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Surviving Sepsis: Improving Care, Saving Lives ...

Surviving Sepsis: Improving Care, Saving Lives
Kristy Molnar
Critical Care Consultants
(sponsored by Philips Healthcare, Alberta Health Services and supported by Edwards Lifesciences)

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  • Early Identification and Treatment of Sepsis using Clinical Decision SupportBased on the Surviving Sepsis Campaign (SSC)Supported by Philips Healthcare SSC “Protocol Watch” softwareSSC Guidelines:1st Edition 2004,2nd Edition 2008, 3rd Edition 2012 (Campaign Bundle Modifications)Challenges related to SepsisReview of Pathophysiology of SepsisSSC GuidelinesRecommended Physiologic MonitoringPractice RecommendationsClinical Decision Support ToolsImplementationResourcesSuccesses & Action Plan“Surviving Sepsis”, 2005 (1st Edition) Publication:Society of Critical Care Medicine (SCCM)European Society of Intensive Care Medicine (ESICM)International Sepsis Forum (ISF)
  • Sepsis is the body’s systemic response to infection and is a serious health care condition that affects neonatal, pediatric and adult patients worldwide. Severe sepsis and septic shock are associated with high mortality rates, despite the ability to manage infection.The cellular processes that occur as a result of INFLAMMATORY RESPONSES in Sepsis, including impaired perfusion and microcirculatory coagulation, can lead to organ system dsyfunction & death.Early recognition of sepsis can help to ensure prompt treatment to improve patients’ outcomes.Severe Sepsis is the leading cause of death in non-coronary ICU~ 1/3 of 750,000 new (US) cases each year are fatal>18 million cases of sepsis occur worldwide each yearSepsis kills some 1,400 people worldwide every dayNEJM, 2001 – mortality from Sepsis could be reduced by 16% with a protocol known as early goal-directed therapy (Rapid Diagnosis and Treatment)!
  • World Sepsis Day, 2012: “Sepsis is a common disease. The global impact of sepsis is enormous, both in terms of lives lost and high cost. Sepsis affects the young and the old, and one of the ongoing challenges is early recognition of sepsis. It is most important at this time to draw attention to this common disease in order to increase awareness and attract funding for research so that we can continue in our fight to reduce the number of people who die each year from sepsis.”Prof. Mitchell M. Levy, Providence RI
  • DisporportionalPrevalence versus Spending!
  • World Sepsis Day, 2012: “An ageing population and increasingly complex medical and surgical practices magnifies the risk of developing Sepsis, one of the few major medical conditions whose incidence and resulting mortality continues to rise!”Prof. Mervyn Singer, London UK
  • Sepsis is defined as a systemic inflammatory response initiated by a source of infection. The incidence, hospitalization rates, and mortality of sepsis remains one of the leading causes of morbidity and mortality worldwide.In Sepsis, stimulation of the innate immune system, activation of white blood cells, and response of endothelial cells can lead to the release of a number of mediators or cytokines. This activation causes a variety of physiological changes including vasodilatation, enhanced expression of adhesion molecules, increased capillary permeability, increased clot formation, and decreased fibrinolysis.Although the immune system response is protective in nature, overactivity of mediators has been cited as a causal factor contributing to endothelial cell damage, microcirculatory permeability changes, capillary leak, and profound vasodilation and hypotension.These responses play a role in the progression of severe sepsis and influence the development of MODS.Early recognition and treatment of sepsis is crucial for clinicians to improve outcomes and decrease sepsis-related mortality.Number of sepsis cases in US is projected to grow at a rate of 1.5% per year, as the population ages and medicine becomes more aggressive.Mortality rates with Sepsis are extremely high: 30% to 50% for severe sepsis and 50%-60% for Septic Shock
  • SEPSIS DOES NOT DISCRIMINATE! Sepsis respects no age, no race, no gender, no economic status. It can strike anyone. Here you can read the stories of real people who have been affected by sepsis. Some of them are famous; most of them are ordinary people like you and me. Some of them are survivors. Some lost their lives. But all of them have something valuable to teach us.
  • World Sepsis Day, 2012: “Sepsis regards no gender, no age, and no ethnicity. It can afflict anybody. It is the number one killer in ICU’s around the world, and only a well-coordinated global effort can overcome such a formidable foe”Prof. Edgar J. Jimenez, Orlando FL
  • Dr. Oz “When Infections Turn Deadly” Part 1, 2, 3, 4 (YouTube) … Rory’s storyToday’s ShowNY State Department’s Cuomo Initiative – LegislationPerformance Gap!
  • World Sepsis Day, 2012: “Severe infections leading to sepsis account for about 70% of infant and childhood deaths worldwide. I support the World Sepsis Day as a step to elevate public awareness, influence policy and generate action to fight this worldwide scrouge. Our future depends on the welfare of our children.”Prof. Niranjan “Tex” Kissoon – BC Children’s, Vancouver.
  • Age 85 and up – highest incidence of Sepsis!
  • World Sepsis Day, 2012: “To solve a problem one must first recognize it. Sepsis has been a largely invisible disease. Those of us who care for critically ill septic patients are constantly frustrated that death from sepsis is described in other terms – “complications of cancer or surgery”, “malaria”, or even “after a brief illness”. Sepsis is the pathway to death for four of the top ten causes of death on our planet; until we recognize this, we cannot change it. Thus, I am thrilled to see the emergence of World Sepsis Day as a global effort to raise the profile of sepsis as a treatable or preventable illness with health care workers, decision-makers, and the general public.”Prof. John Marshall, University of Toronto, Toronto Canada (Past Chair of the International Sepsis Forum).
  • Sepsis places a significant burden on healthcare resources! The majority of your ICU costs are Sepsis-related! The burden on your healthcare workers are in many ways related to Sepsis.
  • World Sepsis Day, 2012: Costs are escalating!Human Costs … immeasurable!
  • World Sepsis Day, 2012: “Sepsis is important. It accounts for the majority of deaths that occur in ICU’s. But few people know about it. We need to call attention to this condition and to give our full support to research dedicated to improving outcomes.” Prof. Anand Kumar, University of Manitoba, Winnipeg, MB.
  • No small change!
  • In a 2002 European/USA survey (1.050 physicians): Without a high index of suspicion, Sepsis can easily be missed, with significant consequence.86% said that the symptoms of Sepsis can easily be misattributed to other conditions
  • 2012 World Sepsis Day: “Although sepsis represents a major threat to our patients, evidence suggests a significant gap between knowledge and practice among our clinicians. The Chinese Society of Critical Care Medicine is proud to be an active partner of the World Sepsis Day, the objective of which is to narrow this gap by encouraging dedicated efforts from multiple relevant disciplines all over the world.”Prof. Bin Du, Peking & Beijing, China
  • 2012 World Sepsis Day: “As a bedside clinician and as someone who has spent the majority of his academic career devoted to education and research in sepsis, I recognize how devastating a disease sepsis can be. Unlike cancer and heart disease, sepsis remains underemphasized in the minds of the public and governmental agencies. The World Sepsis Day will start a journey toward rectifying this problem.”Prof. Phil Dellinger, Camden NJ
  • 2012 World Sepsis Day: “ For the first time, we seek to bring nurses, clinicians and allied health professionals from all disciplines together as a global community to reach out to politicians, policymakers, volunteer organizations, and funding bodies. This gives us real opportunity to reduce the human and economic impact of sepsis on a worldwide scale. I am proud to support World Sepsis Day.”Dr. Ron Daniels, Birmingham UK
  • IHI (Institute for Healthcare Improvement) Map: Where are your Gaps?TrackAnalyzeSharehttp://www.ihi.org/Pages/default.aspx
  • What’s on the IHI Map? Some key initiatives outlines by IHISupport Care Processes (eg – Early Warning Systems, Patient Flow for Efficiency & Safety)Leadership ProcessesPatient Care Processes (eg – Rapid Response Systems, Sepsis Detection & Management)
  • Tell me about the “typical Septic Patient in your ICU” …SUSPECT SEPSIS … SAVE LIVES! (Video: next slide)http://www.sepsisalliance.org/resources/video/Stimulation of the immune system, activation of white blood cells and response to endothelial cells … Release of a number of mediators or cytokines.This activation causes a variety of physiologic changes, including: Vasodilation, Enhanced expression of adhesion molecules, Increased capillary permeability, Increased clot formation, and Decreased fibrinolysis.
  • SEPSIS EMERGENCY! Video from Sepsisalliance.orgCODE SEPSIS!!Immune system response is supposed to be protective in nature – aimed at combating infection in sepsis. Overactivity of mediators(a virtual war zone with an extremely high casualty rate) … causal factor contributing to endothelial cell damage, microcirculatory permeability changes, capillary leak, and profound vasodilation and hypotension.These responses play a role in the progression of severe sepsis and influences the development of multiple organ dysfunction.Strike 1 OrganStrike 2 OrgansStrike 3 Organs … and you are out!
  • APACHE II (Acute Physiology and Chronic Health Evaluation): 1985 Knaus et alAPACHE II uses a point score based upon initial values of 12 routine physiologic measurements, age, and previous health status to provide a general measure of severity of disease. An increasing score (range 0 to 71) was closely correlated with the subsequent risk of hospital death for 5815 intensive care admissions from 13 hospitals. This relationship was also found for many common diseases. When APACHE II scores are combined with an accurate description of disease, they can prognostically stratify acutely ill patients and assist investigators comparing the success of new or differing forms of therapy. This scoring index can be used to evaluate the use of hospital resources and compare the efficacy of intensive care in different hospitals or over time.Time consuming – retrospectiveSOFA (Sequential Organ Failure Assessment): 1996 JL Vincent et alHow do we screen for Sepsis?
  • Sepsisalliance.org resource videos:Animation of how Sepsis developsSpectrum of Critical Illness & Physiologic responses to a widespread insult:Inflammation and CoagulationVasodilatationAttempts at compensationCirculatory dysfunctionRedistributionPerfusion deficitsLoss of autoregulation in the tissue bedsIschemiaTissue HypoxiaOngoing trigger & inflammationMetabolic derangementsOrgan dysfunctionDeath
  • Sepsis Syndrome … a final common pathway to death.
  • How long do we wait? When should we be intervening aggressively? Septic Shock = “Salvage operation” in the ICU?SIRSSEPSISSEVERE SEPSISSEPTIC SHOCKMODSDEATH
  • Infection, documented or suspected, and some of the following:Increased Temperature (> 38.3)(Hypothermia < 36)Tachycardia (> 90)TachypneaAltered Mental StatusSignificant Edema or Positive Fluid Balance (> 20 mL/kg over 24 hours)Hyperglycemia (> 140 mg/dl or 7.7 mmol/L) in the absence of diabetes
  • SIRS: This is my pneumonic!Systemic Inflammatory Response Syndrome requires:Speedy Intervention & Response for Survival!
  • Society of Critical Care Medicine (SCCM) www.sccm.orgEuropean Society of Intensive Care Medicine (ESICM) www.esicm.orgInternational Sepsis Forum (ISF) www.sepsisforum.org68 international experts representing 30 international organizationsThe Campaign was devised in 2002. Joining forces to develop a three-phase Surviving Sepsis Campaign (2003):Phase I – Introduction of the Initiative & development of an Action Plan to reduce global mortality from Sepsis by 25% by 2009.Phase II – Creation of Guidelines, beginning in June, 2003 and published in March, 2004 issue of Critical Care Medicine and April, 2004 Intensive Care MedicinePhase III – Translation of the Guidelines into clinical practice. Partnered with the Institute for Healthcare Improvement (IHI) to develop two sepsis bundles and to create a database-centered change measurement process.The Institute for Healthcare Improvement (IHI) www.ihi.org has a section (0005?) dedicated to Sepsis treatment. It also includes process and outcome measures associated with the sepsis bundles as well as downloadable paper and electronic tools for data tracking and reporting of improvement efforts.PUBLICATION: (Education Grants from Edwards)2005 Manual/User’s Guide (SCCM, ESICM, ISF) Participation in the Surviving Sepsis CampaignSurviving Sepsis Campaign Web site. www.survingsepsis.orgThe success of the Surviving Sepsis Campaign depends on its ability to demonstrate a convincing change in mortality.
  • Howaware is the general public?How are we responding?
  • WITH CRISIS COMES OPPORTUNITY …2012 World Sepsis Day: “Sepsis represents perhaps the greatest challenge to effective delivery of healthcare and certainly provides the greatest hope. For a disease to be so common and so deadly and yet, so unknown, creates a crisis that exceeds the need for new therapeutics and diagnostics. To reduce deaths from Sepsis, we must better organize the delivery of care to those in need, regardless of location. In the developing world, this includes better access to clear water and nutrition – in addition to healthcare facilities and providers. In the developed world, this requires re-organization of our delivery of care so that sepsis is treated as a medical emergency with improved engineering of systems to deliver this care. To drive these changes, increased awareness is required, for only through increased public demand will we in healthcare be provided the resources and expectations we need to improve. While this seems an insurmountable task, the promise is that, by adhering to the care articulated by the Global Sepsis Alliance declaration and raising awareness through World Sepsis Day, we have the opportunity to change the natural history of this disease in our lifetimes – to save millions of lives – without requiring new discoveries – simply by doing what we know works. This hope, this promise is what requires us to continue to push for better sepsis care.”Prof. James M. O’Brien, Ohio State University.
  • To reiterate … what about our investment within our own healthcare organizations?
  • Applying the “Surviving Sepsis Campaign Guidelines” … 100% of patients, 100% of the time.Work of a committee of 68 international experts representing 30 international organizations. A process of continual improvement.The current guidelines use the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system to establish the quality of evidence from High (A) to very low (D) and to determine the strength of recommendations as strong (1) or weak (2).A1 = do!D2 = why do?3 Categories:Recommendations directly targeting the management of severe sepsisRecommendations targeting high-priority general care considerationsPediatric considerations2 Bundles:Initial Resuscitation (Primary focus of recognition & resuscitation) … 3 HoursSepsis Bundles (Specific recommendations for the management of sepsis) … 6 HoursBarriers to initiating and monitoring early quantitative resuscitation (CVP, MAP, ScvO2) have been associated with limited availability of equipment and competence of clinicians. Debate continues regarding the most effective end-points of resuscitation.
  • 3 R’s: Recognize… Resuscitate … Refer (NHS Scotland – 2012 World Sepsis Day) ...
  • 3 Hours – Resuscitation Bundle (Triage)6 Hours – Sepsis Shock Bundle (CVP, ScvO2, Lactate normalization)
  • Discussion – what will it take to implement in your unit, your hospital, your community
  • Community … Pre-Hospital … ER Triage … ER Management … ICU/OR
  • GLOBALALLIANCE
  • Surviving Sepsis Campaign is a group made up of thought leaders representing 26-30 global organizations involved in the care and management patients with Sepsis.The purpose of the campaign is to bring awareness & help bring forth the “best” standards of practice in order to ensure consistent treatment and improved outcomes.Development and modification of treatment protocols based on current literature and a review of evidence-based and peer-reviewed studies.The group meets every 4 years to modify treatment strategies and announce evidence used to make these modifications. The most recent updates and related publications were in June, 2012.
  • 200420082012 – Campaign Bundle ModificationsUse of a “two-tiered” system will continue. The old “Resuscitation” and “Management” bundles have been restructured. There will no longer be a Management bundle, as evidence has shifted significantly on the items that were contained within that area. The new Bundles will be an “Initial Resuscitation” and a “Septic Shock” Bundle.
  • https://www.youtube.com/watch?v=v08mYfxBJAEPublished on Mar 13, 2013Presentations include audio and slides from R. Phillip Dellinger as he describes the process of evaluating and grading evidence for the 2012 guidelines; Mitchell Levy reporting on the data that informed the new bundles; Sean Townsend discussing how regulatory agencies perceive and respond to the sepsis measures; Richard Beale showing regional differences in sepsis data; and Andrew Rhodes urging practitioners to join the Campaign in its next efforts to reduce mortality from sepsis worldwide. The SSC Guidelines: Using a Limited Evidence Base to Guide Clinical PracticeR. Phillip Dellinger, MD, MCCMThe SSC Improvement Initiative: The 2012 Revised Sepsis BundlesMitchell M. LevySepsis Performance Metrics: What Is on the Horizon for Regulatory Agencies?Sean R. Townsend, MDThe Global SSC: Regional and National Variation in PerformanceRichard J. Beale, MD, MBBSSSC Phase IV: What's Next?Andrew Rhodes, MD
  • 1ST EDITION (2004 GUIDELINES):2005 Manual/User’s Guide (SCCM, ESICM, ISF) Participation in the Surviving Sepsis CampaignSurviving Sepsis Campaign Web site. www.survingsepsis.org
  • 2ND EDITION (2008 GUIDELINES)
  • 3rdEDITION (2012 GUIDELINES):636 ReferencesPUBLISHED: www.ccmjournal.orgFebruary, 2013 Vol. 41, No. 2 (58 pages)
  • Nurses play a critical role in the process of early recognition, diagnosis, and treatment of sepsis. Critical Care Nurses are directly involved in the treatment of patients with sepsis and can, therefore, affect outcomes for critically ill patients. Nurses’ knowledge of the recommendations in the new guidelines can help to ensure that patients with sepsis receive therapies that are based on the latest scientific evidence.
  • http://www.sepsisalliance.org/resources/video/Videos from the SepsisAlliance.org (see Rap Video, the Sepsis Way)
  • http://www.sepsisalliance.org/resources/video/
  • http://www.sepsisalliance.org/resources/video/ SEPSIS WAY VIDEO
  • Processes! Dr. Sean Townsend – SCCM Surviving Sepsis Campaign – 2012 Guidelines (10 steps process)~ 30,000 patient database - EBMTime Zero! Start the Clock!! – submit to National Quality Forum (from time at Triage)IHI – Bundles and Reliable Quality Measures (28,000 in Sepsis Database)Quality Improvement CycleNational Quality Forum (NQF) Endorsement – Bundles/Legislation/Compliance/Quality Performance … Pay for Service!EHR Standard!?!https://www.youtube.com/watch?v=v08mYfxBJAE
  • How?Severity Scoring (APACHE II)
  • World Sepsis Day, 2012: “Critical care is where all specialties send their patients for intensive and high-tech care but sepsis is the main killer of our patients and uses most of our resources. I think we need to unify and work together to expose this killer disease to raise awareness and enable the public to use us in this fight.Prof. Hussain Al Rahma, Dubai UAE
  • Critical Care Nurses are directly involved in the assessment of patients at risk for developing sepsis and in the treatment of patients with sepsis and can, therefore, affect outcomes for critically ill patients.Nurses’ knowledge of the recommendations in the new guidelines can help to ensure that patients with sepsis receive therapies that are based on the latest scientific evidence.http://www.ajcconline.org
  • Ruth Kleinpell, Leanne Aitken and Christa A. SchorrAm J Crit Care 2013; 22:212-222AACNhttp://www.ajcconline.org(World Federation of Critical Care Nurses – Representatives on the Guideline revision task force)Critical Care Nurses are directly involved in the assessment of patients at risk for developing sepsis and in the treatment of patients with sepsis and can, therefore, affect outcomes for critically ill patients.Nurses’ knowledge of the recommendations in the new guidelines can help to ensure that patients with sepsis receive therapies that are based on the latest scientific evidence.
  • IHI – 2005 Sepsis Bundles (Don Berwick)2004, 2008 = Screening/Resuscitation/Management2012 = Initial Resuscitation/Septic Shock
  • What we SEE depends mainly on what we LOOK FOR
  • Diagnosis & Action! (Recognize, Resuscitate & Refer)Multi-disciplinary Team! (Physicians, Nurses, Pharmacy, Infection Control, Respiratory Therapists, Dieticians and Administrators)Multi-specialty collaboration! (Medicine, Surgery and Emergency medicine) to promote achievement of goals.Performance improvement involves education, protocol development and implementation, data collection, measurement of indicators and ongoing feedback to clinicians, administrators, quality improvement staff, clinical educators and others.
  • Screening for sepsis as part of a performance improvement process improves early identification of sepsis and decreases sepsis-related mortality.The guidelines identify the benefit of ROUTINE screening of potentially infected patients for severe sepsis to allow earlier implementation of therapy (1C)
  • World Sepsis Day, 2012: “ Sepsis is a common, life-threatening, an increasingly frequent medical problem that consumes huge amounts of resources. Mortality rates remain high, and the long-term effects, including total disability, severe. We desperately need new diagnostic and therapeutic approaches to sepsis.”Prof. Edward Abraham, Winston-Salem NC
  • 2012 Initial Resuscitation Bundle: CVP and standards will be retainedTime Zero
  • 2012: Blood Cultures encouraged at evidence level of (1A)Appropriate cultures before initiating antimicrobial therapy, provided that doing so does not delay the administration of antimicrobial agents longer than 45 minutes! (1C)2 sets of blood samples (aerobic and nonaerobic bottles) – 1 percutaneously and one through each vascular access device (if in situ > 48 hours)Other samples – urine, respiratory secretions, wounds, other body fluids that may be the source should also be collected before antibiotic therapy … as long as it does not delay (1C).
  • 2012: Data suggests that a delay in the administration of antibiotics for diagnosed sepsis by an hour was associated by a 5% increase in mortality.
  • 2012: Early Identification of Serum Lactate values as a baseline (and ongoing assessment for Lactate Clearance) was encouraged at the level of (1A)Video: Tom Shaughnessy, Philip Dellinger, (SCCM)
  • Hernandez,G.k Castro, R., et al. Persistent sepsis-induced hypotension without hyperlactatemia: is it really septic shock? J Crit Care, 2011 Aug; 26(4);435 Need to review the current definition of Septic Shock.Persistent sepsis-induced hypotension without hyperlactatemia may not constitute a real septic shock.Hyperlactatemia could represent an objective parameter to be explored as a potential diagnostic criterion for septic shock.Jan Bakker (www.intensivecare.me):Correlation of Lactate and MortalityOccult hypoperfusion,with associated hyperlactatemia and mortality in patients with suspected infectionTherapy aimed to optimize the Balance between oxygen demand and oxygen supply (ScvO2) and decreased in lactate levels by 20%/2 h for 8 h in patients with increased lactate levels reduced in-hospital mortality and decreased organ failure and use of health care resources.(Incidentally, the Lactate Protocol group ended up receiving more fluid resuscitation, as they were deemed more fluid responsive).Survivors versus Nonsurvivors – a link between their ability to clear lactate. Improved outcomes in patients treated with 8 hr Lactate-directed protocols, particularly apparent at 72 hours.
  • Dugas, Mackenhauer, Salciccioli, Cocchi, Gautam & Donnino: Prevalence and characteristics of nonlactate and lactate expressors in septic shock. Journal of Critical Care, 2012; 27: 344-350.45% of patients did not express lactate, even in the setting of vasopressor-dependent septic shock, yet had a mortality of 20%Lactate levels – no significant difference in 28-day mortality …but a trend toward increasing mortality with increasing lactate. ? Associated Liver disease
  • Dugas, Mackenhauer, Salciccioli, Cocchi, Gautam & Donnino: Prevalence and characteristics of non-lactate and lactate expressors in septic shock. Journal of Critical Care, 2012; 27: 344-350.45% of patients did not express lactate, even in the setting of vasopressor-dependent septic shock, yet had a mortality of 20%Lactate levels – no significant difference in 28-day mortality …but a trend toward increasing mortality with increasing lactate. ? Associated Liver disease
  • Wacharasint,Nakada, Boyd, Russel & Walley: Normal-range blood lactate concentration in septic shock is prognostic and predictive. (March, 2012 Shock Society); Shock, Vol. 38, No. 1, pp. 4-10, 2012.
  • Wacharasint,Nakada, Boyd, Russell & Walley: Normal-range blood lactate concentration in septic shock is prognostic and predictive. (March, 2012 Shock Society); Shock, Vol. 38, No. 1, pp. 4-10, 2012.Dugas, Mackenhauer, Salciccioli, Cocchi, Gautam & Donnino: Prevalence and characteristics of nonlactate and lactate expressors in septic shock. Journal of Critical Care, 2012; 27: 344-350.
  • Wacharasint,Nakada, Boyd, Russel & Walley: Normal-range blood lactate concentration in septic shock is prognostic and predictive. (March, 2012 Shock Society); Shock, Vol. 38, No. 1, pp. 4-10, 2012.Dugas, Mackenhauer, Salciccioli, Cocchi, Gautam & Donnino: Prevalence and characteristics of nonlactate and lactate expressors in septic shock. Journal of Critical Care, 2012; 27: 344-350.
  • Dugas, Mackenhauer, Salciccioli, Cocchi, Gautam & Donnino: Prevalence and characteristics of nonlactate and lactate expressors in septic shock. Journal of Critical Care, 2012; 27: 344-350.
  • Dugas, Mackenhauer, Salciccioli, Cocchi, Gautam & Donnino: Prevalence and characteristics of nonlactate and lactate expressors in septic shock. Journal of Critical Care, 2012; 27: 344-350.
  • 2012: The use of Crystalloids in place of high molecular weighted proteins was encouraged (1B)The initial resuscitation fluid volumes were increased from 20 ml/kg to 30 ml/kg as a standard.(Hydroxyl ethyl starches for fluid resuscitation is not supported).The use of albumin is indicated when patients require substantial amounts of crystalloids (2C)Fluid challenges, as a DYNAMIC test to assess patients fluid responsiveness to fluid administration have been advocated, provided that hemodynamic improvement continues – as measured by dynamic (eg change in pulse pressure, stroke volume variation, stroke volume) or static (BP, heart rate) variables. If hemodynamic improvement does not continue, discontinue and consider vasopressors.Blood is recommended for patients with a hemoglobin of 7 (70) or less.
  • Preload Indicators?CVP (Pressure/Volume relationships)PPVSVVSV
  • (All patients requiring vasopressors should have an arterial catheter places ASAP)Vasopressors should be initiated to maintain a target of MAP > 65 (1C).(even when hypovolemia has not yet been resolved)Below a threshold MAP, autoregulation in critical vascular beds can be lost, and perfusion can become linearly dependent on pressure.Norepinephrine is recommended and the 1st choice vasopressor (1B).Epinephrine (added or substituted) with additional agent is needed (2B)Vasopressin up to 0.03 units per minute can be added, to reach target MAP or to allow for a reduction of Norepinephrine … Not recommended as a single initial vasopressor for sepsis-induced hypotension. Doses > 0.03 to 0.04 units per minute should be reserved for salvage therapy.Dopamine should be used as an alternative vasopressor agent to norepinephrine only in highly selected patients (low risk of tachyarrhythmias and absolute or relative bradycardia)Phenylnephrine is not recommended, except where norepinephrine is associated with serious arrhythmias, CO is known to be high and BP persistently low, or as salvage therapy.Low-dose Dopamine should NOT be used for renal protection (1A)
  • ? Inotropic TherapyTrial of Dobutamine up to 20 micrograms/kg/min in the presence of:Myocardial dysfunction (elevated filling pressure and low CO)Ongoing signs of hypoperfusion, despite adequate intravascular volume and MAP (1C)Increasing CI to predetermined suparnormal levels is not recommended (1B). Sepsis failed to demonstrate benefit from increasing DO2 to supranormal targets by use of Dopamine.
  • General move toward less use of blood products in patients with sepsis. RBC transfusion only recommended for hemoglobin < 7 g/dl to target a Hgb of 7.0 – 9.0 in adults (1B)Erythropoietin is not recommended.Fresh Frozen Plasma is not recommended to correct laboratory clotting abnormalities in the absence of bleeding or planned invasive procedures (2D)Platelet therapy is advocated for patients with severe sepsis when counts are 10,000/mm3 or less in the absence of apparent bleeding or when counts are 20,000/mm3 or less when the patient has a significance risk of bleeding. Higher platelet count > 50,000 are advised for active bleeding, surgery or invasive procedures (2D)
  • 2012: “Septic Shock” Bundle:ScvO2 is retained and a required component in the Septic Shock bundle. Clinical evidence is rated as 1C, as in the past. Additional discussion surrounding the increasing evidence to support its continued measurement.Fluid Management and hemodynamic portion of the bundles have been significantly modified! The standard for the use of STATIC fluid volume measures (CVP, PAoP, and Pad) were discussed. As indicated, CVP will be retained in the initial resuscitation bundle. However, for patients that have received initial fluid resuscitation of 30 ml/kg and remain hypotensive and require vasopressive support, the use of DYNAMIC indicators are now standard (SVV, SVI and PPV)
  • Aitken, Williams, Harvey et al. Critical Care Med, 2011; 39: 1800-1818.“Nursing Considerations to Complement the Surviving Sepsis Campaign” – companion document to the 2008 Surviving Sepsis Campaign Guidelines. Hand-washing, barrier precautions, catheter care, Ventilator-associated Pneumonia prevention; head-of-bed elevation, comprehensive oral care with use of subglottic suctioning, selective oral decontamination and digestive decontamination
  • Crit Care Med. 2011 Jul;39(7):1800-18. doi: 10.1097/CCM.0b013e31821867cc.Nursing considerations to complement the Surviving Sepsis Campaign guidelines.Aitken LM, Williams G, Harvey M, Blot S, Kleinpell R, Labeau S, Marshall A, Ray-Barruel G, Moloney-Harmon PA, Robson W, Johnson AP, Lan PN, Ahrens T.SourceResearch Centre for Clinical and Community Practice Innovation, Griffith University, Nathan, Queensland, Australia. l.aitken@griffith.edu.auhttp://www.ncbi.nlm.nih.gov/pubmed/21685741
  • RESULTS:Sixty-three recommendations relating to the nursing care of severe sepsis patients are made. Prevention recommendations relate to education, accountability, surveillance of nosocomial infections, hand hygiene, and prevention of respiratory, central line-related, surgical site, and urinary tract infections, whereas infection management recommendations related to both control of the infection source and transmission-based precautions. Recommendations related to initial resuscitation include improved recognition of the deteriorating patient, diagnosis of severe sepsis, seeking further assistance, and initiating early resuscitation measures. Important elements of hemodynamic support relate to improving both tissue oxygenation and macrocirculation. Recommendations related to supportive nursing care incorporate aspects of nutrition, mouth and eye care, and pressure ulcer prevention and management. Pediatric recommendations relate to the use of antibiotics, steroids, vasopressors and inotropes, fluid resuscitation, sedation and analgesia, and the role of therapeutic end points.
  • Disseminate information on the new guidelines to members of the critical care team, including staff in the emergency department, where sepsis care measures are implemented before patients arrive in the ICU.Formulate a multidisciplinary/cross-departmental team and outline a timeline for implementing the guidelinesUse the new guidelines as a performance improvement processEnlist nurse champions to spearhead components of the performance improvement process … nurses play an important role in the implementation of the guidelines.
  • AACN AdvCrit Care. 2006 Apr-Jun;17(2):215-23.Continuous physiologic monitoring and the identification of sepsis: what is the evidence supporting current clinical practice?Giuliano KK.SourcePhilips Medical Systems, Andover, MA 01810, USA. Karen.Giuliano@philips.comAbstractSepsis is a multifaceted and complex medical condition that consumes a vast array of critical care resources and creates an exceptionally difficult clinical challenge for critical care clinicians. As a result, many initiatives over the past decade have been set in motion with the goal of improving the clinical care of patients with sepsis. This article provides a review of the consensus definitions of sepsis and the status of current treatment initiatives for sepsis. The focus of this article is to review the evidence supporting the current clinical practice guidelines with regard to the continuous physiologic monitoring of temperature, blood pressure, heart rate, and respiratory rate. These parameters were chosen because they are recommended by both current consensus practice guidelines and early goal-directed therapy practice. In addition, they are continuously or frequently monitored in the setting of critical care, and though nonspecific for sepsis, as a group they may identify septic patients or those at risk for sepsis. Because critical care nurses are responsible for the continuous monitoring of patients at risk for developing sepsis, they may be able to observe the convergence of nonspecific diagnostic criteria and physical assessment cues early in the development of the condition and positively affect outcomes.Elderly, immunocompromised, undergone surgical/invasive procedures, have indwelling catheters, are receiving mechanical ventilation
  • Vital signs, perfusion statusAACN Clin Issues. 2005 Apr-Jun;16(2):140-8.The use of common continuous monitoring parameters: a quality indicator for critically ill patients with sepsis.Giuliano KK, Kleinpell R.SourcePhilips Medical Systems, Andover, Mass, USA. karen.giuliano@philips.comAbstractSepsis is a common source of morbidity and mortality among critically ill patients, and targeting measures to promote early recognition and treatment of sepsis is at the forefront of many critical care initiatives. Starting formally in 1992, with the publication of the definitions of sepsis, continuous monitoring of several common physiologic parameters, including electrocardiogram, blood pressure, and oxygen saturation, have been advocated as important in the early identification and treatment of patients with sepsis. The descriptive study detailed in this article was conducted to assess the perceptions and clinical continuous physiologic monitoring practices of experienced critical care clinicians with regard to their use of common physiologic monitoring parameters in the care of patients with sepsis. A convenience sample of 100 physicians and 517 nurses completed a 20-item survey assessing perceptions and clinical monitoring practices related to the care of patients with sepsis. Results indicated that the basic parameters of electrocardiogram, invasive blood pressure, pulmonary arterial catheter monitoring, and oxygen saturation all have value in the recognition and treatment of patients with sepsis. The majority of clinicians used these parameters routinely and felt they were necessary for patient care. These results indicate that clinical practice is in concordance with current practice recommendations.
  • Nursing Considerations to Complement the Surviving Sepsis Campaign GuidelinesLeanne M. Aitken, RN, PhD, FRCNA; Ged Williams, RN, MHA; Maurene Harvey, RN, MPH; Stijn Blot, RN, Cc, RN, MNSc, PhD; Ruth Kleinpell, RN, PhD; Sonia Labeau, RN, MNSc; Andrea Marshall, RN, PhD; Gillian Ray-Barruel, RN, Grad Cert ICU Nursing, BA (Hons); Patricia A. Moloney-Harmon, RN, MS, CCNS, FAAN; Wayne Robson, RN, MSc; Alexander P. Johnson, RN, MSN, ACNP-BC, CCNS, CCRN; Pang NgukLan, RN, MSc; Tom Ahrens, RN, DNS, FAANCrit Care Med. 2011;39(7):1800-1818
  • Nursing Considerations to Complement the Surviving Sepsis Campaign GuidelinesLeanne M. Aitken, RN, PhD, FRCNA; Ged Williams, RN, MHA; Maurene Harvey, RN, MPH; Stijn Blot, RN, Cc, RN, MNSc, PhD; Ruth Kleinpell, RN, PhD; Sonia Labeau, RN, MNSc; Andrea Marshall, RN, PhD; Gillian Ray-Barruel, RN, Grad Cert ICU Nursing, BA (Hons); Patricia A. Moloney-Harmon, RN, MS, CCNS, FAAN; Wayne Robson, RN, MSc; Alexander P. Johnson, RN, MSN, ACNP-BC, CCNS, CCRN; Pang NgukLan, RN, MSc; Tom Ahrens, RN, DNS, FAANCrit Care Med. 2011;39(7):1800-1818
  • PhilipsProtocolWatch application guides clinicians through screening and treatment recommendations according to the SSC guidelines, and may help you to standardize care across the patient pathway within your hospital.
  • YouTube Video – Review of Sepsis & Scenarios
  • YouTube Video – iMedical School (Dr. Kaye) - Great Summary!
  • BC Patient Safety & Quality Council – Sepsis Group (Qexchange)
  • If we don’t comply, we aren’t delivering Best course of action to our patientsIf we don’t report, we don’t know how we are doing!Evidence-based MedicineContinuous Quality Improvement
  • A feature of ProtocolWatch, Protocol Log, is an electronic record of interventions associated with ProtocolWatch.An improved understanding and utilization of the monitor and its features, like Protocol Log, may help your hospital optimize adherence to the SSC guidelines.The Quality Improvement Strategy could ultimately result in Improved Patient Outcomes, decreased patient length of stay and costs.
  • The Philips ProtocolWatch keeps a log of the SSC Sepsis Protocol, including all clinician interactions, alarms, and protocol phase transitions, to aid clinicians and administrators in analyzing and improving care for patients with severe sepsis and septic shock.
  • This initiative can only work if clinicians implement these tools in their institutions, begin to measure their results, and report back to the SSC.Physicians now realize that such dismal outcomes are no longer beyond their control. Several treatment modalities are availableNEJM, 2001 – mortality from Sepsis could be reduced by 16% with a protocol known as early goal-directed therapy (Rapid Diagnosis and Treatment)!
  • SCCM – YouTube (compliance in Resuscitation Bundle is still only 1 in 5!)Surviving Sepsis Campaign: 2012 Guidelines (1 hour, 28 minute review)
  • “From Time Zero to Tomorrow” (SCCM Webcast, April 29, 2013) … Start the Clock!YouTube Webcast – SCCM Surviving Sepsis Campaign, 2012May 29th, 2013 Webcast: SCCM: “What’s New in the 3rd Edition of the Surviving Sepsis Campaign” – to be posted on the Surviving Sepsis website by early June, 2013.The success of the Surviving Sepsis Campaign depends on its ability to demonstrate a convincing change in mortality.
  • What are you doing for World Sepsis Day? (official Go-Live of the Surviving Sepsis, Protocol Watch?)
  • World Sepsis Day, 2012: “To think of sepsis for one day is a good start but not enough, because every day, every minute, every second patients are dying from this modern plague.”Prof. Beat Muller, Switzerland
  • STOP SEPSIS … SAVE LIVES!25% reduction in mortality accomplished in 10 years (targeted for 5 years). ~ 30,000 patients in databaseExpand from 1,000 Hospitals … 10,000 Hospitals!… potentially save 400,000 lives if we only treat 50% of the patients.Participate & Stay in the campaign!On-going Sepsis trials in Australiasian/Great Britain/USA: ARISE, PROMISE, ProCESS trial (University of Pittsburgh)(currently ~ 50% of the 1980 patients required, and other trials also ~ ½ way through)SCCMESICMDevelopment of Regional Networks:eg. BCPSQ – Sepsis Group
  • https://www.youtube.com/watch?v=v08mYfxBJAEhttps://www.youtube.com/watch?feature=player_detailpage&v=v08mYfxBJAE(R. Philip Dellinger, Mitchell Levy, Sean R. Townsend, Richard Beale, Andrew Rhodes)IHI, NQF, ECDC – continue collaborative efforts to improve compliance (only 1 in 5 comply to Resuscitation Bundle)Public Education, Administrators, Politicians, Funders of Healthcare … ? Require hospitals to adopt best practices for funding/reimbursement (NY Rising, State of Address, January 9, 2013)Rory’s Staunton’s story – Cuomo Initiative, NY StateMust improve compliance!Variations are expected and necessary … process of continual improvementSean Townsend, Manny Rivers, Philip Dellinger
  • Setting the Bar! Challenging us ALL!http://www.survivingsepsis.org (30 international specialist societies contributing to the current guidelines – Gold Standard for Sepsis Care_2012 Surviving Sepsis Guidelines: Read it, Understand it, Share it, Use it!Decrease Mortality, Improve Standard of Care and Patient Outcomes100% of Patients, 100% of the Time!

Surviving sepsis, 2013   kristy molnar, critical care consultants Surviving sepsis, 2013 kristy molnar, critical care consultants Presentation Transcript

  • SURVIVING SEPSIS: Improving Care … Saving Lives Kristy Molnar Professional Education Services, Critical Care Consultants Critical Care Consultants, 2013
  • Sepsis … Claiming Lives Leading cause of morbidity and mortality worldwide Critical Care Consultants, 2013
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  • The “Face” of Sepsis Systemic inflammatory response initiated by a source of infection Critical Care Consultants, 2013
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  • http://www.sepsisalliance.org/resources/video/ Critical Care Consultants, 2013
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  • Rory Staunton’s Story (Profiled on Today’s Show & Dr. Oz) Performance Gaps! http://www.youtube.com/watch?v=k3qz9wCc69w http://www.youtube.com/watch?v=MTeBukCSot8 http://www.youtube.com/watch?v=xwOKZsKlwWs http://www.youtube.com/watch?v=J-bLDoVHYSs Leading to NY State Department’s Cuomo Initiative & Legislation Critical Care Consultants, 2013
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  • What does this mean? Critical Care Update Sp on so re d By Critical Care Consultants, 2013 ICU admissions from EDs up nearly 50% in U.S. U.S. researchers looked at data from the National Hospital Ambulatory Care Survey and found that intensive care admissions from the emergency department rose by nearly 50%, from 2.79 million in 2002- 2003 to 4.14 million in 2008-2009. Of all the ED patients, those aged 85 and older had the highest increase in the rate of ICU admissions. The findings appear in the journal Academic Emergency Medicine. Nurse.com (5/15)
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  • THE BURDEN OF SEPSIS Healthcare Resources Critical Care Consultants, 2013
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  • Sepsis Costs! • 40% of total ICU expenditure • Average cost per individual case is approximately $22,000.00 Critical Care Consultants, 2013
  • GAPS IN CARE Quality Improvement Initiatives - IHI Critical Care Consultants, 2013
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  • Critical Care Consultants, 2013 Sepsis Detection & Management Rapid Response Systems Patient Flow for Efficiency & Safety Early Warning Systems
  • DIFFUSE SYMPTOMS Occult, systemic wide responses Critical Care Consultants, 2013
  • CRITICAL SIGNS … MEDICAL EMERGENCY! Critical Care Consultants, 2013 http://www.sepsisalliance.org/resources/video/
  • SCORING SYSTEMS APACHE II, SOFA … not Screening Systems Critical Care Consultants, 2013
  • Phases & Degrees of Sepsis “A Clinical Spectrum” http://www.sepsisalliance.org/resource s/video/ Critical Care Consultants, 2013
  • TERMS SIRS, SEPSIS, SEVERE SEPSIS, SEPTIC SHOCK, MODS … Critical Care Consultants, 2013
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  • SUSPICION OF SIRS Systemic Inflammatory Response Syndrome Critical Care Consultants, 2013
  • INTERVENTION IN SIRS Speedy Intervention & Response for Survival Critical Care Consultants, 2013
  • The Challenge … The Campaign The Response Critical Care Consultants, 2013
  • SEPSIS IS A TRAGIC & DEADLY DISEASE Increasing Awareness Critical Care Consultants, 2013
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  • ESTABLISHING BEST PRACTICE Surviving Sepsis Guideline updates (using the GRADE system) Critical Care Consultants, 2013
  • TRIAGE Improving Identification & Initiating Timely Intervention Critical Care Consultants, 2013
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  • TIMELINES Saving Tissue, Reducing Mortality Critical Care Consultants, 2013
  • WHO IS RESPONSIBLE? Fighting the War on Sepsis Critical Care Consultants, 2013
  • TRANSITIONS IN CARE Seamless Critical Care Consultants, 2013
  • Recommendations & Guidelines The Global Sepsis Alliance Critical Care Consultants, 2013
  • THE GLOBAL SEPSIS ALLIANCE International Guidelines for the Management of Severe Sepsis & Septic Shock Critical Care Consultants, 2013
  • GUIDELINES & ALGORITHMS 2004, 2008 … Current Updates Critical Care Consultants, 2013
  • Sepsis updates (2004, 2008, 2012) 2012 update on YouTube (1 hr, 28 min): https://www.youtube.com/watch?v=v08mYfxBJAE Critical Care Consultants, 2013
  • Critical Care Consultants, 2013 2005 Manual/User’s Guide (SCCM, ESICM, ISF) Participation in the Surviving Sepsis Campaign Surviving Sepsis Campaign Web site. www.survingsepsis.org
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  • “Implications of the New International Sepsis Guidelines for Nursing Care” Critical Care Consultants, 2013 Kleinpell, R., Aitken, L., & Shorr, C.A.: AJCC, May 2013, Volume 22, No 3, 212-222.
  • ENSURING BEST PRACTICES http://www.sepsisalliance.org/resources/video/ Critical Care Consultants, 2013
  • EDUCATION & COMMITMENT To ALL on the “Front Line” … a Call to Action … Critical Care Consultants, 2013
  • Sepsis video resources: YOUR SEPSIS TEAM Critical Care Consultants, 2013 http://www.sepsisalliance.org/resources/video/
  • GAP ANALYSIS Where do you stand in Sepsis Detection & Management? Critical Care Consultants, 2013
  • THE SCIENCE & MODEL FOR IMPROVEMENT Evidence-Based, Organized & Efficient Care Critical Care Consultants, 2013
  • SCREENING & IMPLEMENTATION OF THE BUNDLES Critical Care Consultants, 2013
  • ENSURING EFFECTIVE & SEAMLESS TRANSITIONS The Clinical Environment Critical Care Consultants, 2013
  • Clinical Decision Support Tools & Documentation Clinical Approaches Critical Care Consultants, 2013
  • CONSISTENT APPLICATION OF EVIDENCE-BASED PRACTICE Critical Care Consultants, 2013
  • GOALS & WORKFLOW Improving Communication Critical Care Consultants, 2013
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  • PROTOCOLS Paper-Based and/or Electronic Clinical Decision Support Tools? Critical Care Consultants, 2013
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  • Critical Care Consultants, 2013 http://www.ajcconline.org
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  • The “Bundles” & SSC Algorithm Critical Care Consultants, 2013
  • “BUNDLE” Evidence-Based, Organized Practice Guidelines within an Organized Process Critical Care Consultants, 2013
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  • PROTOCOLS & PATHWAYS Customization within Clinical Environments Critical Care Consultants, 2013
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  • WORKING TOGETHER Achieving Better Outcomes? Critical Care Consultants, 2013
  • Screening Bundle: Timely Triage Critical Care Consultants, 2013
  • EARLY RECOGNITION! Clinical Assessment, Screening, Monitoring & Surveillance Critical Care Consultants, 2013
  • TAKING ACTION! Early Warning and Rapid Response Systems Critical Care Consultants, 2013
  • SCREENING TOOLS FOR SIRS Critical Care Consultants, 2013
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  • TIMELY NOTIFICATION & COMMUNICATION Standarized Orders/Protocols? Critical Care Consultants, 2013
  • Initial Resuscitation Bundle: Time for Action! Critical Care Consultants, 2013
  • BLOOD CULTURES Prior to Antibiotic Administration Critical Care Consultants, 2013
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  • BROAD-SPECTRUM ANTIBIOTICS Improve Time to Administration Critical Care Consultants, 2013
  • SERUM LACTATE Early identification: Lactate Measures … When, Why and How Much? http://www.youtube.com/watch?v=LVqt0z4-k6E Critical Care Consultants, 2013
  • QUESTIONS & DEBATES ABOUT SERUM LACTATE Identification of Hyperlactatemia &/or Reduced Lactate Clearance Critical Care Consultants, 2013
  • Hyperlactatemia • Regardless of the mechanism of hyperlactatemia, numerous studies show that blood lactate is a relevant prognostic marker of morbidity and mortality in various critical care settings, including patients with Sepsis. • Increased lactate also correlates well with ScvO2 Critical Care Consultants, 2013
  • SSC International Guidelines • Lactate levels of > 4 mmol/L • Is Lactate > 4 mmol/L or impaired Lactate clearance an obligatory criterion for the diagnosis of septic shock? • No significance difference in 28-day mortality across Lactate categories (non, intermediate & high) Critical Care Consultants, 2013
  • Missed Identification? • Although a useful adjunct for hypoperfusion … lactate is not present in 45% of septic patients … it may not be adequate as the only marker … we may miss 45% of patients if Lactate used as a sole obligatory criteria. Critical Care Consultants, 2013
  • Lactate as sole indicator? • One of the fundamental problems of using lactate clearance as a sole resuscitation target is that a normal lactate (< 2mM/L) can be present in 25-50% of septic shock patients. • The mortality of these patients is 20-50% even with aggressive therapy. Critical Care Consultants, 2013
  • 2012 findings • 2012 studies by the Shock Society found that aggressive resuscitation may be beneficial even in the “normal range” lactate concentration. • How Low? … Lactates of 1.4 – 2.3 mmol/L may also be associated with an adverse outcomes! (2 – 2.5 should be a trigger at admission!) Critical Care Consultants, 2013
  • 2012 findings • Yes, Hyperlactatemia had a good sensitivity (86%) for prediction of mortality • But, Lactate cannot be used in isolation due to a low specificity (27%) • The clinician must use other perfusion markers such as ScvO2 and UO to enhance the prediction value. Critical Care Consultants, 2013
  • Lactate as an endpoint for Resuscitation? • These observations indicate that using lactate and ScvO2 are complimentary endpoints, and not mutually exclusive. (8 references; 1993 - 2012) Critical Care Consultants, 2013
  • Lactate as an Indicator of Tissue Hypoxia? • Journal of Critical Care - 2012 study • Almost ½ of patients with vasopressor- dependent septic shock did not express lactate on presentation, although a high mortality remains in this population! Critical Care Consultants, 2013
  • Lactate as an Indicator of Tissue Hypoxia? • Use of lactatemia as the sole indicator for additional IV fluid or an end point of resuscitation in septic shock may be inadequate. Critical Care Consultants, 2013
  • FLUID MANAGEMENT Treat Hypotension, Hypoperfusion & Elevated Lactates Critical Care Consultants, 2013
  • MAINTAIN APPROPRIATE PRELOAD STATUS CVP, SVV, PPV, SV for Volume Responsiveness Critical Care Consultants, 2013
  • Hemodynamics…Blood Flow! Critical Care Consultants, 2013
  • MAINTAIN MAP Vasopressors for ongoing Hypotension? Critical Care Consultants, 2013
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  • Administration of Blood Products? Critical Care Consultants, 2013
  • VENOUS OXYGEN SATURATION Maintain Adequate Central Venous Oxygen Saturation Critical Care Consultants, 2013
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  • (Management) Septic Shock Bundle: Meeting the Goals Critical Care Consultants, 2013
  • Source Control • Within 12 hours • Surgical debridement, draining • Removal of infected devices • Infection prevention! Critical Care Consultants, 2013
  • STEROIDS? Critical Care Consultants, 2013
  • GLYCEMIC CONTROL GOAL Critical Care Consultants, 2013
  • INSPIRATORY PLATEAU PRESSURE GOAL Critical Care Consultants, 2013
  • Patient Outcomes Reducing Sepsis Mortality & Morbidity Critical Care Consultants, 2013
  • Implications for Practice • Integration of the new recommendations can help ensure that critically ill patients with sepsis receive expert nursing care to promote optimal outcomes. Critical Care Consultants, 2013
  • Implications for Practice • By initiating resuscitative measures and indicated sepsis care that are based on the new guidelines, critical care nurses can improve care for patients with sepsis. Critical Care Consultants, 2013
  • Resources, Workflow & Efficiencies Critical Care Consultants, 2013
  • Early Identification “ Observe for the convergence of nonspecific diagnostic criteria and physical assessment cues early in the development of the condition and positively affect outcomes”. Karen Giuliano, 2006 Critical Care Consultants, 2013
  • Critical Care Consultants, 2013 Continuous Monitoring, Physical Assessment & Surveillance Giuliano KK, Kleinpell R. AACN Clin Issues. 2005 Apr-Jun;16(2):140-8
  • Comprehensive Sepsis Treatment • Antibiotic administration • Circulatory assessment & support … Fluids, inotropic agents, vasopressors • Supportive treatment with oxygenation & ventilation Critical Care Consultants, 2013
  • Comprehensive Sepsis Treatment • Use of measures recommended in sepsis guidelines • Monitoring & Surveillance • Reporting patients’ response to treatment Critical Care Consultants, 2013
  • World Federation of Critical Care Nurses (WFCCN) International task force – produced/published a companion guide to the 2008 guidelines in 2011 that outlines 63 additional recommendations. • http://en.wfccn.org/resources_sepsis.php • Crit Care Med. 2011; 39(7):1800-1818 Critical Care Consultants, 2013
  • World Federation of Critical Care Nurses (WFCCN) Crit Care Med. July 2011; 39(7):1800-1818 “Nursing considerations to complement the Surviving Sepsis Campaign guidelines” http://journals.lww.com/ccmjournal/Fulltext/20 11/07000/Nursing_considerations_to_comple ment_the_Surviving.25.aspx Critical Care Consultants, 2013
  • “EXTEND THE CHAIN” Improve the Flow of Care Critical Care Consultants, 2013
  • SEPSIS PRACTICE SUPPORT Industry, Professional Associations & Practice Groups Critical Care Consultants, 2013
  • Critical Care Survival Guide – Sepsis Management https://www.youtube.com/watch?v=rSIoG_QuMmg Critical Care Consultants, 2013
  • iMedicalSchool: Update in Sepsis, 2013 http://www.youtube.com/watch?annotation_id=annotati on_377513&feature=iv&src_vid=o8K3IC1RrP8&v=UcivG HBfSb4 Critical Care Consultants, 2013
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  • Documentation & Reporting Compliance & Quality Improvement Critical Care Consultants, 2013
  • COMPLIANCE & QUALITY IMPROVEMENT Achieving Compliance within the Resuscitation & Management Bundles? Critical Care Consultants, 2013
  • DATA COLLECTION & REPORTING Critical Care Consultants, 2013
  • Call to Action Implementing the Surviving Sepsis Campaign … 10 years later! Critical Care Consultants, 2013
  • 2012 Surviving Sepsis Guidelines - Summary http://www.youtube.com/watch?v=v08mYfxBJAE Critical Care Consultants, 2013
  • “From Time Zero ….” http://www.youtube.com/watch?v=v08mYfxBJAE Critical Care Consultants, 2013
  • World Sepsis Day (September 13, 2013) Critical Care Consultants, 2013
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  • Winning the War on Sepsis Stories of Success & Improvement Critical Care Consultants, 2013
  • Phase IV SCCM Surviving Sepsis Campaign 2012 Guidelines – YouTube video 2013 … Winning IF we stay in the game 2016 - Focus on Guidance, Involvement, Compliance, Quality, Technologies/Processes … ongoing Mortality reductions! Critical Care Consultants, 2013
  • Surviving Sepsis Improving Care … Saving Lives Critical Care Consultants, 2013
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