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Maternal Sepsis June 2 2016

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Maternal Sepsis

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Maternal Sepsis June 2 2016

  1. 1. Implementing a Protocol and Interprofessional Education for Early Recognition and Management of Maternal Sepsis Presented by: Lori Olvera DNP, RNC-OB, EFM-C
  2. 2. Objectives At the conclusion of this learning session the participant will be able to:  Identify differences between Sepsis, Severe Sepsis, and Septic Shock  Identify symptoms for early recognition and how to manage the septic patient  Identify the importance of implementing OB sepsis screening in the perinatal setting  Identify the importance of implementing protocols for early recognition and management of maternal sepsis  Identify the importance of using key stakeholders, RN champions, Physician champions for implementing sepsis screening and management of maternal sepsis.  Identify the importance of using data collection to develop a program in maternal sepsis.  Identify the importance of training all perinatal staff in early recognition & management of maternal sepsis. 2
  3. 3. Code Sepsis in OB: Let’s Intervene before it hits!
  4. 4. Maternal Sepsis Video • http://bcove.me/sd6wl76t
  5. 5. Katie dies of FLU at 26!
  6. 6. Pregnant Patients need to be included in our Sepsis Protocols! “Pregnancies complicated by severe sepsis and septic shock are associated with increased rates of preterm labor, fetal infection, and preterm delivery. Sepsis onset in pregnancy can be insidious,, and patients may appear deceptively well before rapidly deteriorating with the development of severe shock, multiple organ dysfunction syndrome, or death. The outcome and survivability in severe sepsis and septic shock in pregnancy are improved with early detection, prompt recognition of the source of infection, and targeted therapy” Barton & Sibai, 2012
  7. 7.  Acute Pyelonephritis  Retained Products of Conception  Neglected Chorioamnionitis or endometritis  Pneumonia 1. Bacterial 2. Viral  Influenza  H1N1  Unrecognized or inadequately treated necrotizing fasciitis 1. Abdominal incision 2. Episiotomy/Perineal Laceration  Intraperitoneal Etiology 1. Ruptured Appy 2. Acute Cholecystitis 3. Bowel Infarction  Urinary Tract Infections  Mastitis CAUSES OF SEVERE SEPSIS & SEPTIC SHOCK IN PREGNANCY & PUERPERIUM
  8. 8. Infectious disease ranks one of the four most common causes of maternal mortality and severe morbidity Sepsis is one of the leading causes of preventable maternal deaths. This is an example text. Go ahead and replace it The lack of recognition of early warning signs of sepsis and guidelines to manage treatment of sepsis contributes to these preventable deaths 1 2 3 4 5 Sepsis bundles – even when used incompletely –significantly decrease mortality (SSC 2013) Septic shock is rare affecting .002-0.01 % of all deliveries Sepsis Facts
  9. 9.  Sepsis is one of the top four causes of maternal mortality  Pregnant women are more vulnerable to infection and susceptible to serious complications  Screening protocols are needed for early recognition and management of maternal sepsis  All perinatal staff must be trained on early recognition and management of maternal sepsis. What does the literature say….. Acosta, Kurinczuk, Lucas, Tufnell, Sellers & Knight, 2014
  10. 10. 1. More women over 40 becoming pregnant 2. Availability of “assisted reproductive technologies” results in more invasive monitoring due to incidence of multifetal gestation 3. Disorders of pregnancy such as preeclampsia, placental abruption, amniotic fluid embolism, and PPH 4. Increasing rates of Obesity, diabetes, and C/S delivery 5. C/S delivery: 3 times more likely to develop sepsis Maternal Sepsis Why is maternal sepsis on the rise? Acosta & Knight, 2013
  11. 11.  C/S delivery  Emergency C/S  Prolonged Rupture of the Membranes  Retained products of Conception  Preterm Labor  Multiple Vaginal Exams  Obesity  Diabetes  Anemia  Low socioeconomic status  Winter months  Failure to recognize severity Risk Factors for Sepsis
  12. 12. OB Sepsis Syndrome OB Specific Criteria SIRS = Systemic Inflammatory Response Syndrome
  13. 13.  Definition A clinical manifestation resulting from an insult, infection, or trauma, that includes a body-wide activation of immune and inflammatory cascades Systemic Inflammatory Response
  14. 14. Insult: Can be from anything • Burn • Trauma • Infection • Surgery • Myocardial Infarction • Pancreatitis • Anesthesia • Allergic reaction
  15. 15. Pathophysiology of Sepsis https://www.youtube.com/watch?v=o5sYBUarpmI
  16. 16. Inflammatory mediators (histamines, serotonin, cytokines) cause increase vascular permeability and vasodilation Vascular Permeability: Increase permeability of blood vessels; leaky vessels • Migration of leukocytes to site of injury Vasodilation: widening of blood vessels, resulting in pooling of blood, causing a relative decrease in intravascular volume; plasma & molecules leak into extravascular space Pathophysiology Obstetrical patient with Sepsis
  17. 17. • Small molecules such as Na, H2O leak through leaky vessels • Some larger molecules such as ALBUMIN will escape as well (loss of osmotic pressure) • Loss of fluid from intravascular space (tank is dry) Pathophysiology Continued
  18. 18. Effects of Increased Vascular Permeability of Capillaries Reduced Circulating Volume Hypotension Tachycardia Pathophysiology Continued
  19. 19. This Results in…. The following symptoms….. Hypotension Tachycardia Organ Dysfunction Decreased oxygen to the organs
  20. 20. Accumulation of Extravascular Fluid Causes….. Peripheral Edema Pulmonary Edema Renal Edema Liver Impairment
  21. 21. In Sepsis, there is increase oxygen demand Increased oxygen demand Requires increase in oxygen delivery Need to increase HR
  22. 22. Metabolic Acidosis Increased Respiratory Rate Cardiac depression Confusion Anaerobic Respiration Occurs Lactic Acid is a by-product (serum lactate) Pathophysiology of Anaerobic Respiration If Oxygen Demand of the tissues is not met by oxygen delivery Conversion to Anaerobic Respiration Lactate Acid production…..
  23. 23. Disseminated Intravascular Clotting Sepsis causes widespread clotting This causes consumption of platelets, clotting factors and fibrinogen, Impaired coagulation Impaired risk of bleeding CONSUMPTIVE COAGULOPATHY BLEEDINGCLOTTING
  24. 24. Perinatal Parameters • Because of the physiology of pregnancy and labor, we adjusted the screening criteria for Perinatal patients • Increase in blood volume increases maternal heart rate by 10-20 bpm • Minute volume (RR x Tidal Volume) increases 50% due to an increase in Tidal Volume • Due to diaphragm position, lung volumes change causing increased respiratory rate • Increase in WBC in labor and immediate postpartum • Increase in blood flow to the kidneys causes a decrease in the creatinine level 25
  25. 25. “Severe Sepsis and septic shock in pregnancy: indications for delivery and maternal and perinatal outcomes” – Retrospective chart review of OB patients with severe sepsis in the ICU • Severe sepsis N = 20 • Septic shock N = 10 – 24 were antepartum – 6 were postpartum • 11 pylonephritis – responsible for one maternal death • 7 pneumonia • 4 chorio • 2 fatty liver • 1 bacterial meningitis • Mortality rate 33% with septic shock The Journal of Maternal-Fetal Medicine, 2013. Snyder, Barton, Habli, Sibai
  26. 26. Screening Criteria Variable Severe Sepsis Septic Shock P value All patients Temp >38.9 10/20 (50) 7/9 (78) ns SBP <90 6/19 (32) 10/10 (100) <0.001 DBP <50 7/19 (37) 10/10 (100) 0.001 HR > 110 18/20 (90) 9/9 (100) ns RR > 24 14/18 (78) 8/9 (89) ns WBC > 15, 000 16/20 (80) 9/10 (90) ns Lactate >1.0 mmol/L 10/10 (100) 10/10 (100) ns 20/20 (100) Lactate >4.0 mmol/L 2/10 (20) 2/10 (20) ns 4/20 (20) Plt > 60s 0/18 (0) 3/9 (33) 0.03 9/30 (30) Mental status 1/20 (5) 8/10 (80) <0.001 9/30 (30)
  27. 27. Sepsis Screening Criteria for Non-OB adults vs. OB Screening Tool - adjusted for the physiological effects of pregnancy Adult Screening Criteria • Temp > 38°C (100.4°F) or < 36°C (96.8°F) • HR > 90 • Resp Rate> 20 • WBC >12,000, < 4,000 or >10% Bands • New mental status change • Blood glucose > 140 mg/dl in the absence of diabetes Perinatal Screening Criteria Adjustments • Temp > 38°C (100.4°F) or < 36°C (96.8°F) • HR > 110 • Resp Rate > 24 • WBC > 15,000 or < 4,000 or > 10 % immature neutrophils • Altered Mental Status present • Blood glucose > 140 mg/dl in absence of diabetes
  28. 28. When should I perform the sepsis screening? • Upon arrival to the unit (triage or direct admit) • EVERY SHIFT and/or assuming care of patient • PRN for suspicion/indication of new infection
  29. 29. Sepsis • Definition: • The presence of 2 or more SIRS criteria with a presumed or confirmed infectious process
  30. 30. Definition: Sepsis + Organ Dysfunction (resulting from Tissue Hypo-Perfusion) Severe Sepsis
  31. 31. Signs of Organ Dysfunction Respiratory Inadequate oxygenation Or ventilation Neurologic Change in LOC Global Hypoperfusion Lactate > 2mmol/L Cardiovascular Hypotension SBP < 90mmHG or MAP < 65 Renal U/O < 30ml/hr Elevated Cr. (>1.5) Hematologic Platelets < 100,000 Coagulopathy (INR> 1.5 or aPTT > 60sec)
  32. 32. Organ Dysfunction Criteria
  33. 33. Definition Persistent arterial hypotension despite 30ml/kg volume resuscitation or an Initial lactate > 3.9 mmol/L (Both may be present) Septic Shock
  34. 34. Sepsis Syndrome
  35. 35. Bundles Elements when used together, improve outcomes more than when used separately! Evidence based
  36. 36. Severe Sepsis Bundle: TO BE COMPLETED WITHIN 3 HOURS Time zero = time of confirmed positive sepsis screen by RRT – Measure lactate level – Obtain blood cultures prior to administration of antibiotics – Administer broad spectrum antibiotic(s) – Administer 30 mL/Kg crystalloid for hypotension or lactate > 3.9 mmol/L
  37. 37.  Delay in diagnosis and treatment of sepsis has been shown to ↑ mortality  Pregnant patients look deceptively well before rapidly deteriorating  Early recognition and treatment of maternal sepsis will improve survival, decrease length of stay, and length of stay in the ICU WHY DO WE NEED BUNDLES FOR EARLY RECOGNITION? Barton & Sibai, 2012
  38. 38.  Randomly assigned 263 patient who presented to ED with severe sepsis/septic shock  Received either 6 hours of EGDT or conventional care before ICU  Mortality was 30.5% in patients receiving EGDT  Mortality was 46.5% in patients receiving conventional care Implementation of Sepsis Bundle for Early Recognition Rivers, 2001
  39. 39. Blood Cultures? Why?  Recommended to draw prior to antibiotic administration, but should NOT delay antibiotics.  If antibiotics have been administered, still have cultures drawn  When patient not responding to antibiotic regime, blood culture results are used to narrow antibiotic treatment to most appropriate antibiotic choice
  40. 40. Measure Lactate Level Why is it important 1. Prognostic value of raised lactate levels are well established in septic shock patients 2. Elevated levels in sepsis support aggressive resuscitation 3. Mortality is high (46.1 %) in septic patients with both hypotension and lactate > 3.9 mmol/L 4. Mortality in severely septic patients with Lactate >3.9 mmol/L alone is 30% www.survivingsepsis.org
  41. 41. • 52 participants (approximate) • Exclusion criteria: only healthy without risk factors • Lactate levels drawn  Upon admission  Transition, 7-10 cm dilated  6 hours postpartum SMCS Lactate Level in Pregnancy & Postpartum By Beth Stephens-Hennessy CNS, RNC 96% Lactate< 4mmol/dl 88% Lactate<2mmol/dl
  42. 42. The Median Value of Lactate
  43. 43. Fluid Resuscitation  Administer 30ml/kg Crystalloid for Hypotension or Lactate > 3.9 mmol/L NS  Patients with severe sepsis/septic shock experience ineffective circulation due to the vasodilation associated with infection or impaired cardiac output  Poorly perfused tissue beds result in global tissue hypoxia, which result in serum lactate level
  44. 44. Fluid Resuscitation  A serum lactate is correlated with  severity of illness and poorer outcomes even if hypotension is not present.  Patients with hypotension or lactate > 3.9 mmol/L require intravenous fluids to expand circulating volume and restore perfusion pressure  When to give? Lactate > 3.9 mmol/Lor suspected hypovolemia 45
  45. 45. Broad Spectrum Antibiotics – (Administer as soon as possible) within 3 hours of T-0  Administration of APPROPRIATE antibiotics reduces mortality in patients with Gram-positive and Gram- negative bacteremias  Although restricting antibiotics is important for limiting super-infection and decreasing development of antibiotic resistance, patients with severe sepsis and septic shock warrant broad spectrum antibiotic therapy until antibiotic susceptibilities are defined.  Combination therapy is more effective than monotherapy until causative organism is found
  46. 46.  Chorioamnionitis  Ampicillin 2 g IV Q6hr for 60 minutes  Gentamicin 1.5mg/kg/dose IV Q8H for 60 min  Add Clindamycin 900mg IV Q8H for 30 min (for anaerobe coverage if patient has C/S)  Endometritis  Ampicillin 2 g IV Q6H for 60 min  Gentamicin 5mg/kg/dose, IV Q24H for 60 min  Clindamycin 900mg IV Q8H for 30 min Gold Standard Antibiotics for Common Infections In Obstetrical Patients Your Logo
  47. 47.  Pyelonephritis  Rocephin 1g in 50ml NS IV Q24H for 30 min  For Rocephin allergy, order Ampicillin 1 g IV Q6h for 60 min and Gentamicin 1.5 mg/kg/dose, IV Q8h for 60 min  Community Acquired Pneumonia  Rocephin 1g IV Q24H for 30 min  Azithromycin 500mg IV Q24H for 60 min  IF MRSA suspected, Add Vanco 1mg IV Q12H Gold Standard Antibiotics for Common Infections In Obstetrical Patients Your Logo
  48. 48. Medications: Severe Sepsis & Septic Shock Give First pharmacy recommendation Zosyn (Piperacillin- Pazobactum) 3.375 MG IV now and continue pharmacy doing OR If penicillin allergy: Maxipime (Cefepime) 2 gm IV now For Significant PCN allergy (angioedema, resp distress, urticaria), GIVE ATREONAM 2gm IV q8H Vancomycin Per pharmacy dosing schedule and Discontinue all current antibiotics, then give:
  49. 49. Purpose To Evaluate Staff compliance with early recognition and management of management of maternal sepsis before and following the implementation of standardized physician order set and interprofessional education for nurses and physicians in the perinatal setting
  50. 50. Women screening positive for Sepsis between April 2014-January 2015 Women > 20 weeks gestation N=99 Sepsis Screen positive patients IRB Approval obtained METHODOLOGY •
  51. 51.  Using a systematic health record review, COMPLIANCE to the Sepsis Bundles was measured before, during, and following implementation of perinatal sepsis physician order set & education for physician & nurses (n=400) PROJECT DESIGN
  52. 52.  Task Force Team  Physician Education First  A Multidisciplinary Team (stakeholders)  Interprofessional Education from Aug-Nov 2014  A new perinatal sepsis physician order SET was implemented October 2014  Physician & RN Champions  Engagement of frontline leaders INTERVENTIONS
  53. 53. Task Force How we got started…. A small interdisciplinary group collaborated to design the framework for perinatal sepsis orders and protocol
  54. 54.  RN Champions were recruited to represent all departments on all shifts  Pharmacists were recruited including Antimicrobial stewardships  Engaging frontline leaders was crucial to the success of project  Physician Champions  RRT  Laboratory Supervisors  ICU educator  Emergency Room Educator Perinatal Sepsis Committee Formed
  55. 55. Physician Champion Physician Buy-in crucial for the success of the project Provided education to physicians Provided opportunity to discuss “difficult sepsis cases” at MD Grand Rounds Provided literature for physicians
  56. 56. RN Champions Provided 1:1 education to RN’s and MD’s Education re: Sepsis screening, standardized physician order set, and evidence based practice for recognition and management of maternal sepsis Mentoring of bedside RN how to manage patient screening positive for sepsis
  57. 57. Interprofessional Education  Formal 2-hour education for RN’s  M&M Conference for Physicians  Grand Rounds for Physicians  Poster Presentation  Case Studies  Evidence-based literature displayed  A single sheet, quick reference guides  Mandatory completion of computer based module with a post-test
  58. 58.  Guided the practitioner in giving appropriate antibiotic based upon source of infection  Antibiotics safe in pregnant women for common infections such as chorioamnionitis and pyelonephritis were included in order set  Antibiotics safe for pregnancy to treat severe sepsis and septic shock Physician Order Set
  59. 59.  Our patients are young & healthy, did not look septic  The bundles would result in over-treatment  Risk of Pulmonary of Edema  Women with epidurals have fevers  Antibiotic Resistance  Lactate is normally elevated in the laboring woman  To avoid doing Sepsis Screening during second stage of labor Education for Physician & Nurses Addressing the Barriers
  60. 60. Outcome Measure  Health Records of women screening positive for Sepsis were reviewed to determine if educational intervention increased SEPSIS bundle compliance.  Data was divided into 2 groups: 1. Pre-Intervention Data ( April-July 2014) 2. Post-Intervention Data (August 2014-Jan 2015  Data collected for 3 parameters: Sepsis, Severe Sepsis, and Septic Shock  Bundle compliance was measured for all parameters.  Intravenous fluids was measured for Sepsis, however, was not required.
  61. 61. Outcome Outcome Measurement Comparison…..  To measure the difference in bundle compliance pre and post intervention, data from the first time period was compared to data from second time period What was the initial Infection?  Data from the initial infection was measured separately to determine source of infection
  62. 62. The Sources of Infection for Patients Diagnosed with Sepsis during Pregnancy Sutter Medical Center Sacramento April 2014-January 2015 Frequency (N=99) Percent (%) Chorioamnionitis 45 46.4 Pyelonephritis 14 14.4 Endometritis 5 5.2 Urinary Tract Infection 5 5.2 Unknown 29 29
  63. 63. Frequency of Sepsis, Severe Sepsis and Septic Shock Sutter Medical Center Sacramento April 2014-January 2015* * Deliveries ~4000
  64. 64. Results Bundle Compliance Indicators in Patients with Sepsis, Severe Sepsis, and Septic Shock in Pre-and Post-Intervention Numb. (N) Draw Lactate Blood Culture Fluid Bolus Broad Spectrum ATB Bundle Met Repeat Lactate Sepsis 31 66 74% 90.9 38.7% 43.9 64.5% 73 77.4% 95.4 38.7% 45.5 79% 79 Severe Sepsis 13 34 100% 97.1 46.2% 55.9 76.9% 73.5 76.9% 97.1 53.8% 52.9 69.2% 82.4 Septic Shock 3 4 100% 75 66.7% 75 66.7% 100 66.7% 100 66.7% 100 66.7% 100
  65. 65. Weighted Cross Tabulations for Patients with Sepsis Lactate Drawn (yes) Broad- Spectrum Antibiotic Administered (Yes) Repeat Lactate Drawn (yes) Pre- Intervention 23(74.2%) 24 (77.4%) 18(58.1) Post- Intervention 60(90.9%) 63 (95.5%) 52 (78.8%) p Value (<.05) .029 .006 .034 Statistical Significance Achieved
  66. 66. Broad Spectrum Antibiotic Administered (No) Broad Spectrum Antibiotic Administered (Yes) P Value p<.05 Pre- Intervention 4 (25%) 12 (75%) .010 Post- Intervention 1 (2.6%) 37 (97.4%) Weighted Tabulations for Broad-Spectrum ATB Administered In Patients with Severe Sepsis or Septic Shock Statistical Significance Achieved
  67. 67.  Statistical significance for effect of education & perinatal sepsis order on bundle compliance: Draw Lactate Administer Broad Spectrum ATB Draw Repeat Lactate  Adjusted SIRS criteria for Maternal Sepsis is accepted!  Physician & RN champions instrumental  Antibiotic Type & timely administration  Perinatal staff must be educated in early recognition and management of maternal sepsis Key Points
  68. 68. Sutter Health Maternal Sepsis Recommendations Looking at the impact of implementing a project regionally.
  69. 69. SMCS Sepsis Data
  70. 70. SIRS Criteria
  71. 71. Organ Dysfunction Criteria
  72. 72. Chart Data
  73. 73. Sepsis Screening Criteria for Non-OB adults vs. OB Screening Tool - adjusted for the physiological effects of pregnancy Adult Screening Criteria • Temp > 38°C (100.4°F) or < 36°C (96.8°F) • HR > 90 • Resp Rate> 20 • WBC >12,000, < 4,000 or >10% Bands • New mental status change • Blood glucose > 140 mg/dl in the absence of diabetes Perinatal Screening Criteria Adjustments • Temp > 38°C (100.4°F) or < 36°C (96.8°F) • HR > 110 • Resp Rate > 24 • WBC > 15,000 or < 4,000 or > 10 % immature neutrophils • Altered Mental Status present • Blood glucose > 140 mg/dl in absence of diabetes
  74. 74. Obstetrical Sepsis Management Pathway New or suspected infection Evaluate for 2 or more SIRS Criteria Temp > 100.4°F (38°C) HR > 110 RR > 24 WBC > 15,000, < 4,000 OR > 10% immature neutrophils Altered mental status Blood glucose > 140 mg/dL in absence of diabetes Interventions for Simple Sepsis ✓Draw Lactate,  CBC, CMP, PT, PTT, INR, Serum creatinine ☐ U/A  Blood Cultures (2 sets prior to antibiotics) ✓ IV Access ✓Give Antibiotic (considering source of infection) Chest XRAY ✓Rapid Response Team: RRT confirms + Sepsis Screen & initiates STAT labs (standardized proc) √ RRT RN initiates SEPSIS ALERT! Consider Source of Infection SEPTIC SHOCK MORTALITY 40-60% Clinical features are the same as severe sepsis  Distinguishing Feature: Profound Hypotension BP Systolic <90, MAP<65 despite fluid resuscitation! ☐ LACTATE > 3.9 MMOL/L Interventions for Septic Shock √ RRT calls Code Sepsis ✓Broad spectrum antibiotics ✓Call Rapid Response Team ✓ICU admission ✓Anesthesia at bedside ✓IV Fluids Normal Saline bolus 30 ml/kg NOW for lactate > 3.9 mmol or hypotensive ✓Consider Central Venous Access Any 1 or more features of acute organ dysfunction Lactate > 2 mmol/L SBP < 90 mmHG or MAP < 65 ☐ SBP decrease < 40mmHG from baseline ☐Bilirubin > 2mg/dl New (or increased) oxygen requirement to maintain SP O2 > 92%  Urine output < or equal to 30 ml/hr for 2 hours Platelet count < 100,000 Coagulopathy (INR >1.5 or PTT >60 sec Interventions for Severe sepsis ✓Consider IV Fluids N/S for Lactate >2 mmol/L ✓CALL RAPID RESPONSE TEAM ✓Repeat lactate every 4-6 hours until Lactate < 2 ✓SpO2 and oxygen per protocol √Call MD to initiate OB severe Sepsis Order Set SEPSIS SEVERE SEPSIS Sepsis Screen SEPTIC SHOCK Yes Yes Yes Yes    
  75. 75. Sepsis Standard Work Sepsis Recognition and Sepsis Care Should Be Standard For All Inpatients – Including Perinatal Patients
  76. 76. Early Recognition What is Standard Work? • Standard Work is a method used to complete nearly identical processes in a uniform way (used in manufacturing, Toyota) • Improvement teams have adopted this approach in healthcare in attempts to 1) reduce variation in care (“No fluid bolus needed, she’ll just be in pulmonary edema”) 2) errors of omission (“I forgot to order a repeat lactate”) • Typically standard work identifies a task, the operator to complete the task, the equipment required, the time frame for completion • Though there are limits to standardization in work, there is much work that can be standardized 77
  77. 77. Perinatal Sepsis Standard Work Create Protocols with Adjusted SIRS criteria for Maternal Sepsis Early intervention implemented for all patients who screen positive for sepsis Arrival of Rapid Response Team followed by physician/ intensivist evaluation 78
  78. 78. Documentation and Reports Sepsis Summary Flowsheets Sepsis Screen Sepsis Overview Report Sepsis Sidebar Report
  79. 79. 80 Vitals, lab, I/O will populate here from other flowsheets and results so that a complete sepsis assessment (screen can be done) Sepsis Summary Flowsheet YOU MUST COMPLETE ALL 4 QUESTIONS
  80. 80. 1. Is an infection suspected? Symptoms patient may have that indicate Potential Infection Sepsis Screen
  81. 81. 2. Identify 2 or more NEW signs of SIRs Sepsis Screen Axillar y Temp
  82. 82. 3. Identify new signs of organ dysfunction Sepsis Screen
  83. 83. 4. Pt meets criteria for Positive Screen? 84 Note: the criteria to be used when answering this question
  84. 84. Action Taken Rows and groups display if answer to Question 4 is “Yes.”
  85. 85. Sepsis Start Time: TIME ZERO
  86. 86. 87 Severe Sepsis and Septic Shock Bundle Elements This documentation populate the sepsis overview to the specific bundle completionIf YES, patient meets criteria for Code Sepsis / 6 hour bundle
  87. 87. Sepsis Best Practice Alert • Two new Best Practice Alerts 1. Simple Sepsis 2. Severe Sepsis (Organ Dysfunction)
  88. 88. Applying what we have learned Case Scenarios 89
  89. 89. Case Scenario #1 Preterm with PPROM X 8 days • 0848- T-97.8, BP 115/62, P-100, 98%, FHR 160 • 1110-MD here to consent for C/S • 1200-C/S, Apgar 1/8. Baby to NICU • 1230. OBRR- Temp 101.8, P-120, SOB. 88/40. RRT called. CBC, blood culture, lactate drawn. IV Fluids 2 L given. Zosyn started. • 1300- Lactate 9. Urine output < 30ml/hr. Bleeding at incisional site. NS 2 L given on way to ICU. BP 88/44, p-122. Coags drawn in ICU. Extended stay for mother due to septic shock.
  90. 90. Questions • At what point did she meet SIRS criteria? • What signs of organ dysfunction did she have? • List the standard work that was done in response. 91
  91. 91. Scenario #2 2nd stage of Labor • 0900-Twin gest 38.1 weeks, pushing in 2nd stage of labor. No other risk factors. Temp spiked to 102.1, P-130, R-22. Pt screened positive for sepsis. RN called MD in which MD gave orders to follow sepsis protocol. • 0940-Lactate 5.6. WBC 26. LR 2 Liter bolus NS given, Zosyn ordered and administered. • 0955,0958-patient delivered healthy twins. Health care team decided to manage care in L&D for recovery. Orders to redraw lactate at 1200. RN’s did not want to separate the mom-baby couplet. BP stable, P-110, Temp 100.1, R- 20. • 1130- Lactate drawn (1200)-3.9, 1 liter of NS given. Lactate drawn every 6 hours until lactate <2.
  92. 92. Questions • At what point did she meet SIRS criteria? • What signs of organ dysfunction did she have? • List the standard work that was done in response. • List the standard work that was not done. • Does lactate increase during labor and increase with length of pushing? 93
  93. 93. 8/3/13 @2216  Pt presented L&D Triage with R sided flank pain, fever of 101, and vomiting X2. OB Hx:  No risk factors; GA: 24 weeks, G-1, P-0 Vital Signs:  HR=120, bp-103/58, FHR 165-170. Labs:  UA: 2+ nitrites, Pos for leukocyte esterase, 1+ protein, 2+ ketones, >100 WBC 4 RBC, 4+ bacteria Outcome:  Macrobid and D/C home.  T-99.8,FHR=165 MD would call pt when UA culture returns in 48 hrs. Culture…………Cx results: E.Coli >100,000 Leanna presents to Triage at 24 weeks…..
  94. 94. 8/4@1900 Pt returns with fever, R sided flank pain, aches, N&V, chills, feeling dizzy, SOB..POSITIVE SEPSIS SCREEN VS  P=130, BP 85/52, Map 64. O2 sat 99%  FHR=140’s. Treatment  Ampicillin 2 gm given, 1 Liter LR given, RRT At bedside, serial lactates, NS bolus. Gentamicin given. Response:  55 minutes later: T-98.2, P=102, BP101/61, O2 Sat 100, lactic Acid-1.6. Patient transferred to HRM LeeAnna……
  95. 95. 6 hours later: Pt shivering, C/O SOB, o2 at 3L, o2 sat 95%, T=99.2, P=114, BP100/61. Remains SOB. Lactic Acid 2.6 6 1/2 hrs:  RRT at BS. Clammy, O2 sat 94%, required O2 administration 7 hrs:- Orders to transfer to ICU. Central line placed. 12 hrs – chest Xray indicated fluid overload/interstitial edema LeeAnna……
  96. 96. 17 hours:  pt intubated and sedated, VSS; CRP-264.7; albumin 1.8, WBC-21.1, Hgb 7.8 Day 3  R nephrostomy tube, foley catheter. VSS. Transferred to HRM Day 5  Central line d/c; D/C home at 1230! LeeAnna…… continued
  97. 97. 3 months later  Admitted for SROM  Nephrostomy tube in place.  On Cipro 500mg Q12h  11/22@1430-delivered healthy baby girl! LeeAnna…… Day of Delivery….
  98. 98. LeeAnna Septic Shock Survivor……
  99. 99. Let’s Begin the Campaign to promote Early Recognition & Management of Maternal Sepsis 100

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