1. New Treatments for an Ongoing Problem Steven Marshall, RNIII, CCRN Chip Harris, RN, BSN Moses Cone Surgical ICU – 2300 Sepsis

2. Material From: Sepsis: New Insights to the Most Lethal Condition in Acute and Critical Care (NTI 2010 Mastery Session) Incidence, Pathogenesis, and Management of Sepsis. An Overview (AACN Advanced Critical Care Article, Volume 17, Number 4, 2006) Sepsis: Stopping an Insidious Killer (American Nurse Today Article, January 2007)

3. Signs of systemic inflammatory response syndrome SIRS include: a. respiratory acidosis b. pain c. hypotension d. tachypnea

4. Signs of systemic inflammatory response syndrome SIRS include: a. respiratory acidosis b. pain c. hypotension d. (tachypnea)‏

5. What is the definition of sepsis? a. infection plus multi organ dysfunction b. inflammation with high wbc c. infection as the cause of sirs d. presence of positive blood cultures

6. What is the definition of sepsis? a. infection plus multi organ dysfunction b. inflammation with high wbc c. (infection as the cause of sirs)‏ d. presence of positive blood cultures

7. Which is the treatment of sepsis? a. hydrocortisone 300mg qd if hypotension resistant to pressors b. activated protein c c. arachidonic acid inhibitors d. fluids to keep scvo2 > 70%

8. Which is the treatment of sepsis? a. hydrocortisone 300mg qd if hypotension resistant to pressors b. (activated protein c)‏ c. arachidonic acid inhibitors d. fluids to keep scvo2 > 70%

9. What lab test do you want with suspected sepsis? a. protein c b. procalcitonin c. serum sodium d. lactate

10. What lab test do you want with suspected sepsis? a. protein c b. procalcitonin c. serum sodium d. (lactate)‏

11. A patient is at risk for sepsis when receiving: a. insulin b. antibiotics c. vasopressors d. steroids

12. A patient is at risk for sepsis when receiving: a. insulin b. (antibiotics)‏ c. vasopressors d. steroids

13. What is the first treatment for suspected sepsis? a. antipyretics b. activated protein c c. vasopressors d. fluids

14. What is the first treatment for suspected sepsis? a. antipyretics b. activated protein c c. vasopressors d. (fluids)‏

15. What is the most common organ to fail? a. pulmonary b. renal c. cardiovascular d. central nervous system

16. What is the most common organ to fail? a. (pulmonary)‏ b. renal c. cardiovascular d. central nervous system

17. Which of the following is true with activated protein c administration in pt with severe sepsis? a. patient must have failed all other tx b. based on new research xigris is currently not indicated c. patient must be at high risk of death d. any patient with sepsis is a candidate for activated protein c

18. Which of the following is true with activated protein c administration in pt with severe sepsis? a. patient must have failed all other tx b. based on new research xigris is currently not indicated c. (patient must be at high risk of death)‏ d. any patient with sepsis is a candidate for activated protein c

19. What is the least valuable tool for rapid response nurse? a. capnography b. stethoscope c. point of care lactate, glucose, ph d. non invasive stroke volume monitor

20. What is the least valuable tool for rapid response nurse? a. capnography b. (stethoscope)‏ c. point of care lactate, glucose, ph d. non invasive stroke volume monitor

21. How many patients will die of bleeding after receiving protein c? a.<1/2 of 1% b. 5-10% c. 25% d. 30-40%

22. How many patients will die of bleeding after receiving protein c? a.(<1/2 of 1%)‏ b. 5-10% c. 25% d. 30-40%

23. Why is sepsis so difficult to recognize? a. very similar to blood stream infection b. infrequent and overlooked c. presents with subtle signs d. sepsis has no common pattern in how it presents

24. Why is sepsis so difficult to recognize? a. very similar to blood stream infection b. infrequent and overlooked c. (presents with subtle signs)‏ d. sepsis has no common pattern in how it presents

25. Which of following statement regarding fluid resuscitation in severe sepsis is most correct? a. both crystalloid and colloid may be used b. ns is superior to lr c. albumin should not be used d. hespan has been associated with improved outcome comp to ns

26. Which of following statement regarding fluid resuscitation in severe sepsis is most correct? a. (both crystalloid and colloid may be used)‏ b. ns is superior to lr c. albumin should not be used d. hespan has been associated with improved outcome comp to ns

27. Which area has the most sepsis cases? a. icu b. hosp floor c. ed d. nursing homes

28. Which area has the most sepsis cases? a. icu b. hosp floor c. (ed)‏ d. nursing homes

29. Which is the best method to improve outcomes? a. appropriate use antibiotics b. activated protein c c. prevention of infection d. use of fluids early in sepsis

30. Which is the best method to improve outcomes? a. appropriate use antibiotics b. activated protein c c. (prevention of infection)‏ d. use of fluids early in sepsis

31. Sepsis is subtle until it is so obvious you can't miss it

32. For a diagnosis of SIRS (Systemic Inflammatory Response Syndrome), you need to have 2 of the following criteria: Tachycardia Tachypnea Wbc >12 <4 Hypothermic or Hyperthermic

33. Sepsis is SIRS plus documented or presumed source of infection -No need for positive cultures -Only 50% Pneumonias grow out an organism

34. Septicemia is infection of the blood stream but is not necessary for sepsis and no longer a used term

35. Patients get sick in response to the virus or bacteria “ The patient appears to die from the body's response to infection rather than from it” Sir William Osler

36. Common Signs of Acute Organ System Dysfunction in Sepsis Cardiovascular: Tachycardia Dysrhythmias Hypotension Elevated central venous and pulmonary artery pressures

37. Common Signs of Acute Organ System Dysfunction in Sepsis Respiratory: Tachypnea Hypoxemia

38. Common Signs of Acute Organ System Dysfunction in Sepsis Renal: Oliguria Anuria Elevated creatinine levels

39. Common Signs of Acute Organ System Dysfunction in Sepsis Hematologic: Jaundice Elevated liver enzymes Decreased albumin Coagulopathy

40. Common Signs of Acute Organ System Dysfunction in Sepsis Gastrointestinal: Ileus (absent bowel sounds)‏

41. Common Signs of Acute Organ System Dysfunction in Sepsis Hepatic: Thrombocytopenia Coagulopathy Decreased protein C levels Increased D-dimer levels

42. Common Signs of Acute Organ System Dysfunction in Sepsis Neurologic: Altered consciousness Confusion Psychosis

43. Evidence-based Treatment Strategies in Severe Sepsis Level A recommendations Prophylaxis measures Deep vein thrombosis Stress ulcer

44. Evidence-based Treatment Strategies in Severe Sepsis Level B recommendations Initial resuscitation for sepsis-induced hypoperfusion Fluid resuscitation to a central venous pressure of 8–12 mm Hg Early goal directed therapy (to maximize perfusion status)‏ Transfusion of packed red blood cells to achieve a hematocrit of 30% Administration of inotropic infusion (eg, dobutamine)‏

45. Evidence-based Treatment Strategies in Severe Sepsis Level B recommendations Mechanical ventilation Lung protective ventilation for acute lung injury/acute respiratory distress syndrome Blood product administration To target hemoglobin of 7.0–9.0 g/dL Drotrecogin alfa (activated)‏ For patients with sepsis-induced multiple organ failure with no absolute contraindication related to bleeding risk Renal replacement For acute renal failure Sedation, analgesia, and neuromuscular blockade To provide comfort yet avoid prolonged sedation

46. Evidence-based Treatment Strategies in Severe Sepsis Level C recommendations Enhance perfusion Fluid therapy Steroids For patients with relative adrenal insufficiency

47. Evidence-based Treatment Strategies in Severe Sepsis Level D recommendations Diagnosis Obtain cultures: at least 2 blood cultures, with one drawn percutaneously and one drawn through each vascular access device; cultures of other sites such as urine, wounds, and respiratory secretions should be obtained before antibiotic therapy is initiated Glucose control To maintain blood glucose 150 mg/dL

48. Evidence-based Treatment Strategies in Severe Sepsis Level E recommendations Antibiotic therapy Empirical antibiotics Source control Removal of potentially infected device, drainage of abscess, and debridement of infected necrotic tissue Enhance perfusion Vaspressors Inotropic therapy

49. Evidence-based Treatment Strategies in Severe Sepsis Level E recommendations Diagnosis Diagnostic studies (eg, ultrasound, imaging studies)‏ Consideration for limitation of support Discuss end-of-life care for critically ill patients Promote family communication to discuss use of life-sustaining therapies

50. Evidence-based Treatment Strategies in Severe Sepsis *These recommendations are based on the following levels of evidence: level A research evidence supported by at least 2 level I investigations (large, randomized trials with confident results); level B evidence supported by one level I investigation; level C evidence supported by level II investigations only (small, randomized trials with uncertain results); level D evidence supported by at least one level III investigation (nonrandomized study); and level E evidence supported by level IV (nonrandomized, historical controls, and expert opinion) or level V evidence (case series, uncontrolled studies, and expert opinion).

51. Saving Lives from Sepsis Step By Step Evaluate a patient who has an infection or is receiving antibiotics for these signs and symptoms of systemic inflammatory response syndrome (SIRS): • Tachycardia • Tachypnea • Fever • High or low white blood cell count

52. Saving Lives from Sepsis Step By Step If the patient has an infection and signs and symptoms of SIRS, suspect sepsis. If the patient has sepsis, begin treatment as soon as possible. Start all appropriate therapies within 24 hours.

53. Saving Lives from Sepsis Step By Step Determine the severity of sepsis: • Obtain lactate levels. • Detemine if the patient is hypotensive. • Obtain central venous oxygen saturation (ScvO2) measurements via a central I.V. line. • Provide fluids, vasopressors, and inotropic agents to raise ScvO2 above 70%.

54. Saving Lives from Sepsis Step By Step Obtain blood glucose level. If it’s more than 150 mg/dl, start insulin therapy. If the patient is hypotensive or has a low serum cortisol level, give 200 to 300 mg of hydrocortisone daily for 7 days as replacement corticosteroid therapy.

55. Saving Lives from Sepsis Step By Step If the patient has a high risk of death, administer activated protein C.

56. Saving Lives from Sepsis Step By Step Activated protein C controversies Therapy with activated protein C is controversial, in part because of its cost. This recombinant DNA protein costs about $7,000 for a 4-day course of therapy. But one study indicates that using activated protein C rapidly and appropriately shaves 4 days off the average intensive care unit length of stay. That translates into a cost savings of about $9,000. The drug is also controversial because we don’t yet know whom it benefits most. The Food and Drug Administration suggests that it should be given only to patients with a high risk of death and that a high risk of death be determined using an APACHE II score. This method, which estimates the severity of illness, works well at predicting group responses. But many nurses and physicians don’t use APACHE II scores, or they use them incorrectly. In Europe, one indicator of a high risk of death is the failure of at least two organs. Because no universally accepted criteria exist for defining high risk of death , the best criterion may be the bedside clinician’s assessment. If the bedside clinician believes the patient is at high risk for death, activated protein C therapy should be considered.

57. Lab tests and Hemodynamic Measurements for Determination of Sepsis Hemodynamic response to sepsis: Hypovolemia – low cvp, low scvo2, tachycardia Give boluses!

58. Lab tests and Hemodynamic Measurements for Determination of Sepsis Stroke volume monitoring – swan ganz obsolete except for pa pressure monitoring in pulm htn Stethoscope is vague – use with guidance Stroke volume is needed to monitor responses CVP – research does not support much but it is some marker of success

59. Lab tests and Hemodynamic Measurements for Determination of Sepsis Stroke Volume may be increased with fluid when CVPs may not Limitations of pressure measurement: CVP and PAOP (Wedge) should never be used in isolation

60. Lab tests and Hemodynamic Measurements for Determination of Sepsis Measures of tissue oxygenation Lactate/Ph Normal lactate 1-2 ph normal 7.35-7.45 If lactate >4 and PH less than 7.30 consider tissue hypoxemia

61. Lab tests and Hemodynamic Measurements for Determination of Sepsis Triple lumen oximetry Expands ability to assess tissue oxygenation An easier—less expensive— way to measure ScvO2 levels Measuring central venous oxygen saturation (ScvO2) levels requires a central I.V. line. Typically, you’ll take frequent blood samples from the right atrium, using the central I.V. line, so fluids can be titrated to return ScvO2 to 70%. An easier way to obtain frequent measurements is to use a fiberoptic ScvO2 central line catheter. This tool provides continuous ScvO2 readings. Using a fiberoptic catheter has proven to be cost effective: It reduces length of stay by about 4 days, more than offsetting its cost.

62. Lab tests and Hemodynamic Measurements for Determination of Sepsis Measurement of blood flow Doppler based Arterial line based Pulse contour technique Show stroke volume - normal stroke index 25-35 – if decreased get tachycardia to compensate Noninvasive doppler measurement of blood flow aortic and pulmonic valve flows Noninvasive co/sv measurement Esophageal doppler on sedated patients Microcirculation – sublingual blood flow

63. The latest in sepsis treatment and studies can be found at: www.survivingsepsis.org