1. Sepsis Protocol Go Live December 1, 2009 Hendricks Regional Health

2. Phases of Sepsis Phase I: SIRS (System Inflammatory Response Syndrome) Criteria Phase II: Septic Phase III: Severe Septic Phase IV: Septic Shock

3. SIRS – Phase I SIRS (Systemic Inflammatory Response Syndrome) Criteria Temp >38 C (100.4 F) or < 36 C (96.8 F) HR > 90 RR > 20 or PaCO2 < 32 or mechanical ventilation WBC > 12,000 or 10% band forms

4. Sepsis – Phase II The patient has Sepsis, if 2 of 4 SIRS criteria present suspected or confirmed source of infection

5. Severe Sepsis – Phase III A patient with sepsis complicated by: Tissue hypoperfusion (need fluid) Elevated venous lactate (> 2.1 mmol/L) Oliguria Sepsis-induced hypotension SBP < 90 MAP < 65 mm Hg Decrease in SBP of > 40 mm Hg below normal Organ dysfunction

6. Septic Shock – Phase IV Despite adequate fluid therapy, SBP < 90 or MAP < 65 Sometimes difficult to distinguish between severe sepsis from septic shock Carries a mortality rate of 40-60%

7. HRH Data Audited 44 patient charts in 2008: Admitted with Sepsis diagnosis - 18 patients (41%) Admitted to Med/Surg - 28 patients (63.6%) FASTeam to ICU - 7 patients (25%) Admitted to ICU - 16 patients (36.3%) Met SIRS Criteria/Septic, different diagnosis than sepsis– 14 patients (31%)

8. Average cost of hospitalization $29,000 Average hospital length of stay 7.3 days Average hospital length of stay in ICU – 9.4 days Death 2 patients (4.17%) Xigris was not administered in 2008

9. 2008 Review of Data

10. Lactate Levels Indication for tissue hypoperfusion and oxygenation Elevated Lactates > 2.1 mmol/L Identified before the patient is hypotensive (early indication) Common with severe septic and septic shock patients All patients are to be started on the protocol, regardless of BP Serial lactate levels are helpful to assess adequacy of therapies in shock patients Lactate levels will be drawn q 3 hours x 3

11. Room for Improvement Recognize early signs of Sepsis (41%) Obtain venous lactate (0%) Earlier initiation of pressors Blood cultures obtained

12. Sepsis Resuscitation Bundle – First 6 hours Measure venous lactate (other labs and tests: ABG, CBC, BMP, CK/Trop, urine cultures, sputum cultures, CXR) Blood cultures obtained prior to antibiotic administration Administer broad-spectrum antibiotics within 3 hours of ED admission and within one hour of non-ED admission Hypotensive/serum lactate >2.1 mmol/L Deliver 20 ml/kg of NS (adequate amount) Administer Vasopresors for hypotension not responding to fluid resuscitation to maintain MAP > 65

13. Sepsis Resuscitation Bundle – ED/ICU If hypotension continues after adequate fluid bolus and/or lactate level > 2.1 mmol/L, insert PreSep Catheter: Central venous pressure (CVP) 8-12 mm Hg Central venous saturation (ScvO2) >/= 70% Temp-Sensing Foley Catheter: Urine Output > 0.5ml/kg/hour Temperature monitoring Mechanical Ventilation PaO2/FiO2 ratio </= 250 Plateau Pressures < 30 Start Vasopressors (norepinephrine preferred-need central line) Xigris may be considered If no central line, start dopamine and titrate to MAP >/= 65 or SBP >/= 90 mm Hg

14. ED/ICU

15. Sepsis Management Bundle – (24 Hours) Followed on any Severe Septic patient Low dose steroids Maintain glucose control greater then the lower limit of normal, but less then 150 mg/dl GI Bleeding Prophylaxis DVT Prophylaxis Venous Lactate levels q 3 hours x 3

16. Enteral nutrition is preferred over parenteral because it is associated with improved patient outcomes. Suggest initiate enteral nutrition when: Patient is malnourished Patient not expected to resume po within 5 days Patient is fluid resuscitated and hemodynamically stable Enteral feeding route can be established There is no bowel obstruction distal to the site of feeding Information provided by: Robin Matejcek, Registered Dietitian at HRH

17. OXEPA Complete, balanced nutrition formula with eicosapentanoic acid, gamma-linolenic acid, and elevated levels of antioxidants to help modulate the inflammatory response. Use in critically ill patients with sepsis, ALI or ARDS clinically shown to: Reduce markers of pulmonary inflammation Improve oxygenation Decrease requirements for vent support Decrease ICU stay Decrease development of new organ failures Reduce mortality Information provided by: Robin Matejcek, Registered Dietitian at HRH

18. Conclusions New sepsis orders are intended to smooth processes of care. Nursing and other ED and ICU staff have been educated on the early recognition and aggressive resuscitation of sepsis patients. For comments, please provide feedback to Adam Andres, David Farman or John Sparzo