Sepsis: Early Identification and Intervention

Sepsis: Early Identification
and Intervention
DeAmber Piel, MSN, RN, CNL
Sepsis Coordinator
OU Medical Center, Oklahoma City
Objectives
• Define criteria for SIRS, Sepsis, Severe
Sepsis and Septic Shock
• Review Sepsis Screening
• Identify goal directed treatment
Why talk about Sepsis?
•
•
•
•
Early recognition and treatment saves lives
Early sepsis often goes unrecognized
Many sepsis survivors suffer long term effects
Mortality rate is up to 50% for Septic Shock
patients
• Death from sepsis has killed more people than
AIDS or breast cancer
• High risk population: Aging,
immunosuppressed, invasive medical
treatments, and drug resistant organisms
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Faces of Sepsis™
Faces of Sepsis™ stories have been submitted by people who
have been touched by sepsis. Some stories are of survival, of
fighting back from this devastating illness. Other stories are
written by people who have been left behind because
someone they loved died of sepsis.
https://vimeo.com/sepsisalliance/faces
ofsepsis
SECTION 1
KEY COMPONENTS
DEFINED
Key Components:
Systemic Inflammatory Response Syndrome (SIRS)
Sepsis
Severe Sepsis
Septic Shock
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Let’s start with SIRS
SIRS is an inflammatory state affecting the whole body,
frequently a response of the immune system to infection, but
not necessarily.
SIRS Criteria
Temp: <36 °C (96.8 °F) or >38 °C (100.4 °F)
HR: >90/min
RR: >20/min
WBC: <4000/mm³ or >12,000/mm³
*A patient has SIRS with any 2 of the above*
SEPSIS
Sepsis = SIRS with a known or
HIGHLY suspected infection
Let’s look at an example:
Pt: Doe, John
Age: 85 Sex: M
Adm. Diag: PNA
Temp: 101
HR: 99
RR: 18
WBC: 12.9
CXR: left lower lobe pneumonia
So… do you think this patient has Sepsis?
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Let’s look again…
Pt: Doe, John
Adm. Diag: PNA
Age: 85 Sex: M
Temp: 101 +
HR: 99 +
RR: 18
WBC: 12.9 +
CXR: left lower lobe pneumonia +
So you have SIRS and a KNOWN infection = Sepsis
IF YOU SAID YES,
YOU’RE CORRECT!
Now that we’ve covered SIRS and SEPSIS, let’s
move on to SEVERE SEPSIS
Severe Sepsis= Sepsis
with ACUTE organ
dysfunction
Before we move on, we need to define what
exactly acute organ dysfunction means…
Organ dysfunction is defined as a
condition in which an organ does
not function as it is expected to.
When screening a patient
for Sepsis, it is important to
distinguish ACUTE organ
dysfunction from
CHRONIC.
ACUTE organ
dysfunction should relate
to something that is new
or different in the last 2448hrs.
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Maybe we should look at Mr. Doe again now.
We already know he has:
• SIRS
• SEPSIS
Looks like Mr. Doe is
sicker than you
originally thought…
You have his labs now and
his Creatinine is 4, but
according to Mr. Doe, he has
never had any renal issues
and his last Creatinine in the
computer (done 2 days ago)
was 0.3. Also, you notice
he’s had no urine output,
despite having given him
2000cc of NS in 1hr.
Now that Mr. Doe has an ACUTE organ
dysfunction, he has progressed to SEVERE
SEPSIS.
SIRS
SEPSIS
SEVERE
SEPSIS
Let’s review what you’ve learned so far:
1. SIRS = Systemic Inflammatory Response
Syndrome
2. Sepsis = SIRS with a known or highly suspected
infection
3. Severe Sepsis = Sepsis with ACUTE organ
dysfunction
So, what’s next?
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SEPTIC SHOCK
Septic Shock = Severe Sepsis
with persistent hypotension
despite fluid boluses and/or lactic
acid ≥4.
SEPTIC SHOCK IS A
MEDICAL EMERGENCY!
Let’s check on Mr. Doe again… Maybe his
condition will help to explain some things.
We’ve already established that Mr. Doe
has:
SIRS
SEPSIS
And… SEVERE SEPSIS
Now, his blood pressure is 72/40 and he is
less responsive.
So, what do you do?
Any type of bacteria can cause Septic Shock and the
body’s own inflammatory response (SIRS) may
contribute to organ dysfunction.
Mr. Doe is exhibiting the signs/symptoms of
SEPTIC SHOCK
For patient with Severe Sepsis or Septic
Shock
Notify Physician Immediately
Why? It’s a medical emergency and interventions must be
implemented immediately!
What will happen? Patient needs to be moved to a higher level of
care for appropriate, life saving interventions.
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PUTTING IT ALL TOGETHER…
• SIRS
You start with…
then you confirm an
infection (or strongly
suspect one)…
then you have acute
organ dysfunction…
then you have a
continued low BP and/or
a lactic acid ≥4
• SEPSIS
•SEVERE SEPSIS
•SEPTIC SHOCK
Section II
SCREENING FOR
SEVERE SEPSIS
AND/OR
SEPTIC SHOCK
THE SCREENING PROCESS
Step 1
SIRS
*based on vital signs & CBC
results*
Step 2
SEPSIS
*based on a known or suspected
infection*
Step 3
ORGAN DYSFUNCTION
*based on your assessment of
patient and labs*
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Common causes of Infection
to look for:
•
•
•
•
Respiratory Infections: CAP, HCAP
Urinary Tract Infections
GI Infections: C Diff, perforated bowel
Skin or soft tissue infections: decubitus
ulcers, cellulitis
SIRS:
Temp ³38 or ≤ 36
HR >90
SEPSIS SCREENING
RR >20
WBC ³ 12000 or ≤4000
SEVERE SEPSIS=
SIRS (+) 1 (or more) of the following Organ Dysfunctions:
Resp. – PcO2 ≤32, Increased FiO2 needs or Mech. Ventilated or BiPAP
Renal – U.O. <0.5cc/kg/hr despite fluid bolus, creatinine >2
Hem. – Platelets <100,000 or INR >1.5 (unless on Warfarin)
Hepatic – Bilirubin >2, new onset
CNS – AMS or altered level of consciousness not related to drugs/ETOH
SEPTIC SHOCK=
SIRS (+) 1 (or more) of the following:
Metabolic – lactic acid ³4
Cardiac – MAP ≤65 or Systolic BP ≤90 despite fluid bolus
SBAR
S:
Situation-(a concise statement of the problem)
B:
Background- (pertinent and brief information related to the
situation)
A:
Assessment-(analysis and considerations of options —
what you found/think)
R:
Recommendation-(action requested/recommended — what
you want)
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SepsisSBAR
Section III
EARLY GOAL
DIRECTED THERAPY
3 hour Bundle
1.Measure Lactic Acid
2.Obtain Blood Culture (prior to antibiotic
administration)
3.Administer Broad Spectrum Antibiotics
4.Administer 30ml/kg crystalloid fluid for
hypotension or lactic acid >4
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6 hour bundle
• Repeat lactic acid if initial was >2
• Administer vasopressors for hypotension
that does not respond to initial fluid
resuscitation
• Septic Shock reassessment for volume
status and tissue perfusion
• Focused exam to include:
• Cardiopulmonary assessment
• Complete vital sign review
• Capillary refill
• Peripheral Pulse
• Skin Assessment
Case Studies
Case #1 – Bernie
• 50 year old man presented to the hospital complaining of trouble
breathing and fever
• Past medical history: sarcoidosis (inflammatory lung disease)
• Temp 38.4 C, Pulse 95, Resp 28
• Admitted to hospital ICU for pneumonia and immediately placed on
mechanical ventilation
• Cardiac arrest twice before dying in the hospital
Bernie Mac
Stand-up comedian and actor
Died August 9, 2008
Cause of Death: Septic Shock secondary to pneumonia
Case Studies
Case #2 – Muhammad
• 74 year old male presented to the hospital for a respiratory illness and
admitted to the hospital in fair condition
• Past medical history of Parkinson’s Disease since 1984
• Condition declined while in the hospital and died with family and
friends at bedside
• Family stated cause of death was “Septic Shock due to unspecified
natural causes”
Muhammad Ali
American Olympic and professional boxer
Died June 3, 2016
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Case Studies
Case #3 – Garry
• 81 year old male
• Died in July 2016 from “complications of pneumonia” (most likely
septic shock)
Garry Marshall
Actor, Director, Writer and Producer
• Happy Days, The Odd Couple, Pretty Woman, Princess Diaries
Others believed to die due to sepsis include:
• Ray Price (cancer)
• Lily Rose Depp (E Coli)
• Christopher Reeves (infected wound)
• Patty Duke (GI infection)
• Jim Henson (pneumonia)
• Pope John-Paul II (UTI)
DeAmber Piel, MSN, RN, CNL
Sepsis Coordinator
OU Medical Center
Brenda Baehler, BSN, RN
Sr. Quality Coordinator
OU Medical Center
Enjoy this video from the Medical Residents at UCLA-Kern Medical Center
https://vimeo.com/129916157
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