1 / 49

Severe Sepsis Education

Severe Sepsis Education. Why is there a Severe Sepsis Project?. TJUH observed to expected mortality ratio in sepsis is high United Health Consortium expected mortality from sepsis 21% TJUH observed mortality from sepsis 34% Observed/expected ratio 1.59

tao
Download Presentation

Severe Sepsis Education

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Severe Sepsis Education

  2. Why is there a Severe Sepsis Project? • TJUH observed to expected mortality ratio in sepsis is high • United Health Consortium expected mortality from sepsis 21% • TJUH observed mortality from sepsis 34% • Observed/expected ratio 1.59 • More patients died from sepsis than stroke and CHF combined • Sepsis processes and outcomes will be monitored similarly to patients with chest pain, stroke, and community acquired pneumonia in regards to time sensitive treatment and therapy • Implementation of a severe sepsis protocol reduces mortality* *The Surviving Sepsis Campaign. Crit Care Med 2010(38):367.

  3. Baseline Data at TJUH • Gram negative pyelonephritis was the most common etiology (50%) • Areas of needed improvement • Early identification of severe sepsis • Cultures before antibiotics • Early, appropriate, adequate antibiotics • Adequate fluid, vasopressor resuscitation • Documentation of I/O’s • Prompt triage to intensive care unit

  4. Objectives • To differentiate between SIRS, sepsis, severe sepsis, and septic shock • To evaluate all patients for potential severe sepsis by clinical assessment and use of tools such as SIRS alerts and sepsis first line orders • To implement severe sepsis protocol in an efficient and timely manner • To promptly transition care to an intensive care unit

  5. Sepsis: a growing concern • 10th leading cause of death (200,000 deaths/year) • 5-10 billion dollars/year of healthcare cost The number of cases and case fatalities from sepsis is expected to increase due to: • Aging of the population • Increasing patients with multiple co-existing morbidities • Increasing bacterial resistance and opportunistic infections • Increasing use of invasive devices for monitoring and therapy • Increasing use of immunosuppressive medications

  6. Infection: inflammatory response to microorganisms, or invasion of normally sterile body tissues Systemic Inflammatory Response Syndrome (SIRS): systemic response to a variety of insults (burns, trauma, pancreatitis, infection) Sepsis is SIRS in the setting of suspected or proven infection SIRS/Sepsis: ACCP/SCCM Definitions

  7. SIRS/Sepsis: Definitions SIRS: presence of 2 or more of the following criteria • Fever (core temperature > 38.3 C or 101.0 F) or hypothermia (core temperature < 36 C or 96.8 F) • Heart rate > 90 beats/min • Respiratory rate > 20 breaths/min or PaCO2 < 32 or need for mechanical ventilation for an acute respiratory process • WBC > 12,000/mm3, < 4,000/mm3, or bands > 10% Sepsis: patient meets the criteria for SIRS and has a suspected or confirmed infection.

  8. Potential Clinical Clues for Suspected Infection History/symptoms Fever, chills, lethargy, or malaise Productive cough Headache Sore throat Diarrhea, abdominal pain Dysuria, cloudy urine Sick contacts Recent surgery/instrumentation Recent chemotherapy Signs Disorientation Tachypnea Tachycardia Hypoxia Hyper/hypo-thermia Decreased urine output Hypotension

  9. Continuum from Sepsis to Septic Shock • Sepsis • 2 SIRS criteria plus suspected or documented infection • Severe sepsis • Sepsis plus at least one organ dysfunction (see next slide) • Septic shock • Sepsis plus persistent hypotension despite fluid resuscitation, or • Perfusion abnormalities

  10. Acute Organ Dysfunction in Severe Sepsis Tachycardia Hypotension Vasodilatation  Contractility Altered Consciousness Confusion Psychosis Oliguria Anuria  Creatinine Tachypnea PaO2 <70 mm Hg SaO2 <90% PaO2/FiO2300  Platelets  PT/APTT  Protein C  D-dimer Jaundice  Enzymes  Albumin  PT Neuropathy Myopathy

  11. Increased Mortality Along a Continuum Mortality (%) Rangel-Frausto, et al. JAMA 1995;273:117-23.

  12. Severe Sepsis Criteria Patient meets sepsis definition and has at least 1 sign of organ dysfunction*: • SBP < 90 mmHg, MAP < 65 mmHg for at least one hour despite adequate fluid resuscitation (20 ml/kg saline) or use of vasopressors • Lactate > 4 mmol/L • Urine output < 0.5 ml/kg/hr after adequate fluid resuscitation or rise in creatinine > 0.5 mg/dL over baseline • PaO2/FiO2 ratio < 300 or requiring > 4 liters oxygen via nasal cannula to maintain SpO2 > 90% • Platelets < 100,000/mm3, INR > 1.5, PTT > 60s *Organ dysfunction must be new onset

  13. Early Antibiotics Improves Survival in Septic Shock

  14. “Golden Hours of Sepsis” • Early recognition and intervention of patients with severe sepsis leads to improved outcomes • Similar concept to: • Acute coronary syndrome • Stroke • Trauma

  15. Steps to Early Recognition and Management of Sepsis in ED • First step: SIRS alert and identification • Second step: First-line order sets • Third step: Severe sepsis order set and rapid triage

  16. SIRS alert will be triggered electronically in WellSoft when 2 or more SIRS criteria are fulfilled (Clinical Decision Support column will turn pink) First Step: SIRS Alert and Identification

  17. Second Step: First-line ED Order Sets • If there is a suspected or confirmed infection, sepsis first line (initial) orders are initiated in the emergency department:

  18. Second Step: First-line ED Order Sets

  19. Use Severe Sepsis ED initial management order set for patients who meet case definition Provides single doses broad spectrum IV antibiotics Other labs, vasopressors as needed Initiate rapid triage pathway Contact Pulmonary critical/care fellow and/or attending (or SICU attending for surgical patients) for admission Notify patient flow management center for ICU bed assignment Notify ICU charge nurse to help facilitate transfer Third Step: Severe Sepsis Initial Management Order Set in the ED and Rapid Triage

  20. Severe Sepsis ED Initial Management Order Set • Assess airway • Insert/maintain 2 peripheral IV lines (18 gauge or larger) or place TLC for central IV access. • Obtain baseline CBC with diff, Chem 7, lactate, Accucheck, VBG, blood cultures x 2, U/A with culture, PT/PTT, and CXR. • Obtain further labs as indicated e.g. other cultures, cortisol level, LFTs, urine pregnancy. • Begin broad spectrum IV antibiotics within 1 hour of RECOGNITION of severe sepsis* (see Figure) • Administer 0.9% sodium chloride x 2 liter IV fluid bolus (or 20cc/kg) • Place foley catheter to monitor urine output *ED staff: Time from door to administration of antibiotics needs to be within 3 hours

  21. Severe Sepsis Emergency Dept. Mgmt Orders (provides single doses of broad spectrum IV antibiotics)

  22. Sepsis Emergency Dept. Management(Meds)

  23. Severe Sepsis Order Set (continued) If MAP < 65 or SBP < 90 after initial bolus, place central venous line (preferably SC or IJ) and initiate vasopressors Continue IV fluids as per physician discretion Document vital signs (HR, BP including MAP, RR, O2 sat) and I&Os Q1hour x 2 sets, then frequency as per physician discretion

  24. Antibiotic Management • Begin intravenous antibiotics within 1 hour of recognizing severe sepsis • Use broad spectrum agents active against likely bacterial/fungal pathogens and with good penetration into presumed source (see Figure on next slide) • Reassess antimicrobial regimen daily to optimize efficacy, prevent resistance, and avoid toxicity • All antibiotic regimens will be reviewed within 48-72 hours by the antimicrobial stewardship program

  25. History of multi-drug resistant gram negative infection/colonization within past 90 days OR Prior broad spectrum IV antibiotics within a hospital or long term care facility for > 72 hrs within previous 14 days NO YES Beta Lactam Allergy Beta Lactam Allergy Start antibiotics within1 hour of recognizing suspected severe sepsis Start antibiotics within1 hour of recognizing suspected severe sepsis YES NO Pip/Tazo + Vancomycin + Tobramycin SUBSTITUTE Ceftriaxone for pip/tazo in suspected meningitis Aztreonam + Vancomycin + Tobramycin + or - Metronidazole add metronidazole only if intra-abdominal infection suspected Meropenem + Vancomycin + Amikacin Consider previous susceptibilities and/or ID consultation Aztreonam + Vancomycin + Amikacin + Tigecycline Consider previous susceptibilities and/or ID consultation If suspected intra-abdominal catastrophe (i.e. perforation) suspected, add anidulafungin If community acquired or health-care associated pneumonia is suspected, add moxifloxacin NO YES

  26. History of multi-drug resistant gram negative infection/colonization within past 90 days OR Prior broad spectrum IV antibiotics within a hospital or long term care facility for > 72 hrs within previous 14 days NO YES Beta Lactam Allergy Beta Lactam Allergy Start antibiotics within1 hour of recognizing suspected severe sepsis Start antibiotics within1 hour of recognizing suspected severe sepsis YES NO Pip/Tazo + Vancomycin + Tobramycin SUBSTITUTE Ceftriaxone for pip/tazo in suspected meningitis Aztreonam + Vancomycin + Tobramycin + or - Metronidazole add metronidazole only if intra-abdominal infection suspected Meropenem + Vancomycin + Amikacin Consider previous susceptibilities and/or ID consultation Aztreonam + Vancomycin + Amikacin + Tigecycline Consider previous susceptibilities and/or ID consultation If suspected intra-abdominal catastrophe (i.e. perforation) suspected, add anidulafungin If community acquired or health-care associated pneumonia is suspected, add moxifloxacin NO YES

  27. History of multi-drug resistant gram negative infection/colonization within past 90 days OR Prior broad spectrum IV antibiotics within a hospital or long term care facility for > 72 hrs within previous 14 days NO YES Beta Lactam Allergy Beta Lactam Allergy Start antibiotics within1 hour of recognizing suspected severe sepsis Start antibiotics within1 hour of recognizing suspected severe sepsis YES NO Pip/Tazo + Vancomycin + Tobramycin SUBSTITUTE Ceftriaxone for pip/tazo in suspected meningitis Aztreonam + Vancomycin + Tobramycin + or - Metronidazole add metronidazole only if intra-abdominal infection suspected Meropenem + Vancomycin + Amikacin Consider previous susceptibilities and/or ID consultation Aztreonam + Vancomycin + Amikacin + Tigecycline Consider previous susceptibilities and/or ID consultation If suspected intra-abdominal catastrophe (i.e. perforation) suspected, add anidulafungin If community acquired or health-care associated pneumonia is suspected, add moxifloxacin NO YES

  28. History of multi-drug resistant gram negative infection/colonization within past 90 days OR Prior broad spectrum IV antibiotics within a hospital or long term care facility for > 72 hrs within previous 14 days NO YES Beta Lactam Allergy Beta Lactam Allergy Start antibiotics within1 hour of recognizing suspected severe sepsis Start antibiotics within1 hour of recognizing suspected severe sepsis YES NO Pip/Tazo + Vancomycin + Tobramycin SUBSTITUTE Ceftriaxone for pip/tazo in suspected meningitis Aztreonam + Vancomycin + Tobramycin + or - Metronidazole add metronidazole only if intra-abdominal infection suspected Meropenem + Vancomycin + Amikacin Consider previous susceptibilities and/or ID consultation Aztreonam + Vancomycin + Amikacin + Tigecycline Consider previous susceptibilities and/or ID consultation If suspected intra-abdominal catastrophe (i.e. perforation) suspected, add anidulafungin If community acquired or health-care associated pneumonia is suspected, add moxifloxacin NO YES

  29. History of multi-drug resistant gram negative infection/colonization within past 90 days OR Prior broad spectrum IV antibiotics within a hospital or long term care facility for > 72 hrs within previous 14 days NO YES Beta Lactam Allergy Beta Lactam Allergy Start antibiotics within1 hour of recognizing suspected severe sepsis Start antibiotics within1 hour of recognizing suspected severe sepsis YES NO Pip/Tazo + Vancomycin + Tobramycin SUBSTITUTE Ceftriaxone for pip/tazo in suspected meningitis Aztreonam + Vancomycin + Tobramycin + or - Metronidazole add metronidazole only if intra-abdominal infection suspected Meropenem + Vancomycin + Amikacin Consider previous susceptibilities and/or ID consultation Aztreonam + Vancomycin + Amikacin + Tigecycline Consider previous susceptibilities and/or ID consultation If suspected intra-abdominal catastrophe (i.e. perforation) suspected, add anidulafungin If community acquired or health-care associated pneumonia is suspected, add moxifloxacin NO YES

  30. History of multi-drug resistant gram negative infection/colonization within past 90 days OR Prior broad spectrum IV antibiotics within a hospital or long term care facility for > 72 hrs within previous 14 days NO YES Beta Lactam Allergy Beta Lactam Allergy Start antibiotics within1 hour of recognizing suspected severe sepsis Start antibiotics within1 hour of recognizing suspected severe sepsis YES NO Pip/Tazo + Vancomycin + Tobramycin SUBSTITUTE Ceftriaxone for pip/tazo in suspected meningitis Aztreonam + Vancomycin + Tobramycin + or - Metronidazole add metronidazole only if intra-abdominal infection suspected Meropenem + Vancomycin + Amikacin Consider previous susceptibilities and/or ID consultation Aztreonam + Vancomycin + Amikacin + Tigecycline Consider previous susceptibilities and/or ID consultation If suspected intra-abdominal catastrophe (i.e. perforation) suspected, add anidulafungin If community acquired or health-care associated pneumonia is suspected, add moxifloxacin NO YES

  31. Antibiotic Compatibilities Compatible Incompatible or No Data Available Regarding Compatibilities

  32. Antibiotic ManagementImportant Things to Remember • Check antibioticcompatibilities to see if antibiotics can be administered concurrently • If antibiotics can not be administered together due to incompatibility (e.g. piperacillin/tazobactam and tobramycin), use second peripheral IV line (or different lumens of TLC) to avoid delay • If only one IV line available, give gram negative agent first (piperacillin/tazobactam, aztreonam, or meropenem) unless specified (e.g. suspect gram positive line infection)

  33. Hemodynamic Management • Administer 0.9% Sodium chloride x 2 L IV bolus (or 20 ml/kg IV bolus) for volume resuscitation • If MAP < 65 or SBP < 90 after initial bolus, place central venous line (ideally SC or IJ) and initiate vasopressors • Continue IV fluids as per physician discretion

  34. Vasopressor Management • If MAP < 65 or SBP < 90 after initial volume resuscitation, initiate norepinephrine at 0.1 mcg/kg/min. (preferred) or dopamine • If patient has persistent or increasing vasopressor requirements, initiate vasopressin infusion at 0.04 units/min. • All patients on vasopressors require vital signs with every titration and every 1 hour once blood pressure goal is achieved • IV site should be checked frequently

  35. Vasopressors in Severe Sepsis • Administer norepinephrine or dopamine via central line • Peripheral administration of norepinephrine or dopamine permitted for no longer than 60 minutes via at least a 20 gauge catheter until central line placed

  36. Vasopressors in Severe Sepsis • If patient has persistent or increasing vasopressor requirements, initiate vasopressin continuous infusion • Emergent peripheral administration of vasopressin permitted for no longer than 60 minutes via at least a 20 gauge catheter until central line placed

  37. Importance of Documentation • Documentation in a manner that is accurate and accessible to all disciplines is imperative: • Necessary for the ongoing treatment of the patient • Necessary to monitor quality of care metrics • Blood cultures before antibiotics • Early, appropriate, adequate antibiotics • Initial fluid resuscitation • Use of vasopressors for hypotension despite initial fluids

  38. Documentation: Antibiotics • Name of antibiotics • Dosage of antibiotics • Time started • Route of administration • Note: 2 blood cultures, U/A, and urine culture should be obtained before administration of antibiotics

  39. Documentation: Fluid Resuscitation • All fluid boluses must be ordered in Jeff Chart • Nursing must sign out each bolus and record in a timely matter • Document response to fluids (Vital signs, urine output) • Accurate documentation of inputs and outputs • Document initiation and titration of vasopressor

  40. Rapid Triage Pathway • Patients identified as having SEVERE SEPSIS will have the rapid triage pathway initiated: • Call MICU Pulmonary/Critical Care fellow and/or attending (or SICU attending for surgical patients) for admission • Notify patient flow management center for bed assignment. Patient will be prioritized to MICU (or SICU for surgical patients). • Notify ICU charge nurse to help facilitate transfer ****Process of transfer should not delay therapy **** • Antibiotics MUST be initiated in ED • Provide vasopressors, additional IV fluids, perform imaging, etc. as needed prior to transfer

  41. Hand-off Communication • Physician to physician communication • ED physician must sign out patient to ICU resident OR nurse practitioner • Nurse to nurse communication - ED nurse report • Time severe sepsis identified and pathway initiated • Labs, cultures sent • Times each antibiotic started • Fluids received (IV fluid type and amount); urine output • Venous access available (central access/large bore peripherals) • Pending diagnostic studies (i.e. CXR, ABGs, labs, CT scans) • Next steps for therapy

  42. ICU Nurse Report • Highlight on report sheet “severe sepsis protocol” • Important documentation for severe sepsis patient • Time severe sepsis was identified • Total amount of fluids given for resuscitation and when • Time and type of pressor (if started) • Confirm 2 blood cultures, U/A, and urine culture sent • Times each antibiotic was started • ***If delay in antibiotics, document why and notify the physician immediately***

  43. ICU Initial Care **Sepsis Inpatient Managementorder set must be entered into JeffChart • Assure room properly prepared for admission • Possible arterial line set up (cables) • Have line cart available • Communicate with pharmacy regarding any need for back up IV drips (i.e. vasopressors, fluids) • Charge Nurse enters patient name in database with primary diagnosis of severe sepsis • Notify respiratory if ventilator is needed

  44. Use Severe Sepsis Inpatient Management Order (following ED order set with one time antibiotic doses )

  45. Choose Maintenance only for those patients who HAVE received one time dose of antibiotics Sepsis Inpatient Management Order Set (Choose the appropriate MEDS) Choose Initialand Maintenance for those patients who HAVE NOT received any appropriate antibiotics thus far

  46. Other Sepsis Management Steps • Control the source of infection • Use the ARDS protocol if there is a concern for acute lung injury • Consider use of cortisol replacement • Use goal directed resuscitation (lactate clearance, CVP, ScVO2 acceptable)

  47. Continued Sepsis Management • Promptly de-escalate/ alter antibiotics based on culture results and other clinical data • Stop antimicrobial therapy if cause is found to be noninfectious • Remove catheters (central lines, foley) as soon as no longer required • Duration of antibiotic therapy typically limited to 7-10 days, longer if response is slow or there are undrainable foci of infection or immunologic deficiencies

  48. Summary • Promptly identify Severe Sepsis using clinical judgment and ED assessment tools such as the WellSoft SIRS alert and first-line order set • Use severe sepsis order set to expedite treatment • Efficient management also requires: • Rapid triage to ICU • Accurate documentation • Effective communication during transition of care

  49. Severe Sepsis Protocol Key Elements • Collect blood cultures before antibiotics • Start appropriate IV antibiotics within 1 hour • Administer rapid, adequate fluid resuscitation • Start vasopressor if MAP <65 after initial IV fluid bolus

More Related