Transcript Sepsis Protocol - Hendricks Regional Health

Sepsis Protocol
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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
• 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
• The patient has Sepsis, if
• 2 of 4 SIRS criteria present
• suspected or confirmed source of infection
Severe Sepsis – Phase III
• A patient with sepsis 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
• 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
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%)
• 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
2008 Review of Data
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
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Recognize early signs of Sepsis (41%)
Obtain venous lactate (0%)
Earlier initiation of pressors
Blood cultures obtained
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
• 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
ED/ICU
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
Enteral nutrition is preferred over parenteral
because it is associated with improved patient
outcomes.
• Suggest initiate enteral nutrition when:
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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
• 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:
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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
• 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