diagnosing & managing sepsis syndrome: the emerging role of bedside analyte testing

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Sepsis Self-Study

Diagnosing & Managing Sepsis Syndrome: The Emerging Role of Bedside Analyte TestingThe title of this program is Diagnosing and Managing Sepsis Syndrome: The Emerging Role of Bedside Analyte Testing.1Continuing Education CreditDate of Release: 6/29/2011Date of Expiration: 6/29/2013 Estimated time to complete this educational activity: 1 hourContinuing education credits are available from June 29, 2011 through June 29, 2013 for 1.0 credit hour.2Continuing Education CreditNursing - Educational Review Systems is an approved provider of continuing education in nursing by ASNA, an accredited provider by the ANCC/Commission on Accreditation. Provider #5-115. This program is approved for one (1.0) hour. Educational Review Systems is also approved for nursing continuing education by the State of California and the District of Columbia.Physicians - This program has been reviewed and is acceptable for up to one (1.0) prescribed credit hour by the American Academy of Family Physicians. AAFP prescribed credit is accepted by the AMA as equivalent to AMA PRA Category I for the AMA PhysiciansRecognition Award. When applying for the AMA PRA, prescribed hours earned must be reported as prescribed hours, not as Category I.Respiratory Therapy - This program has been approved for 1 contact hours Continuing Respiratory Care Education (CRCE) credit by the American Association for Respiratory Care, 9425 N. MacArthur Blvd. Suite 100 Irving TX 75063 Course # 213078000Physicians, nurses, and respiratory therapists are eligible to receive 1.0 hour of credit once the post-test and evaluation have been completed and a passing score is achieved.3Statement of NeedSepsis kills more than 210,000 Americans each year and is becoming more common, especially in the hospital. Sepsis is a medical emergency that can be difficult to define, diagnose, and treat, but every minute counts in the effort to save lives. This learning activity will describe how bedside analyte testing could aid therapeutic decision making and improve the prognosis for patients with sepsis. Sepsis kills more than 210,000 Americans each year and is becoming more common, especially in the hospital. Sepsis is a medical emergency that can be difficult to define, diagnose, and treat, but every minute counts in the effort to save lives. This learning activity will describe how bedside analyte testing could aid therapeutic decision making and improve the prognosis for patients with sepsis.

4Intended AudienceThe primary audience for this learning activity are health care professionals (physicians and nurses) who are involved in the testing, diagnosis, treatment, and management of sepsis and are interested in the role of biomarkers to improve the care forthese patients.

The primary audience for this learning activity are health care professionals (physicians and nurses) who are involved in the testing, diagnosis, treatment, and management of sepsis and are interested in the role of biomarkers to improve the care for these patients.5Learning Objectives Discuss the scope of sepsis morbidity and mortality. After completing this activity, the participant should be able to: Describe the role of sepsis biomarkers in screening, diagnosis, risk stratification, and monitoring of response to therapy in sepsis. List factors to be considered when evaluating sepsis testing and results.Identify situations where point-of-care analyte testing might benefit patients with a suspected or confirmed diagnosis of sepsis.Apply information to assist in the identification and treatment of patients with sepsis and improve patient outcomes.After completing this activity, the participant should be able to(1) discuss the scope of sepsis morbidity and mortality; (2) describe the role of sepsis biomarkers in screening, diagnosis, risk stratification and monitoring of response to therapy; (3) list factors that should be considered when evaluating sepsis testing and results; (4) identify situations where point-of-care analyte testing might benefit patients with a suspected or confirmed diagnosis of sepsis; and (5) apply information to assist in the identification and treatment of patients with sepsis and improve patient outcomes.6

Medical AdvisementWe would like to acknowledge the following medical expertswho served as advisors to this educational program:Emanuel P. Rivers, MD, MPHThomas Ahrens, DNS, RN, PhDArthur P. Wheeler, MDJill A. Sellers, BSPharm, PharmD

We would like to acknowledge the following medical experts who served as advisors to this educational program: Thomas Ahrens, DNS, RN, PhD; Emanuel P. Rivers, MD, Jill A. Sellers, BSPharm, PharmD, and Arthur P. Wheeler, MD.7DisclosuresThomas Ahrens, DNS, RN, PhDNo financial relationships to disclose.Emanuel P. Rivers, MD, MPHNo financial relationships to disclose.Jill A. Sellers, BSPharm, PharmDNo financial relationships to disclose.Arthur P. Wheeler, MDNo financial relationships to disclose.The medical faculty advisors have the following relationships to disclose.8

Introduction to SepsisDefinition, Etiology, Morbidity and MortalityBefore we can assess and diagnose sepsis, we must first define sepsis and discuss the causation or etiology. To further enhance our understanding of this devastating disease, we must also discuss the morbidity and mortality and how this impacts our health care system.9Definition of Sepsis SepsisACCP/SCCM Consensus Conference. Crit Care Med. 1992;20(6):864-74.Systemic response to infectionManifested by two or more SIRS criteria as a result of proven or suspected infectionTemperature 38C or 36C HR 90 beats/minRespirations 20/minWBC count 12,000/mm3 or 4,000/mm3 or > 10% bandsPaCO2 < 32 mmHgAccording to the ACCP/SCCM consensus conference guidelines, sepsis is a systemic response to infection that is manifested by two or more SIRS criteria as a result of an infection. Severe sepsis occurs when sepsis is associated with organ dysfunction, hypoperfusion, or hypotension. Septic shock is severe sepsis which also presents with other perfusion abnormalities such as lactic acidosis, oliguria, or an acute alteration in mental status.10

Case StudyThe case you are about to study will help you experience a real-life patient and what occurred during the course of diagnosing sepsis. 11Case Study: Mr. ZHe tells you My tooth is killing me! You can pull it if you need to. I feel like it is going to explode.

His tooth pain is severe and he cameto the emergency department since he could not see his dentist until themorning. He has drainage from tooth #20, for which a culture has been obtained and sent to the lab.

Mr. Z is a 47 year-old male who was admitted to the emergency department. He is complaining of a toothache that has been present for 7 days.

Mr. Z is a 47 year-old male who was admitted to the emergency department. He is complaining of a toothache that has been present for 7 days. His tooth pain is severe and he came to the emergency department since he could not see his dentist until the morning. He has drainage from tooth #20, for which a culture has been obtained and sent to the lab. He tells you My tooth is killing me! You can pull it if you need to. I feel like it is going to explode.12Case Study: Mr. ZHe is started on Cefoxitin (Mefoxin) 2 g IV q6h.

Mr. Z is alert and oriented.

He has a history of hypertension and had a hemorrhagic stroke 10 years ago but has had no major health issues since this time.

His heart and lung sounds are normal and his skin is cool and moist. He has good capillary refill, abdomen soft and non-tender.

Mr. Zs history and physical assessment reveals the following: He is alert and oriented with a history of hypertension. He had a hemorrhagic stroke 10 years ago but has had no major health issues since then. His heart and lung sounds are normal and his skin is cool and moist. He has good capillary refill, abdomen soft and non-tender. He is currently on cefoxitin (Mefoxin) 2 g intravenous every 6 hours.13Case Study: Mr. ZAdmissionHeart Rate111Temperature38.7SPO20.96NIBP128/88 (101)Respiratory Rate22QuestionsDoes Mr. Z have signs of sepsis? Yes2) What is a blood test that would be useful? LactateSPO2: Pulse oximetry oxygen saturation; NIBP: Non-invasive blood pressure

Upon admission, Mr. Zs heart rate was 111, temperature 38.7 degrees Celsius, pulse oximetry oxygen saturation 0.96, non-invasive blood pressure of 128/88 (101), and a respiratory rate of 22.14Case Study: Mr. ZAdmissionHeart Rate111Temperature38.7SPO20.96NIBP128/88 (101)Respiratory Rate22Serum Lactate3.5After 20 mg/kg normal saline (10 minutes)Heart Rate104Temperature38.6SPO20.96NIBP130/88 (102)Respiratory Rate22

After Mr. Z received 20 mg/kg of normal saline, then his vitals were as follows: heart rate 104, temperature 38.6 degrees Celsius, pulse oximetry oxygen saturation 0.96, non-invasive blood pressure 130/88 (102), and a respiratory rate of 22.15Case Study: Mr. ZAfter 4 HoursHeart Rate88Temperature38.1SPO20.98NIBP133/78 (94)Respiratory Rate17Serum Lactate1.8Often, vital signs are normal when lactates are elevated.The use of the lactate allowed the clinician to better evaluate the seriousness of the situation. If the lactate had remained elevated, more fluids could have been given.A decrease in lactate shows improved perfusion.

After 4 hours, Mr. Zs vitals were as follows: heart rate 88, temperature 38.1 degrees Celsius, pulse oximetry oxygen saturation 0.98, non-invasive blood pressure 133/78 (94), respiratory rate of 17, and a serum lactate level of 1.8. A decrease in lactate shows improved perfusion. If the lactate had remained elevated, then more fluids could have been given. The use of the lactate allowed the clinician to better evaluate the seriousness of the situation. Often, vital signs are normal when lactates are elevated.16Sepsis is Serious.Sepsi