www.survivingsepsis.org

• 52 participants (approximate)• Exclusion criteria: only healthy without risk factors• Lactate levels drawn

Upon admission Transition, 7-10 cm dilated 6 hours postpartum

SMCS Lactate Level in Pregnancy & Postpartum By Beth Stephens-Hennessy CNS, RNC

96% Lactate< 4mmol/dl88% Lactate<2mmol/dl

The Median Value of Lactate

Fluid Resuscitation

Administer 30ml/kg Crystalloid for Hypotension or Lactate > 3.9 mmol/LNS

Patients with severe sepsis/septic shock experience ineffective circulation due to the vasodilation associated with infection or impaired cardiac output

Poorly perfused tissue beds result in global tissue hypoxia, which result in serum lactate level

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Fluid Resuscitation

A serum lactate is correlated with severity of illness and poorer outcomes even if hypotension is not present.

Patients with hypotension or lactate > 3.9 mmol/L require intravenous fluids to expand circulating volume and restore perfusion pressure

When to give? Lactate > 3.9 mmol/Lor suspected hypovolemia

Broad Spectrum Antibiotics – (Administer as soon as possible) within 3 hours of T-0

Administration of APPROPRIATE antibiotics reduces mortality in patients with Gram-positive and Gram-negative bacteremias

Although restricting antibiotics is important for limiting super-infection and decreasing development of antibiotic resistance, patients with severe sepsis and septic shock warrant broad spectrum antibiotic therapy until antibiotic susceptibilities are defined.

Combination therapy is more effective than monotherapy until causative organism is found

ChorioamnionitisAmpicillin 2 g IV Q6hr for 60 minutesGentamicin 1.5mg/kg/dose IV Q8H for 60 min

Add Clindamycin 900mg IV Q8H for 30 min (for anaerobe coverage if patient has C/S)

Endometritis Ampicillin 2 g IV Q6H for 60 min Gentamicin 5mg/kg/dose, IV Q24H for 60 min Clindamycin 900mg IV Q8H for 30 min

Gold Standard Antibiotics for Common Infections In Obstetrical Patients

Your Logo

PyelonephritisRocephin 1g in 50ml NS IV Q24H for 30 minFor Rocephin allergy, order Ampicillin 1 g IV Q6h for 60

min and Gentamicin 1.5 mg/kg/dose, IV Q8h for 60 min Community Acquired Pneumonia

Rocephin 1g IV Q24H for 30 minAzithromycin 500mg IV Q24H for 60 min IF MRSA suspected, Add Vanco 1mg IV Q12H

Gold Standard Antibiotics for Common Infections In Obstetrical Patients

Your Logo

Medications:Severe Sepsis &

Septic Shock

Give First pharmacy

recommendation

Zosyn (Piperacillin-Pazobactum)

3.375 MG IV now and continue pharmacy doing

ORIf penicillin allergy: Maxipime (Cefepime) 2 gm IV now For Significant PCN allergy (angioedema, resp distress, urticaria), GIVE ATREONAM 2gm IV q8H

VancomycinPer pharmacy dosing schedule

and

Discontinue all current antibiotics, then give:

Purpose

To Evaluate Staff compliance with early recognition and management of management of maternal sepsis before and following the implementation of standardized physician order set and interprofessional education for nurses and physicians in the perinatal setting

Women screening positive for Sepsis between April 2014-January 2015

Women > 20 weeks gestationN=99 Sepsis Screen positive patientsIRB Approval obtained

METHODOLOGY

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Using a systematic health record review, COMPLIANCE to the Sepsis Bundles was measured before, during, and following implementation of perinatal sepsis physician order set & education for physician & nurses (n=400)

PROJECT DESIGN

Task Force Team Physician Education First

A Multidisciplinary Team (stakeholders)

Interprofessional Education from Aug-Nov 2014

A new perinatal sepsis physician order SET was implemented October 2014

Physician & RN Champions Engagement of frontline leaders

INTERVENTIONS

Task Force

How we got started….

A small interdisciplinary group collaborated to design the framework for perinatal sepsis orders and protocol

RN Champions were recruited to represent all departments on all shifts

Pharmacists were recruited including Antimicrobial stewardships

Engaging frontline leaders was crucial to the success of project

Physician Champions RRT Laboratory Supervisors ICU educator Emergency Room Educator

Perinatal Sepsis Committee Formed

Physician Champion

Physician Buy-in crucial for the success of the projectProvided education to physiciansProvided opportunity to discuss “difficult sepsis cases” at MD Grand RoundsProvided literature for physicians

RN Champions

Provided 1:1 education to RN’s and MD’s

Education re: Sepsis screening, standardized physician order set, and evidence based practice for recognition and management of maternal sepsis

Mentoring of bedside RN how to manage patient screening positive for sepsis

Interprofessional Education

Formal 2-hour education for RN’sM&M Conference for PhysiciansGrand Rounds for PhysiciansPoster PresentationCase StudiesEvidence-based literature displayedA single sheet, quick reference guidesMandatory completion of computer based

module with a post-test

Guided the practitioner in giving appropriate antibiotic based upon source of infection

Antibiotics safe in pregnant women for common infections such as chorioamnionitis and pyelonephritis were included in order set

Antibiotics safe for pregnancy to treat severe sepsis and septic shock

Physician Order Set

Our patients are young & healthy, did not look septic The bundles would result in over-treatment Risk of Pulmonary of Edema Women with epidurals have fevers Antibiotic Resistance Lactate is normally elevated in the laboring woman To avoid doing Sepsis Screening during second stage of

labor

Education for Physician & Nurses

Addressing the Barriers

Outcome Measure

Health Records of women screening positive for Sepsis were reviewed to determine if educational intervention increased SEPSIS bundle compliance.

Data was divided into 2 groups:1. Pre-Intervention Data ( April-July 2014)2. Post-Intervention Data (August 2014-Jan 2015

Data collected for 3 parameters: Sepsis, Severe Sepsis, and Septic Shock

Bundle compliance was measured for all parameters. Intravenous fluids was measured for Sepsis, however,

was not required.

Outcome Outcome Measurement

Comparison….. To measure the difference

in bundle compliance pre and post intervention, data from the first time period was compared to data from second time period

What was the initial Infection? Data from the initial

infection was measured separately to determine source of infection

The Sources of Infection for Patients Diagnosed with Sepsis during PregnancySutter Medical Center Sacramento April 2014-January 2015

  Frequency (N=99) Percent (%)

Chorioamnionitis 45 46.4

Pyelonephritis 14 14.4

Endometritis 5 5.2

Urinary Tract Infection 5 5.2

Unknown 29 29

Frequency of Sepsis, Severe Sepsis and Septic ShockSutter Medical Center SacramentoApril 2014-January 2015*

* Deliveries ~4000

Results

Bundle Compliance Indicators in Patients with Sepsis, Severe Sepsis, and Septic Shock in Pre-and Post-Intervention

Weighted Cross Tabulations for Patients with Sepsis

Lactate Drawn (yes)

Broad-Spectrum Antibiotic

Administered (Yes)

Repeat Lactate Drawn (yes)

Pre-Intervention

23(74.2%) 24 (77.4%) 18(58.1)

Post-Intervention

60(90.9%) 63 (95.5%) 52 (78.8%)

p Value (<.05) .029 .006 .034

Statistical SignificanceAchieved

 Broad Spectrum Antibiotic Administered (No)

Broad Spectrum Antibiotic Administered (Yes)

P Value

p<.05

Pre-Intervention 4 (25%) 12 (75%) .010Post-Intervention 1 (2.6%) 37 (97.4%)  

Weighted Tabulations for Broad-Spectrum ATB Administered

In Patients with Severe Sepsis or Septic Shock

Statistical SignificanceAchieved

Statistical significance for effect of education & perinatal sepsis order on bundle compliance:

Draw LactateAdminister Broad Spectrum ATBDraw Repeat Lactate

Adjusted SIRS criteria for Maternal Sepsis is accepted! Physician & RN champions instrumental Antibiotic Type & timely administration Perinatal staff must be educated in early recognition and

management of maternal sepsis

Key Points

Sutter HealthMaternal Sepsis Recommendations

Looking at the impact of implementing a project regionally.

SMCS Sepsis Data

SIRS Criteria

Organ Dysfunction Criteria

Chart Data

Sepsis Screening Criteria for Non-OB adults vs. OB Screening Tool - adjusted for the physiological effects of pregnancy

Adult Screening Criteria• Temp > 38°C (100.4°F) or < 36°C

(96.8°F)• HR > 90• Resp Rate> 20• WBC >12,000, < 4,000 or >10%

Bands• New mental status change• Blood glucose > 140 mg/dl in the

absence of diabetes

Perinatal Screening Criteria Adjustments

• Temp > 38°C (100.4°F) or < 36°C (96.8°F)

• HR > 110• Resp Rate > 24• WBC > 15,000 or < 4,000 or

> 10 % immature neutrophils• Altered Mental Status present• Blood glucose > 140 mg/dl in absence

of diabetes

Obstetrical Sepsis Management Pathway

New or suspected infection

Evaluate for 2 or more SIRS Criteria

Temp > 100.4°F (38°C)HR > 110RR > 24WBC > 15,000, < 4,000 OR > 10% immature neutrophilsAltered mental statusBlood glucose > 140 mg/dL in absence of diabetes

Interventions for Simple Sepsis✓Draw Lactate, CBC, CMP, PT, PTT, INR, Serum creatinine☐ U/A Blood Cultures (2 sets prior to antibiotics)✓ IV Access✓Give Antibiotic (considering source of infection)Chest XRAY✓Rapid Response Team: RRT confirms + Sepsis Screen & initiates STAT labs (standardized proc)√ RRT RN initiates SEPSIS ALERT!Consider Source of Infection

SEPTIC SHOCKMORTALITY 40-60%

Clinical features are the same as severe sepsis Distinguishing Feature: Profound Hypotension BP Systolic <90, MAP<65 despite fluid resuscitation!

☐ LACTATE > 3.9 MMOL/L

Interventions for Septic Shock√ RRT calls Code Sepsis✓Broad spectrum antibiotics ✓Call Rapid Response Team✓ICU admission✓Anesthesia at bedside✓IV Fluids Normal Saline bolus 30 ml/kg NOW for lactate > 3.9 mmol or hypotensive✓Consider Central Venous Access

Any 1 or more features of acute organ dysfunction

Lactate > 2 mmol/LSBP < 90 mmHG or MAP < 65

☐ SBP decrease < 40mmHG from baseline ☐Bilirubin > 2mg/dlNew (or increased) oxygen requirement to maintain SP O2 > 92% Urine output < or equal to 30 ml/hr for 2 hours Platelet count < 100,000Coagulopathy (INR >1.5 or PTT >60 sec

Interventions for Severe sepsis✓Consider IV Fluids N/S for Lactate >2 mmol/L✓CALL RAPID RESPONSE TEAM✓Repeat lactate every 4-6 hours until Lactate < 2 ✓SpO2 and oxygen per protocol√Call MD to initiate OB severe Sepsis Order Set

SEPSIS

SEVERE SEPSIS

Sepsis Screen

SEPTICSHOCK

Yes

Yes

Yes

Yes

Sepsis Standard Work

Sepsis Recognition and Sepsis Care Should Be Standard For All Inpatients – Including Perinatal Patients

Early RecognitionWhat is Standard Work?

• Standard Work is a method used to complete nearly identical processes in a uniform way (used in manufacturing, Toyota)

• Improvement teams have adopted this approach in healthcare in attempts to

1) reduce variation in care (“No fluid bolus needed, she’ll just be in pulmonary edema”) 2) errors of omission (“I forgot to order a repeat lactate”)

• Typically standard work identifies a task, the operator to complete the task, the equipment required, the time frame for completion

• Though there are limits to standardization in work, there is much work that can be standardized

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Perinatal Sepsis Standard Work

Create Protocols with Adjusted SIRS criteria for Maternal Sepsis Early intervention implemented for all patients who screen

positive for sepsisArrival of Rapid Response Team followed by physician/

intensivist evaluation

Documentation and ReportsSepsis Summary Flowsheets

Sepsis ScreenSepsis Overview ReportSepsis Sidebar Report

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Vitals, lab, I/O will populate here from other flowsheets and results so that a complete sepsis assessment (screen can be done)

Sepsis Summary Flowsheet

YOU MUST COMPLETE ALL 4 QUESTIONS

1. Is an infection suspected?

Symptoms patient may have that

indicate Potential Infection

Sepsis Screen

2. Identify 2 or more NEW signs of SIRs

Sepsis Screen

Axillary Temp

3. Identify new signs of organ dysfunction

Sepsis Screen

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4. Pt meets criteria for Positive Screen?

Note: the criteria to be used when answering this question

Action Taken

Rows and groups display if answer to Question 4 is “Yes.”

Sepsis Start Time: TIME ZERO

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Severe Sepsis and Septic Shock Bundle Elements

This documentation populate the

sepsis overview to the specific

bundle completionIf YES, patient meets criteria for Code

Sepsis / 6 hour bundle

Sepsis Best Practice Alert

• Two new Best Practice Alerts1. Simple Sepsis2. Severe Sepsis (Organ Dysfunction)

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Applying what we have learnedCase Scenarios

Case Scenario #1Preterm with PPROM X 8 days

• 0848- T-97.8, BP 115/62, P-100, 98%, FHR 160• 1110-MD here to consent for C/S• 1200-C/S, Apgar 1/8. Baby to NICU• 1230. OBRR- Temp 101.8, P-120, SOB. 88/40. RRT

called. CBC, blood culture, lactate drawn. IV Fluids 2 L given. Zosyn started.

• 1300- Lactate 9. Urine output < 30ml/hr. Bleeding at incisional site. NS 2 L given on way to ICU. BP 88/44, p-122. Coags drawn in ICU. Extended stay for mother due to septic shock.

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Questions

• At what point did she meet SIRS criteria?• What signs of organ dysfunction did she have?• List the standard work that was done in response.

Scenario #2 2nd stage of Labor

• 0900-Twin gest 38.1 weeks, pushing in 2nd stage of labor. No other risk factors. Temp spiked to 102.1, P-130, R-22. Pt screened positive for sepsis. RN called MD in which MD gave orders to follow sepsis protocol.

• 0940-Lactate 5.6. WBC 26. LR 2 Liter bolus NS given, Zosyn ordered and administered.

• 0955,0958-patient delivered healthy twins. Health care team decided to manage care in L&D for recovery. Orders to redraw lactate at 1200. RN’s did not want to separate the mom-baby couplet. BP stable, P-110, Temp 100.1, R-20.

• 1130- Lactate drawn (1200)-3.9, 1 liter of NS given. Lactate drawn every 6 hours until lactate <2.

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Questions

• At what point did she meet SIRS criteria?• What signs of organ dysfunction did she have?• List the standard work that was done in response.• List the standard work that was not done.• Does lactate increase during labor and increase with

length of pushing?

8/3/13 @2216 Pt presented L&D Triage with R sided flank pain,fever of 101, and vomiting X2. OB Hx:

No risk factors; GA: 24 weeks, G-1, P-0Vital Signs:

HR=120, bp-103/58, FHR 165-170. Labs:

UA: 2+ nitrites, Pos for leukocyte esterase, 1+ protein, 2+ ketones, >100 WBC 4 RBC, 4+ bacteria

Outcome: Macrobid and D/C home. T-99.8,FHR=165 MD would call pt when UA culture returns in 48 hrs.

Culture…………Cx results: E.Coli >100,000

Leanna presents to Triage at 24 weeks…..

8/4@1900 Pt returns with fever, R sided flank pain, aches, N&V, chills, feeling dizzy, SOB..POSITIVE SEPSIS SCREENVS

P=130, BP 85/52, Map 64. O2 sat 99% FHR=140’s.

Treatment Ampicillin 2 gm given, 1 Liter LR given, RRT At bedside,

serial lactates, NS bolus. Gentamicin given.Response: 55 minutes later: T-98.2, P=102, BP101/61, O2 Sat 100,

lactic Acid-1.6. Patient transferred to HRM

LeeAnna……

6 hours later:Pt shivering, C/O SOB, o2 at 3L, o2 sat 95%, T=99.2,

P=114, BP100/61. Remains SOB. Lactic Acid 2.6 6 1/2 hrs:

RRT at BS. Clammy, O2 sat 94%, required O2 administration

7 hrs:-Orders to transfer to ICU. Central line placed.

12 hrs –chest Xray indicated fluid overload/interstitial edema

LeeAnna……

17 hours: pt intubated and sedated, VSS; CRP-264.7; albumin

1.8, WBC-21.1, Hgb 7.8Day 3

R nephrostomy tube, foley catheter. VSS. Transferred to HRM

Day 5 Central line d/c; D/C home at 1230!

LeeAnna……

continued

3 months laterAdmitted for SROM Nephrostomy tube in place. On Cipro 500mg Q12h 11/22@1430-delivered healthy baby girl!

LeeAnna……

Day of Delivery….

LeeAnna Septic Shock Survivor……

Let’s Begin the Campaign to promote Early Recognition & Management of Maternal Sepsis

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