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Sepsis Protocol Go Live December 1, 2009. Hendricks Regional Health. Phases of Sepsis. Phase I: SIRS (System Inflammatory Response Syndrome) Criteria Phase II: Septic Phase III: Severe Septic Phase IV: Septic Shock. SIRS – Phase I.

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Sepsis Protocol Go Live December 1, 2009


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phases of sepsis
Phases of Sepsis
  • Phase I: SIRS (System Inflammatory Response Syndrome) Criteria
  • Phase II: Septic
  • Phase III: Severe Septic
  • Phase IV: Septic Shock
sirs phase i
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 < 4,000 or > 10% band forms
sepsis phase ii
Sepsis – Phase II
  • The patient has Sepsis, if
    • 2 of 4 SIRS criteria present
    • suspected or confirmed source of infection
severe sepsis phase iii
Severe Sepsis – Phase III
  • A patient withsepsis 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
septic shock phase iv
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%
hrh data
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%)
slide8
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
lactate levels
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
room for improvement
Room for Improvement
  • Recognize early signs of Sepsis (41%)
  • Obtain venous lactate (0%)
  • Earlier initiation of pressors
  • Blood cultures obtained
sepsis resuscitation bundle first 6 hours
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
sepsis resuscitation bundle ed icu
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
sepsis management bundle 24 hours
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
slide16
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

oxepa
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

conclusions
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