Cindy Johnson, MS, RN, CAPA Clinical Simulation Educator-NGHS
Susan A. Irick MS, RN, ACNP-C Disease Manager Sepsis & Pneumonia-NGHS
¡ Identify knowledge about the impact of sepsis in healthcare
¡ Review basic pathophysiology involved in sepsis
¡ Identify the importance of early recognition and rapid interventions for improved patient outcomes
¡ Identify nursing’s role in the process ¡ Review Surviving Sepsis Campaign’s updated guidelines
SEPSIS
In 2009, Sepsis:
¡ Caused 1.7 million hospitalizations in U.S.
¡ Caused 258,000 deaths in 2009
¡ Sepsis care costs $15 -‐ $17 billion dollars per year in the U.S.
¡ Sepsis has a higher annual death rate than heart attacks, stroke, or cancer
¡ In-‐hospital incidence of sepsis has increased 9% yearly since 2000.
Non-healthcare providers commonly refer to sepsis as blood poisoning or blood infection. Although blood poisoning is a
common term for sepsis, it isn’t an accurate description of the disease and the two terms should not be used interchangeably. Sepsis is not an infection in of itself. Sepsis is the body's often
deadly response to infection or injury
2011 Sepsis Alliance/Harris Poll demonstrated that less than ½ of Americans have ever even heard the word “SEPSIS”
Sepsis is a Medical Emergency that is caused by an overwhelming immune response of the body to infection.
The body’s normal defense mechanism is amplified, setting off a
cascade of events that can lead to widespread inflammation, leaky vessels, and microvascular coagulation
This causes impaired blood flow to the organs thus causing damage by
depriving them of nutrients and oxygen, which leads to organ failure.
Symptoms are not caused by the germ (microorganism) itself, but by the body’s response to fight the germ !!!
§ Triggered by invasion of bacteria in the tissue § Complex process ▪ Localizes/controls bacterial invasion ▪ Activates phagocytic cells ▪ Generates cytokines (nonspecific mediators of inflammation) ▪ Neutrophils are activated to perform phagocytosis and release of mediators
§ Results in tissue repair and healing
Neviere, R. (2013). Pathophysiology of sepsis. UpToDate.
¡ Generalized immune response leads to widespread cellular injury
¡ Cellular injury results in organ dysfunction ¡ Circulatory dysfunction results in diffuse vasodilation, redistribution of intravascular fluid
¡ Decreased microcirculation and microvascular clotting
¡ Coagulation abnormalities Neviere, R. (2013). Pathophysiology of sepsis. UpToDate.
Sepsis is defined by the following stages: ¡ SIRS : defined by 2 or more of the following criteria
¡ SEPSIS : SIRS plus present or suspected infection
¡ SEVERE SEPSIS : Sepsis plus one other criteria
¡ SEPTIC SHOCK : Severe Sepsis that fails to respond to fluid resuscitation –(30ml/kg)
¡ SIRS -‐ 10% ¡ Sepsis -‐ 20% ¡ Severe Sepsis 20 – 40% ¡ Septic Shock 40 – 60%
Kleinpell R, Aitken L, Schorr CA. (2013).Implications of the new international sepsis guidelines for nursing care. Am J Crit Care, 22(3):212-‐22.
Systemic Inflammatory Response Syndrome (defined by TWO or more of the following)
¡ Heart rate > 90 beats per minute ¡ Temperature < 96.8ºF (36º C) or
> 1oo.4º F (38º C) ¡ Respiratory rate > 20 breaths per minute or PaCO2 < 32mmHg
¡ White blood cell count > 12,000/mm3 or < 4000 mm
¡ OR normal WBC with > 10% bands
¡ SIRS criteria met: § plus present or suspected infection § Other symptoms include: ▪ Altered mental status ▪ Hyperglycemia (>140mg/dl with no hx diabetes) ▪ Mottled skin, delayed capillary refill ▪ Tachypnea ▪ Lactate > 1
The key to this stage is the presence of infection. Studies show the actual source of infection is not known in 49% of
sepsis cases.
Severe Sepsis : ¡ Sepsis plus one other criteria – organ dysfunction
§ Acute oliguria for two hours (<0.5 ml/kg per hour) despite fluid resuscitation
§ Organ dysfunction (serum lactate > 4) § Hypo-‐perfusion (MAP < 65 mmHg, acute oliguria, increase in creatinine)
§ Platelets count < 100,000 § Hypotension SBP < 90mm/hg or > 40mm drop below baseline BP
¡ Septic Shock is severe sepsis that fails to respond to fluid resuscitation –(30ml/kg) § Acute Lung Injury with PaO2/FiO2 ratio<250 in absence of pneumonia or <200 in presence of pneumonia
§ New elevation bilirubin >2.0, Creatinine > 2.0 § New Platelet Count <100,000 § Unexplained PT (INR)> 1.5
Bone RC, et al. Chest 1992;101:1644-55.
► Sepsis ● Known or suspected
infection, plus ● ≥2 SIRS criteria
► Severe Sepsis ● Sepsis plus ● ≥1 organ dysfunction
► Septic Shock ● Sepsis with hypotension
despite fluid resuscitation, plus perfusion abnormalities
Sepsis Definitions - Summary
Macrophage Ingesting Staphyloccocus Bacteria
www.cellsalive.com
Active Phagocytosis www.cellsalive.com
Pathogenic insult resulting in infection
Microthrombi formation Endothelial damage ↑ Capillary permeability and
edema formation
Enhanced expression of adhesion molecules
Massive cytokine production
Effector molecule release
Inflammatory/Immune System Response
Specific genetic signaling
Neutrophil and Monocyte activation
Endothelial cell activation Platelet dysfunction
Apoptosis Imbalance between inflammation and
antiinflamation
↓ Fibrinolysis
↑ Coagulation
Quadrad of dysfunction in sepsis
Reduced tissue/cellular perfusion
Oxygen & substrate debt
Organ dysfunction
Insult phase
Molecular activation
phase System
dysfunction phase
Organ dysfunction
phase
¡ ↑ formation of microthrombi
¡ ↓ clot breakdown (impaired fibrinolysis)
¡ Results in: § Widespread coagulopathy
§ Microvascular thrombosis
§ Multiple organ dysfunction
Ahrens, T. (2013). Sepsis update: Early identification and management. AACN Webinar Series
¡ Role of endothelium § Lines blood vessels § Reacts to mediators § Results in dysfunction
¡ Increase in vascular permeability § Physical disruption allows capillary leak into interstitial space and results in peripheral hypoxia
§ Vasodilation – hypotension
Ahrens, T. (2013). Sepsis update: Early identification and management. AACN Webinar Series
Stimulation of Mediator Release via WBC
Journal of Critical Illness, 1991
Interruption of Endothelium Integrity
Journal of Critical Illness, 1991
Progression of Endothelial Dysfunction
Journal of Critical Illness, 1991
1. Assess for adequacy/patency of airway – high flow oxygen
2. Antibiotics – within the first hour along with rapid source identification and control. Do not delay initiation of antibiotics.
3. IV Fluid therapy – Maintain BP and hemodynamic parameters. Initial fluid resuscitation should be with crystalloid IVF(NS, LR, etc) at 30mL/kg.
4. Vasopressors – ONLY if fluids not effective. Target MAP >65 mmHg.
Norepinephrine, Epinephrine, Vasopressin
1. Labs – Blood Cultures x 2 PRIOR to antibiotics within 1 hour of sepsis diagnosis, Lactate level, CBC w/diff
For every hour delay in antibiotic administration, the patient’s risk of dying increases by 7.6%.
¡ Pneumonia ¡ Intra-‐abdominal infection ¡ Acute pyelonephritis ¡ Skin/soft tissue infection ¡ Possible necrotizing fasciitis ¡ Neutropenic fever ¡ Unknown source
¡ Treatment should not be delayed ¡ Importance of protocols to implement
¡ Essential elements § Definitive antibiotics § Supportive treatment with oxygenation, ventilation
§ Circulatory support with fluid & inotropic administration
§ Maintain glucose level <180 mg/dL
¡ Knowledge of the pathophysiology, signs & symptoms, and treatment of severe sepsis is critical § Early detection is key to reducing mortality
§ Recognition of SIRS criteria § Recognition of clinical evidence of sepsis
§ Prompt institution of treatment measures
Kleinpell, Graves & Ackerman. AACN Clinical Issues 2006;17;4:1-9
Surviving Sepsis Campaign: Phase III
► A global, multi-‐center, 2-‐year trial ● Multiple hospital networks ● 166 sites ● 15,022 patients
► Primary outcome ● The impact of a model for changing bedside management of sepsis
► Secondary outcome ● Mortality
Surviving Sepsis Campaign
► Primary outcome of SSC: Use multi-faceted intervention – Facilitate knowledge transfer and
change clinical practice • 20% increase in compliance over 24 months
► Secondary outcome – Change in clinical practice would be
associated with decreased mortality • 7.0% ARR, 19% RRR • 5.4% ARR after severity adjustment
¡ To be completed within 3 hours § Measure lactate level § Obtain blood cultures prior to antibiotic administration § Administer broad spectrum antibiotics § Administer 30ml/kg crystalloid for hypotension or lactate ≥ 4 mmol/L
¡ To be completed within 6 hours § Apply vasopressors (for hypotension that does not respond to initial fluid
resuscitation) to maintain a MAP ≥ 65 mmHg § In the event of persistent arterial hypotension despite volume resuscitation
(septic shock) or initial lactate ≥ 4: ▪ Measure central venous pressure (CVP)** ▪ Measure central venous oxygen saturation (Scvo2)** ▪ Remeasure lactate if initial lactate was elevated.
¡ American Association of Critical Care Nurses
¡ Society of Critical Care Medicine (Survivingsepsis.org)
¡ Sepsis Alliance (sepsisalliance.org)
¡ World Sepsis Day (world-‐sepsis-‐day.org)
¡ American College of Emergency Physicians (www.acep.org/sepsis/)
¡ I.D.S.A. – Infectious Disease Society of America (www.idsociety.org)
¡ Delinger, RP, Levy, MM, et.al. (2013). Surviving Sepsis Campaign : International guidelines for management of severe
sepsis and septic shock. Critical Care Medicine Journal, 41, 2.
¡ Picard, K., O’Donoghue, S., Young-‐Kershaw, D., & Russell, K. (2006). Development and Implementation of a
Multidisciplinary Sepsis Protocol. Critical Care Nurse, 26, 43-‐54.
¡ Levinson, A., Casserly, B., Levy, M. (2011). Reducing mortality in severe sepsis and septic shock. Seminars in Respiratory
and Critical Care Medicine, 32:2.
¡ Casserly, B., Baram, M., et.al. (2011). Implementing a collaborative protocol in a sepsis intervention program : lessons
learned. Lung ,189: 11-‐19.
¡ Giardis, M., Rinaldi, L., Donno, L. et.al. (2009). Effects on management and outcome of severe sepsis and septic shock
patients admitted to the intensive care unit after implementation of a sepsis program : a pilot study. Critical Care ,13:R143.
¡ Ahrens, T. (2013). Sepsis update: Early identification and management. AACN Webinar Series.
¡ Kleinpell R, Aitken L, Schorr CA. (2013). Implications of the new international sepsis guidelines for nursing care. Am J Crit
Care,22(3):212-‐22.
THANK YOU !!!
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