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Sepsis-Identification and Management in an Acute Care Setting PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "Sepsis: Identification and Management in an Acute Care Setting" by Dr. Barbara M. Mills DNP.

This medical PowerPoint presentation talks about Sepsis, a serious medical condition that can develop when the bodys immune system overreacts to an infection, leading to systemic inflammation and organ dysfunction. If left untreated, sepsis can progress to septic shock, a life-threatening condition characterized by extremely low blood pressure and organ failure.

Sepsis is a medical emergency that requires prompt identification and management to prevent complications and improve outcomes. Healthcare providers in acute care settings should be vigilant for signs and symptoms of sepsis, and initiate appropriate interventions as soon as possible.

Tags : Sepsis, medical emergency, Emergency Medicine, Emergency Medicine PowerPOint presentation

Published on : Apr 12, 2023 | Views : 1308 | Downloads : 1

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Sepsis: Identification and Management in an Acute Care Setting SEPSIS LECTURE NPA 2018 Dr. Barbara M. Mills DNP Director Rapid Response Team/ Code Resuscitation Stony Brook University Medical Center
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oBJECTIVES To understand and be able to identify the differences between SIRS, Sepsis, Severe Sepsis, and Septic Shock. To understand the morbidity and mortality of Sepsis in relation to length of stay, current guidelines, cost to health care systems. To understand modalities of treatment which include management, such as fluid resuscitation and pharmacological interventions.
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.http://www.cdc.gov/nchs/data/databriefs/db62.pdf accessed August 7, 2015 In-hospital death 8X higher compared to other diagnoses
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Sepsis Bundle Project (SEP)National Hospital Inpatient Quality MeasuresSEP-1 Early Management Bundle, Severe Sepsis/Septic Shock Discharges 10-01-2015 (4Q15) through 06-30-16 (2Q16)
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Sepsis ECONOMICS Sepsis is a major and economically significant disease in the ICU, costing over $20 billion in the United States in 2011 (5.2% of all U.S. hospital costs) with costs growing to over $23 billion in 2013 (6.2% of all U.S. hospital costs)
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Sepsis ECONOMICS Sepsis: major health problem with increasing prevalence, high costs, and poor outcomes.
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Sepsis ECONOMICS Increased hospitalizations for more than 1 million people in 2008
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Sepsis ECONOMICS Between 1999 and 2014: 2,470,666 deaths with sepsis on the death certificate with increase annual sepsis related deaths by 31%
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Sepsis ECONOMICS Severe Sepsis and Septic Shock are subsets of sepsis conditions with at least one organ dysfunction, which accounts for 25-50% of in-hospital mortality…
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Sepsis ECONOMICS …that can range with a 45%-65% mortality within 6 months of discharge.
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INFECTION SEPSIS SEVERE SEPSIS SEPSIS INFECTION INFECTION
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Those who survive tend to have increasing complications, morbidity, high costs of care, and decreasing quality of life.
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HISTORICAL PERSPECTIVE Source: CHEST 1992 SIRS Criteria ( > 2) Temperature > 38 C < 36 C Heart rate > 90 bpm Respiratory rate > 20 /min or a PaCO2 < 32 mmHg White blood cell count > 12,000 / cu mm or < 4,000 / cu mm, or > 10 bands
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NEW SEPSIS DEFINITION Guidelines were revised in 2008, 2012, and most recently updated in 2015. These guidelines have shaped how hospitals must identify and treat patients who are identified as having sepsis, severe sepsis, and septic shock.
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NEW SEPSIS DEFINITION The Surviving Sepsis Campaign (SSC) international guidelines were developed for early detection and treatment of severe sepsis and septic shock
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NEW SEPSIS DEFINITION “Sepsis is a life threatening organ dysfunction caused by a dysregulated host response to an infection.” The European Society of Intensive Care Medicine/Society of Critical Care Medicine Third International Consensus definitions for Sepsis and Septic Shock task force (the Sepsis-3 task force)
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New sepsis definition Persistent hypotension requiring vasopressors to keep MAP > 65 mmHg despite adequate fluid resuscitation Serum lactate > 2 mmol/L JAMA 2016
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Quick SOFA / qSOFA > 22/ min SBP ≤100mmHg In patients with infection a qSOFA score > 2 is associated with higher mortality and prolonged ICU stay. SEPSIS Scoring tool
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Research trials
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SEP-1 Two Clocks 3 hour
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3 hr. 6 hr. SEP-1: EARLY MANAGEMENT BUNDLE Interventions Required: Blood culture before antibiotics Antibiotics Lactate level Set Measure ID # SEP-1-8; Early Management Bundle, Severe Sepsis/Septic Shock Interventions Required: Lactate level repeated (If elevated) Severe Sepsis Time Zero SEP-1 Two Clocks
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2012 NQF: SEPSIS 0500 TO BE COMPLETED WITHIN 3 HOURS OF TIME OF PRESENTATION: Obtain blood cultures prior to administration of antibiotics. Measure lactate level. Administer broad spectrum antibiotics. Administer 30ml/kg crystalloid for hypotension, defined as a “mean arterial pressure” MAP<65 or lactate ≥4mmol/L. SEP-1 Two Clocks
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Focused Exam SEP-1 Two Clocks
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SEP-1 Two Clocks “Delays in administering all four guidelines recommendations, even when they did not exceed 3 hours, were associated with a significant increase in in-hospital mortality.” SCCM journal April 2018. Volume 46. Number 4
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3 hr. 6 hr. Severe Sepsis Time Zero Interventions Required: ALL of Severe Sepsis + Fluid 30 ml/kg (NO exclusionary criteria) Physical Exam (ALL) Vital Signs (T, HR, RR, BP) Cardiopulmonary exam Capillary refill evaluation Peripheral Pulse evaluation Skin evaluation Hemodynamics (2 of 4) CVP SVO2 Bedside cardiovascular ultrasound Passive leg raise / fluid challenge Shock Assessment Interventions Required: Persistent Hypotension Within 1 hour of fluid add VASOPRESSOR Persistent Hypotension OR Lactate > 4 Shock Assessment (1 of 2) SEPTIC SHOCK ONLY
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2012 NQF: SEPSIS 0500 Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure (MAP) ≥65mmHg) SEP-1 Two Clocks TO BE COMPLETED WITHIN 6 HOURS OF TIME OF PRESENTATION:
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Mean arterial pressure Urinary output (mL) 49 +18 56 + 21 43 +13 .60/.71 Capillary blood flow (mL/min/100 g) 6.0 + 1.6 5.8 + 11 5.3 + 0.9 .59/.55 Red Cell Velocity (au) 0.42 + 0.06 0.44 +016 0.42 + 0.06 .74/.97 Pico2 (mm Hg) 41 + 2 47 + 2 46 + 2 .11/.12 Pa-Pico2 (mm Hg) 13 + 3 17 + 3 16 + 3 .27/.40 75 mm Hg 65 mm Hg 85 mm Hg F/LT Adapted from Table 4, page 2731, from LeDoux, Astiz ME, Carpati CM, Rackow ED. Effects of perfusion pressure on tissue perfusion in septic shock. Crit Care Med 2000; 28:2729-2732
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2012 NQF: SEPSIS 0500 TO BE COMPLETED WITHIN 6 HOURS OF TIME OF PRESENTATION: In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate ≥4 mmol/L (36mg/dl): Measure central venous pressure (CVP) Measure central venous oxygen saturation (ScvO2) Remeasure lactate if elevated SEP-1 Two Clocks
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FLUID RESUSCITATION
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RESEARCH SUPPORTING FLUID RESUSCITATION BUNDLE
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Choice of Fluids Crystalloids Colloids Ringers Lactate Normal Saline Albumin Gelatins Hetastarch
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IV FLUID COMPOSITIONS
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FLUID REPLACEMENT CHALLENGES End Stage Renal Disease on Dialysis Compensated Congestive Heart Failure
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HEMODYNAMIC CHANGES IN SEPTIC SHOCK Interstitial Edema in Septic Shock Lungs Brain Kidney
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Dellinger RP. Cardiovascular management of septic shock. Crit Care Med 2003;31:946-955.
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During Septic Shock Courtesy of Joe Parrillo Hackensack NJ
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RESEARCH RECOMMENDATION SCCM recommends that, in the resuscitation of sepsis-induced hypoperfusion, at least 30 ml/kg of IV crystalloid fluid be given within the first 3 hours (strong recommendation, low quality of evidence).
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ANTIBIOTIC THERAPY Started within 3 hrs after severe sepsis presentation Monotherapy vs. Combination Therapy
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Choose Aminoglycosides or Aztreonam or Ciprofloxacin Cephalosporins, (1st and 2nd Generation) - or – Clindamycin - or - Daptomycin - or - Glycopeptides - or - Linezolid - or - Macrolides - or - Penicillins COMBINATION THERAPY
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Choice of vASOPRESSERS First Line Second Line Niche Drugs Norepinephrine Epinephrine Low Dose Vasopressin (.01-.03 units/min) Dopamine (sinus bradycardia) Phenylephrine (high cardiac output or serious tachyarrhythmias and salvage)
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We suggest against using IV hydrocortisone to treat septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability. If this is not achievable, we suggest IV hydrocortisone at a dose of 200 mg per day Surviving sepsis campaign 2016
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No ACTH stimulation tests or serum cortisol testing No additional mineralocorticoid 7 days Taper Surviving sepsis campaign 2016
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Hydrocortisone provides adequate glucocorticoid and mineralocorticoid effects so fludrocortisone is not needed. Tapering of steroids is recommended. Although the current hypothesis for the use of steroids in septic shock is to treat relative adrenal insufficiency, current evidence suggests no value in measuring this with a corticotropin response test. WHAT DO WE KNOW?
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Steroids are of no benefit in the treatment of severe sepsis in the absence of shock. Low dose steroid therapy reduces time to reversal of septic shock Still controversial as to whether or not there is a meaningful reduction in mortality. The more severely ill and hemodynamically unstable the patient is the more likely to benefit from stress-dose steroids. WHAT DO WE KNOW?
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To Save Lives..... Early fluid resuscitation Early identification Early antibiotics
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Thank You!