Recognizing Sepsis

1. Recognizing Sepsis April 9, 2010 Jan Appel, RN, CEN References: Caring for Patients with Sepsis According to the Guidelines by Steven D. Glow American Heart Association. Pediatric Advanced Life Support Provider Manual Delores Privette Nelson, BSN,RN, et al. Recognizing Sepsis in the Adult Patient AJN March 2009 Mo. 109, No.3 Surviving Sepsis Campaign Web site. http://www.survivingsepsis.org

2. Case Study: A 32 yr old female presented to the ED with kidney pain. She was diagnosed with a kidney stone and sent home with painkillers. The next day, still in pain, she returned to the hospital and was diagnosed with sepsis, but by then she’d lost blood flow to her hands and feet and nothing could be done to prevent quadruple amputation and loss of sight in one eye.

3. Sepsis Moves Fast and is often diagnosed TOO LATE Analyzing 1995 hospital discharge data from 847 US hospitals . . . Incidence of more than 750,000 yearly cases of sever sepsis, with a mortality rate of nearly 30%. . . Hospitalization rates for severs sepsis almost doubled between 1993 – 2003 . . Proportion of patients with severe sepsis among all patients with sepsis grew by 70%. Early recognition and rapid response are essential . .

4. Identification of Sepsis: The initial presentation of sepsis is often subtle. Assessment findings that may indicate sepsis: A documented or suspected infection with one or more of the following:

5. General variables: • Fever: Core temperature >38.3°C (102.2°F) • Hypothermia: Core temperature <36°C (96.8°F) • Heart rate: >90 bpm-1 or >2 standard deviations [SD] above the normal value for age • Tachypnea: Respiratory rate ≥20 breaths/min or hyperventilation manifested as PaCO2 ≤32 mm Hg • Altered mental status: Confusion, agitation, decreased responsiveness • Significant edema or positive fluid balance: >20 ml/kg over 24 h • Hyperglycemia: Plasma glucose >120 mg/dl in the absence of diabetes

6. Inflammatory variables: • Leukocytosis: WBC count >12,000 cells/mm3 • Leukopenia: WBC count <4000 cells/mm3 • Bandemia: Normal WBC count with >6% immature forms • Elevated plasma C-reactive protein (CRP)>2 SD above the normal value • Elevated plasma procalcitonin >2 SD above the normal value

7. Other: • Elevated mixed venous oxygen saturation (SvO2)>70% • Increased cardiac index (CI)>3.5 L/min/m2

8. Severe sepsis: • Sepsis plus • Organ dysfunction • Hypoperfusion, or • Hypotension

9. Organ dysfunction variables: • Arterial hypoxemia: The ratio of PaO2 to FiO2 <300; PEEP >7.5; or requiring mechanical ventilation • Acute oliguria: Urine output <0.5 ml/kg/h for at least 2 h • Elevated creatinine level OR renal dysfunction OR needing dialysis: >2 mg/dl • Coagulation abnormalities: INR >1.5 or aPTT >60 sec • Thrombocytopenia: Platelet count <100,000 mm3 • Elevated liver enzymes: AST and ALT >40 units/L

10. Tissue perfusion variables: • Increased serum lactate: >2 mmol/L (metabolic dysfunction) Hemodynamic variables: • Arterial hypotension (unresponsive to fluid resuscitation or need for vasopressors): Systolic blood pressure (SBP) <90 mm Hg, mean arterial pressure (MAP) <70 mm Hg, or a decrease in SBP >40 mm Hg

11. Septic shock: acute circulatory failure unexplained by other causes • Acute circulatory failure: Persistent arterial hypotension (SBP <90 mm Hg, MAP <60 mm Hg, or a reduction in SBP >40 mm Hg from baseline despite adequate volume resuscitation)

14. Sepsis Resuscitation Bundle The goal is to perform all indicated tasks 100% of the time within the first 6 hours of identification of severe sepsis. The tasks are: • Measure serum lactate • Obtain blood cultures prior to antibiotic administration • Administer broad-spectrum antibiotic, within 3 hrs of ED admission & within 1 hr of non-ED Admission • In the event of hypotension and/or a serum lactate > 4 mmol/L. Deliver an initial minimum of 20 ml/kg of crystalloid or an equivalent • Apply vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) > 65 mm Hg • In the event of persistent hypotension despite fluid resuscitation (septic shock) and/or lactate > 4 mmol/L • Achieve a central venous pressure (CVP) of > 8 mm Hg • Achieve a central venous oxygen saturation (ScvO2) > 70 % or mixed venous oxygen saturation (SvO2) > 65 %

16. Case Study: You are caring for a 65 yr old female 8hrs after admission from the ER with diagnosis of MVA that occurred while driving to the ER for evaluation of severed epigastric pain. She has had frequent admissions & complicated medical history: CAD, Endstage renal disease/peritoneal dialysis, HTN, Breast Cancer, Hx of peritonitis & pancreatitis. At report you note that her BP has progressively declined since admission (141/88). Assessment: Bedside abdominal ultrasound is in progress at the bedside. Patient is alert, c/o pain all over, color pale, skin cool. VS: T: 97.3 BP: 64/34 HR: 89 RR: 14 SaO2: 97% on 2L/min. Medications: Saline lock is intact. No IV fluids are ordered. Long list of routine meds. No antibiotics. The physician is on the unit & on the phone. What additional information do you need? Red flags? What do you suspect? Interventions?

17. Case Study: You are assuming the care of a 8hr old infant with history of possible Meconium Aspiration. Apgars 3,6 & 7. Assessment: The baby is at breast for the first time & nursed for about 15 min. Alert, normal cry & tone, color pink. VS: HR 120 T: 97.5 RR: 40 BG: 48 What additional information do you need? Red flags? What do you suspect? Interventions? The baby is placed in the radiant warmer & supplemented with 15cc of formula. VS 2hr. later: T: 98.1 RR: 60 BG: 31 What additional information do you need? Red flags? What do you suspect? Interventions?