Severe SepsisSevere SepsisInitial recognition and resuscitationInitial recognition and resuscitation

Issued August 2010Issued August 2010

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Expected Practice

Assess all patients and immediately notify physician when a patient presents with risk factors for sepsis.

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Clinical Findings

Documented or suspected infection

Two or more SIRS criteria

At least one indicator of tissue hypoperfusion or related acute organ dysfunction

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SIRS criteria

Heart rate > 90 beats per minuteTemperature < 36°C (98.8°F) or >

38.3°C (100.4°F)Respiratory rate > 20 breaths per

minute White blood cell count > 12,000/mm3 or

< 4000 mm

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Tissue hypoperfusionSepsis related acute organ failure

Acute altered mental status

SBP <90mmHg or MAP < 70mmHg or SBP Decrease of 40 mmHg

Blood glucose > 140 mg/dL, non-diabetic patients

Arterial hypoxemia

Acute oliguriaCreatinine increase

above baselineCoagulation

abnormalitiesIleusThrombocytopeniaHyoperbilirubinemia

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Expected Practice

Obtain serum lactate measurements. Hyperlactatemia is defined as lactic acid level > 4.

Obtain blood cultures as well as cultures from all potential sites of infection prior to initiating broad spectrum antibiotics

Blood cultures should be drawn prior to initiation of antibiotic therapy and within 1 hour of sepsis diagnosis

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Expected Practice

Evaluate for and remove other potential sources of infection

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Maintain Therapeutic Endpoints

MAP at >65 mmHgCVP 8-12 mmHgCentral venous or mixed venous

oxygen saturation > 70%

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Expected Practice

Administer fluids to maintain:Mean arterial pressure at >65 mmHgCentral venous pressure (CVP)

8-12 mmHgCentral venous or mixed venous oxygen

saturation > 70%.

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Expected Practice

Administer vasopressors if necessary to achieve a mean arterial pressure of 65 mmHg

If Venous Oxygen saturation goal not attained consider;

Additional fluidsBlood transfusion Dobutamine infusion

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Expected Practice

Maintain blood glucose levels at < 150 mg/dL.

Consider administration of human recombinant activated protein C

Note: Administration of human recombinant activated protein C (drotrecogin alfa activated) is no longer recommended. The FDA sent out notification on October 25, 2011 that Eli Lilly has withdrawn this drug from the market.

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Scope and Impact of the Problem

Severe sepsis is a major healthcare problem that affects millions of people around the world each year with an extremely high mortality rate of 30-60%.

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Scope and Impact of the Problem

Mortality from sepsis is greater than that of breast cancer, lung cancer, and colon cancer combined and is the number one cause of death in the non-coronary ICU. The incidence of severe sepsis is expected to double over the next 25-30 years.

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Supporting Evidence

More than 750,000 cases of severe sepsis occurred annually

Sepsis can rapidly progress to severe sepsis to septic shock within 24 hours

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Supporting evidence

Treatment should be initiated regardless of where the patient is located within the hospital.

Patients treated aggressively within the first 6 hours of presentation have lower mortality

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Supporting evidence

Serum lactate levels can be elevated in the setting of a normal or increased cardiac output.

The measurement of serum lactate can reflect occult decreases in global tissue perfusion and may be an indicator of organ dysfunction.

The presence and the clearance rate of lactate are associated with increases in patient morbidity and mortality.

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Supporting evidence

Early administration of appropriate antibiotics decreases mortality in patients with Gram- positive and negative bacteremias.

Empiric broad spectrum antibiotics should be initiated prior to identification of the infecting organism

Reassess after 48-72 hours based on culture results and clinical data.

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Supporting evidence

Surviving Sepsis Campaign guidelines state that the goal of the first 6 hours of treatment

Achieve and maintain a CVP of 8-12 mm Hg or 12-15 mm Hg for patients receiving mechanical ventilation and a MAP of at least 65 mm Hg with fluid resuscitation.

Dobutamine is identified as the medication of choice to increase cardiac output to normal levels or to improve lactate clearance

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Supporting evidence

No benefit has been shown for increasing cardiac output above physiologic normal levels.

Available data do not support the use of low dose dopamine for renal protection

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Supporting evidence

Colloids have not been shown to be of more benefit than crystalloid for fluid resuscitation.

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Supporting evidence

Fluid replacement should be optimized before vasopressors are started.

Norepinephrine or dopamine are identified as the initial vasopressors to increase vascular tone and blood pressure.

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Supporting evidence

Meta analyses concluded that administration of high dose corticosteroids are of no benefit or may be detrimental to patients with septic shock.

In vasopressor dependent shock, low-dose exogenous cortisol may improve the uptake of the patient’s own and the exogenously administered sympathetic stimulants when serum cortisol levels are low.

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Supporting evidence

Glucose levels within 80-110 mg/dL may decrease morbidity and morality in a surgical population.

Glucose levels < 150mg/dL showed reduced morbidity in critically ill medical patients.

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Supporting evidence

Administration of human recombinant activated protein C (drotrecogin alfa activated) is no longer recommended. The FDA sent out notification on October 25, 2011 that Eli Lilly has withdrawn this drug from the market. In a recently completed clinical trial (PROWESS-SHOCK trial), the drug failed to show a survival benefit for patients with severe sepsis and septic shock.

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Actions for Nursing Practice

Educate all nursing staff on the risk factors and clinical signs of sepsis.

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Actions for Nursing Practice

Create an interdisciplinary team to develop protocols or guidelines.

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Actions for Nursing Practice

Consider development of a rapid response team to facilitate prompt identification of patients with sepsis.

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