Severe Sepsis Initial recognition and resuscitation

1. Severe SepsisInitial recognition and resuscitation Issued August 2010

2. Expected Practice • Assess all patients and immediately notify physician when a patient presents with risk factors for sepsis. Severe Sepsis: Initial recognition and resuscitation

3. Clinical Findings Documented or suspected infection • Two or more SIRS criteria • At least one indicator of tissue hypoperfusion or related acute organ dysfunction Severe Sepsis: Initial recognition and resuscitation

4. 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 Severe Sepsis: Initial recognition and resuscitation

5. Acute altered mental status SBP <90mmHg or MAP < 70mmHg or SBP Decrease of 40 mmHg Blood glucose > 140 mg/dL, non-diabetic patients Arterial hypoxemia Acute oliguria Creatinine increase above baseline Coagulation abnormalities Ileus Thrombocytopenia Hyoperbilirubinemia Tissue hypoperfusionSepsis related acute organ failure Severe Sepsis: Initial recognition and resuscitation

6. 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 Severe Sepsis: Initial recognition and resuscitation

7. Expected Practice • Evaluate for and remove other potential sources of infection Severe Sepsis: Initial recognition and resuscitation

8. Maintain Therapeutic Endpoints • MAP at >65 mmHg • CVP 8-12 mmHg • Central venous or mixed venous oxygen saturation > 70% Severe Sepsis: Initial recognition and resuscitation

9. 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%. Severe Sepsis: Initial recognition and resuscitation

10. 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 Severe Sepsis: Initial recognition and resuscitation

11. 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. Severe Sepsis: Initial recognition and resuscitation

12. 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 30-60%. Severe Sepsis: Initial recognition and resuscitation

13. 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 non-coronary ICU. The incidence of severe sepsis is expected to double over the next 25-30 years. Severe Sepsis: Initial recognition and resuscitation

14. 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 Severe Sepsis: Initial recognition and resuscitation

15. 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 Severe Sepsis: Initial recognition and resuscitation

16. 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. Severe Sepsis: Initial recognition and resuscitation

17. 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. Severe Sepsis: Initial recognition and resuscitation

18. 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 Severe Sepsis: Initial recognition and resuscitation

19. 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 Severe Sepsis: Initial recognition and resuscitation

20. Supporting evidence • Colloids have not been shown to be of more benefit than crystalloid for fluid resuscitation. Severe Sepsis: Initial recognition and resuscitation

21. 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. Severe Sepsis: Initial recognition and resuscitation

22. 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. Severe Sepsis: Initial recognition and resuscitation

23. 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. Severe Sepsis: Initial recognition and resuscitation

24. 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. Severe Sepsis: Initial recognition and resuscitation

25. Actions for Nursing Practice • Educate all nursing staff on the risk factors and clinical signs of sepsis. Severe Sepsis: Initial recognition and resuscitation

26. Actions for Nursing Practice • Create an interdisciplinary team to develop protocols or guidelines. Severe Sepsis: Initial recognition and resuscitation

27. Actions for Nursing Practice • Consider development of a rapid response team to facilitate prompt identification of patients with sepsis. Severe Sepsis: Initial recognition and resuscitation

28. Need More Information or Help? • For additional information/assistance go to www.aacn.org then select PRN. Severe Sepsis: Initial recognition and resuscitation