Transcript Slide 1

Severe Sepsis
Initial recognition and resuscitation
Issued August 2010
Expected Practice
Assess all patients and immediately
notify physician when a patient
presents with risk factors for sepsis.
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Clinical Findings
Documented or suspected infection
Two or more SIRS criteria
At least one indicator of tissue
hypoperfusion or related acute organ
dysfunction
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SIRS criteria
Heart rate > 90 beats per minute
Temperature < 36°C (98.8°F) or >
38.3°C (100.4°F)
Respiratory rate > 20 breaths per
minute
White blood cell count > 12,000/mm3 or
< 4000 mm
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Tissue hypoperfusion
Sepsis related acute organ failure
Acute altered
mental status
SBP <90mmHg or
MAP < 70mmHg or
SBP Decrease of 40
mmHg
Blood glucose >
140 mg/dL, nondiabetic patients
Arterial hypoxemia
Severe Sepsis: Initial recognition and
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Acute oliguria
Creatinine increase
above baseline
Coagulation
abnormalities
Ileus
Thrombocytopenia
Hyoperbilirubinemia
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Expected Practice
Obtain serum lactate measurements.
 Hyperlactatemia is defined as lactic acid level > 4.
Obtain blood cultures as well as cultures
from all potential sites of infection prior to
initiating broad spectrum antibiotics
 Blood cultures should be drawn prior to initiation of
antibiotic therapy and within 1 hour of sepsis diagnosis
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Expected Practice
Evaluate for and remove other potential
sources of infection
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Maintain Therapeutic Endpoints
MAP at >65 mmHg
CVP 8-12 mmHg
Central venous or mixed venous
oxygen saturation > 70%
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Expected Practice
Administer fluids to maintain:
 Mean arterial pressure at >65 mmHg
 Central venous pressure (CVP)
8-12 mmHg
 Central venous or mixed venous oxygen
saturation > 70%.
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Expected Practice
Administer vasopressors if necessary
to achieve a mean arterial pressure of
65 mmHg
If Venous Oxygen saturation goal not
attained consider;
 Additional fluids
 Blood transfusion
 Dobutamine infusion
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Expected Practice
Maintain blood glucose levels at
< 150 mg/dL.
Consider administration of human
recombinant activated protein C
 Note: Administration of human recombinant activated protein C
(drotrecogin alfa activated) is no longer recommended. The FDA sent
out notification on October 25, 2011 that Eli Lilly has withdrawn this
drug from the market.
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Scope and Impact of the
Problem
Severe sepsis is a major healthcare
problem that affects millions of people
around the world each year with an
extremely high mortality rate of 3060%.
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Scope and Impact of the
Problem
Mortality from sepsis is greater than that
of breast cancer, lung cancer, and
colon cancer combined and is the
number one cause of death in the noncoronary ICU. The incidence of severe
sepsis is expected to double over the
next 25-30 years.
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Supporting Evidence
More than 750,000 cases of severe sepsis
occurred annually
Sepsis can rapidly progress to severe sepsis
to septic shock within 24 hours
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Supporting evidence
 Treatment should be initiated
regardless of where the patient is
located within the hospital.
 Patients treated aggressively within the
first 6 hours of presentation have lower
mortality
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Supporting evidence
Serum lactate levels can be elevated in
the setting of a normal or increased
cardiac output.
 The measurement of serum lactate can reflect
occult decreases in global tissue perfusion and
may be an indicator of organ dysfunction.
 The presence and the clearance rate of lactate
are associated with increases in patient
morbidity and mortality.
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Supporting evidence
Early administration of appropriate
antibiotics decreases mortality in
patients with Gram- positive and
negative bacteremias.
Empiric broad spectrum antibiotics
should be initiated prior to identification
of the infecting organism
 Reassess after 48-72 hours based on culture
results and clinical data.
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Supporting evidence
Surviving Sepsis Campaign guidelines state
that the goal of the first 6 hours of treatment
 Achieve and maintain a CVP of 8-12 mm Hg or 12-15
mm Hg for patients receiving mechanical ventilation and
a MAP of at least 65 mm Hg with fluid resuscitation.
Dobutamine is identified as the medication of
choice to increase cardiac output to normal
levels or to improve lactate clearance
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Supporting evidence
No benefit has been shown for
increasing cardiac output above
physiologic normal levels.
Available data do not support the use
of low dose dopamine for renal
protection
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Supporting evidence
Colloids have not been shown to be of
more benefit than crystalloid for fluid
resuscitation.
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Supporting evidence
Fluid replacement should be optimized
before vasopressors are started.
Norepinephrine or dopamine are
identified as the initial vasopressors to
increase vascular tone and blood
pressure.
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Supporting evidence
Meta analyses concluded that administration
of high dose corticosteroids are of no benefit
or may be detrimental to patients with septic
shock.
In vasopressor dependent shock, low-dose
exogenous cortisol may improve the uptake
of the patient’s own and the exogenously
administered sympathetic stimulants when
serum cortisol levels are low.
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Supporting evidence
Glucose levels within 80-110 mg/dL
may decrease morbidity and morality in
a surgical population.
Glucose levels < 150mg/dL showed
reduced morbidity in critically ill medical
patients.
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Supporting evidence
Administration of human recombinant
activated protein C (drotrecogin alfa
activated) is no longer recommended. The
FDA sent out notification on October 25,
2011 that Eli Lilly has withdrawn this drug
from the market. In a recently completed
clinical trial (PROWESS-SHOCK trial), the
drug failed to show a survival benefit for
patients with severe sepsis and septic shock.
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Actions for Nursing
Practice
Educate all nursing staff on the risk
factors and clinical signs of sepsis.
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Actions for Nursing
Practice
Create an interdisciplinary team to
develop protocols or guidelines.
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Actions for Nursing
Practice
Consider development of a rapid
response team to facilitate prompt
identification of patients with sepsis.
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Need More Information or
Help?
For additional information/assistance
go to www.aacn.org then select PRN.
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