1. Sepsis

2. Statistics
Lake Health averages 29 deaths associated with Sepsis every month
Severe Sepsis is reported in 2.26 cases per 100 hospital discharges and one in five admissions to the ICU
Of the 750,000+ severe sepsis cases each year in the US, an estimated 215,000 (28.6%) die.
In the US more than 500 people a day die of sepsis
Between 28-50% of people who get sepsis die
60% of cases occur in those aged 65 years or older
Mortality from sepsis is greater than breast cancer, lung cancer, and colon cancer combined and is the #1 cause of death in the non-coronary ICU
Overall sepsis is the 10th leading cause of death in the US
Every 20 seconds someone in the US is diagnosed with Sepsis

3. Severe Sepsis & Septic Shock Mortality
April 2015 – March 2016 Lake Health Severe Sepsis & Septic Shock Deaths
Lake Health averaged 7 deaths per week
TriPoint Medical Center averaged 11 deaths per month
West Medical Center averaged 18 deaths per month

4. Statistics
The risk of death should you develop severe sepsis is the same as if you were a pedestrian hit by a car at 44mph.
Data comes from Britain- graphic but true.

5. Statistics
So…
Equals

6. Goals Identify high-risk patients based on early symptoms
Mobilize resources for intervention
Protocols to implement early goal directed therapy for sepsis
Reduce morbidity and mortality from sepsis

7. SIRS Systemic Inflammatory Response Syndrome
SIRS is nonspecific and can be caused by ischemia, inflammation, trauma, infection, or several insults combined. Thus, SIRS is not always related to infection

8. What is Sepsis?
Sepsis is a continuum of hyper-accentuated bodily responses to infection…
Sepsis is SIRS with a proven, or strongly suspected infectious source
SIRS will set off the screen – sepsis requires clinical thought!
SIRS is a little pile of snowballs… SEPSIS is SIRS with a proven or strongly suspected infectious source…. Like a big pile of snow – like this snowman. Sepsis can be a continuum. There is sepsis and moderate sepsis, the diagnosis is extremely objective.

9. Identifying Organ Dysfunction in Severe Sepsis
CNS
Alteration in mental status
Respiratory
PaO2/FiO2 < 200 if lung only dysfunction/site of infection.
PaO2/FiO2 < 250 if other organ dysfunction is present. Lung NOT site of infection
Cardiovascular
Tachycardia
SBP <90mmHg
MAP <70mmHg for at least 1 hour despite adequate fluid resuscitation
Need for vasopressors
Metabolic
Unexplained metabolic acidosis
pH <7.3 or base deficit > 5.0
Elevated lactate
Renal
Urine output < 0.5 ml/kg/hour
Acute Renal Failure
Hematologic
Platelet count < 80 or
Decreased by 50% over the last 3 days (DIC)
Gastrointestinal
Hepatic dysfunction

10. Identifying Organ Dysfunction: Cardiovascular
Tachycardia
Hypotension due to diffuse vasodilation
Arterial Hypotension
Signs & Symptoms
HR > 90 sustained
SBP < 90
MAP < 70
Confusion / Lethargic
Mottled Skin
Skin cool & clammy
Capillary Refill > 3 seconds
MAP = SBP + 2(DBP) 3

11. Identifying Organ Dysfunction: Respiratory
Inadequate Capillary Blood Flow
Increased Alveolar Capillary Permeability
Leads to Pulmonary Edema
Inadequate Oxygen Exchange in the Alveolocapillary Membrane
Leads to Hypoxemia
Signs & Symptoms
Tachypnea / Shortness of Breath
Respiratory Rate > 20 breaths/min
Diminished Breath Sounds
Cyanosis
Pleuritic Chest Pain
Confusion / Agitation
Low pulse oximeter
New need for supplemental oxygen

12. Identifying Organ Dysfunction: Renal
Acute tubular necrosis due to hypoperfusion and/or hypoxemia
Microcirculatory dysfunction
Elderly patients carry a higher incidence rate of Sepsis Associated Acute Kidney Injury (AKI)
Bacteremia, abdominal and genitourinary sepsis, and infective endocarditis higher likelihood to develop AKI
Signs & Symptoms
Decrease urine output < 0.5 ml/kg/hour
Fluid retention, peripheral edema
Drowsiness / Confusion
Nausea
Creatinine > 2.0 or 0.5 increase from baseline

13. Identifying Organ Dysfunction: Hematologic
Neutropenia seen with at risk patients (Post chemotherapy, elderly, chronic alcohol abuse, and co-morbid conditions such as COPD)
Thrombocytopenia often precedes DIC
Elevated bands with normal white blood cell count is associated with infection (especially gram-negative, pneumococcal bacteremia and C. diff)
Signs & Symptoms
Perceived or actual fever
Hypothermia
Rigors/Shivering
Flu-like symptoms
Petechiae
Decrease Platelets

14. Identifying Organ Dysfunction: Hepatic
Liver normally acts as the first line of defense in clearing bacteria and endotoxins
Liver dysfunction prevents the elimination of the endotoxins resulting in spillover into the systemic circulation
Coagulation abnormalities may increase risk of bleeding
Altered glucose metabolism due to increase gluconeogenesis
Signs & Symptoms
Jaundice
Encephalopathy
Ascites
Right upper quadrant tenderness
Hematemesis
Hypotension
Elevated Serum Total Bilirubin > 2.0
Acute on Chronic

15. Identifying Organ Dysfunction: Metabolic
Lactate can identify tissue hypo-perfusion in patients who are not yet hypotensive but who are at risk for septic shock
Early indicator of severe sepsis
Lactate
Severe Sepsis / Organ Dysfunction > 2.0
Septic Shock > 4.0
Lactate Clearance: For every 10% increase in lactate clearance the mortality decreases by 11%

16. Identifying Organ Dysfunction: Neurologic
CNS complications are usually an early sign of sepsis
Brain dysfunction includes impaired cerebral perfusion, blood-brain barrier dysfunction, altered neurotransmission
Change in Mentation must be new
(a change from the patient’s baseline)
Altered Consciousness
GCS < 15
Confusion
Lethargy
Psychosis
Encephalopathy

19. Click on the clip board to find the sepsis screening assessment
ED Tracking Board
Sepsis Icon triggered by 2 abnormal vital signs (SIRS Criteria) upon triage.
Click on the clip board to find the sepsis screening assessment

20. Sepsis Screening Assessment
Click to Locate Assessment

21. Select the two abnormal vital signs in section 1
Select all abnormal vital signs
Click the box to open section 2 of screening tool

22. Assess patient for any one item in section 2
Select all applicable risk factors based on your patient assessment
Click the box to open section 3 of screening tool

23. Assess patient for any one item in section 3 and complete the form
Select all applicable risk factors based on your patient assessment

24. Sepsis Screening Tool Downtime Form

25. Notify Physician
If YES to all 3 questions regarding abnormal vital signs, exam/lab, patient history
Notify Physician ASAP that patient may have sepsis
Initiate Code Sepsis
Repeat screening if patient condition changes

28. New process…to better care for our patient ED to ICU
All ED orders are to be followed until the inpatient physician writes orders.
This rule applies to SEPSIS ONLY
These patients will not necessarily be stabilized! However, the orders will stand to allow us to continue the resuscitation until we get MD orders.

29. Draw before antibiotics are given
Part of the 3 hour bundle
Part of the 3 hour bundle
Part of the 3 hour bundle
Draw before antibiotics are given
Administration of antibiotics are also part of the 3 hour bundle

30. SEPSIS BUNDLE Sepsis Bundle 3 HOUR Bundle Lactate
Blood Cultures x2 drawn before antibiotics
Broad Spectrum antibiotics administered
IV Fluids 0.9% Normal Saline 30 ml/kg bolus if SBP < 90 or Lactate > 4.0
6 HOUR Bundle
Vasopressors if patient does not respond to IV Fluid Bolus
Repeat Lactate 4 hours after initial draw
Physician Assessment
We are 100% responsible for completing the 3 hour bundle!!

31. Norepinephrine (Levophed) is the first line vasopressor to treat hypotension after fluid administration.
Dopamine should be considered only in patients at very low risk of tachy arrhythmias and with a low cardiac output and/or low heart rate

32. Questions? Time to start saving lives and improving patient outcomes 