Download - Diagnosing & Managing Sepsis Syndrome: The Emerging Role of Bedside Analyte Testing

Diagnosing & Managing Sepsis Syndrome:

The Emerging Role of Bedside Analyte Testing

Continuing Education Credit

Date of Release: 6/29/2011

Date of Expiration: 6/29/2013

Estimated time to complete this educational activity: 1 hour

Continuing Education Credit

• Nursing - 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 Physicians‘Recognition 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 # 213078000

Statement of Need

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.

Intended Audience

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 forthese patients.

Learning Objectives

1. Discuss the scope of sepsis morbidity and mortality.

After completing this activity, the participant should be able to:

2. Describe the role of sepsis biomarkers in screening, diagnosis, risk stratification, and monitoring of response to therapy in sepsis.

3. List factors to 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.

5. Apply information to assist in the identification and treatment of patients with sepsis and improve patient outcomes.

Medical Advisement

We would like to acknowledge the following medical expertswho served as advisors to this educational program:

Emanuel P. Rivers, MD, MPH

Thomas Ahrens, DNS, RN, PhD Arthur P. Wheeler, MD

Jill A. Sellers, BSPharm, PharmD

Disclosures

Thomas Ahrens, DNS, RN, PhD No financial relationships to disclose.

Emanuel P. Rivers, MD, MPH No financial relationships to disclose.

Jill A. Sellers, BSPharm, PharmD No financial relationships to disclose.

Arthur P. Wheeler, MD No financial relationships to disclose.

Introduction to Sepsis

Definition, Etiology, Morbidity and Mortality

Definition of Sepsis

• Sepsis

ACCP/SCCM Consensus Conference. Crit Care Med. 1992;20(6):864-74.

– Systemic response to infection

– Manifested by two or more SIRS criteria as a result of proven or suspected infection

• Temperature ≥ 38C or ≤ 36C

• HR ≥ 90 beats/min

• Respirations ≥ 20/min

• WBC count ≥ 12,000/mm3 or ≤ 4,000/mm3

or > 10% bands

• PaCO2 < 32 mmHg

Case Study

Case Study: Mr. Z

• He 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.

Case Study: Mr. Z

• He 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.

Case Study: Mr. Z

Admission

Heart Rate 111

Temperature 38.7

SPO2 0.96

NIBP 128/88 (101)

Respiratory Rate 22

Questions

1) Does Mr. Z have signs of sepsis? Yes

2) What is a blood test that would be useful? Lactate

SPO2: Pulse oximetry oxygen saturation; NIBP: Non-invasive blood pressure

Case Study: Mr. Z

AdmissionHeart Rate 111

Temperature 38.7

SPO20.96

NIBP 128/88 (101)

Respiratory Rate 22

Serum Lactate 3.5

After 20 mg/kg normal saline (10 minutes)

Heart Rate 104

Temperature 38.6

SPO20.96

NIBP 130/88 (102)

Respiratory Rate 22

Case Study: Mr. Z

After 4 Hours

Heart Rate 88

Temperature 38.1

SPO2 0.98

NIBP 133/78 (94)

Respiratory Rate 17

Serum Lactate 1.8

• Often, 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.

Sepsis is Serious.

• Sepsis is a serious medical condition caused by an overwhelming immune response to infection.

http://www.nigms.nih.gov/Education/factsheet_sepsis.htm

• Complex chain of events:

– Inflammatory and anti-inflammatory processes

– Humoral and cellular reactions

– Circulatory abnormalities

• Results in impaired blood flow, which damages organs by depriving them of nutrients and oxygen.

The Intracellular Immune Response to Infection

Adapted from Holmes CL, Russell JA, Walley KR. Chest. 2003;124:1103-15.

Symptoms of Sepsis

• Sepsis can begin in different parts of the body and can have many different symptoms.

• Rapid breathing and a change in mental status, may be the first signs of sepsis.

• Other symptoms include:

– Chills/hypothermia

– Decreased urination

– Tachycardia

– Nausea and vomiting

– Fever

Clinical Manifestations of Shock

Delirium and Encephalopathy

Acute Lung Injury or ARDS Oliguria

Anuria CreatinineMetabolic acidosis

Platelets PT/APTT Protein C D-dimer

Adrenal Dysfunction

Altered Glucose Metabolism

Jaundice Enzymes Albumin PT

Gut Dysfunction

Hyperpyrexia or Hypothermia

ARDS: Acute respiratory distress syndrome; PT: Prothrombin time; APTT: Activated partial thromboplastin time

The Sepsis Continuum

Adapted from Bone RC, Balk RA, Cerra FB et al. Chest. 1992;101:1644-55.

Infection/Trauma

SIRS SepsisSevere Sepsis

A clinical response arising from a nonspecific insult, including ≥ 2 of the following:

• Temperature > 38ºC or < 36ºC

• Heart rate > 90 beats/min

• Respiratory rate > 20 breaths/min or PaCO2 < 32 Torr

• WBC > 12,000 cells/mm3, < 4,000 cells/mm3, or > 10% immature

SIRS with a presumed or confirmed infection

Sepsis with ≥ 1 sign of organ failure:

• Cardiovascular (refractory hypotension)

• Renal

• Respiratory

• Hepatic

• Hematologic

• CNS

• Unexplained metabolic acidosis

Local or systemic infection or traumatic injury

SevereSepsis

Bone RC, Balk RA, Cerra FB et al. Chest. 1992;101:1644-55.

Trauma

Infection

SepsisOther

Pancreatitis

Burns

SIRS

The Relationship Between SIRS, Sepsis, and Severe Sepsis

Locations for Common Infection

Lungs

Urinary Tract

Abdomen

Vascular Catheters(endovascular)

Appendix


Skin and soft tissue

Microbes

• Many different types of microbes can cause sepsis:


CDC/ Matthew J. Arduino CDC/ Robert Simmons

Staphylococcus sp. (Bacteria) Aspergillus sp. (Fungi) Influenza (Virus)

CDC/ Erskine. L. Palmer, PhD; M. L. Martin

• Severe cases often result from a localized infectionbut sepsis can also spread throughout the body.

– Bacteria (most common)

– Fungi

– Viruses

Mortality Rates

• Sepsis remains the leading cause of death in critically ill patients in the United States.

• Each year 750,000 people will develop sepsis.

Angus DC, Linde-Zwirble WT, Lidicker J et al. Crit Care Med. 2001;29(7):1303-10.

National Center for Health Statistics, 2001. American Cancer Society, 2001.

0

50,000

100,000

150,000

200,000

250,000

Dea

ths

Per

Year

AIDS SevereSepsis

Breast Cancer

Sepsis Incidence in Men and Women

Martin GS et al. N Engl J Med. 2003;348:1546-54.

1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001

300

200

100

0

MenWomen

Po

pu

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on

-Ad

just

ed I

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den

ce

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Sep

sis

(No

./10

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0)

Martin GS, Mannino DM, Eaton S et al. N Engl J Med. 2003;348:1546-54.

1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001

OtherBlackWhite

Po

pu

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on

-Ad

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nci

den

ce

of

Sep

sis

(No

./10

0,00

0)

500

400

300

200

100

0

Sepsis Incidence by Race

Sepsis Incidence in the United States: 2000

Martin GS, Mannino DM, Eaton S et al. N Engl J Med. 2003;348:1546-54. SEER Cancer Statistics Review. National Cancer Institute. www.cancer.gov. 2007. HIV/AIDS Surveillance Report. Centers for Disease Control. 2001;11.Incidence & Prevalence: 2006 Chart Book on Cardiovascular and Lung Diseases. NHLBI, NIH. 2006. Turabelidze G. J Neurol Sci. 2008;269:158-62.

0

50

100

150

200

250

Sepsis BreastCancer

AcuteMyocardial

Infarction

MultipleSclerosis

LungCancer

ColonCancer

AIDS

Inci

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er 1

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00

Sepsis Morbidity and Mortality

• In severe cases, one or more organs fail.


• Worst case scenario:– Blood pressure drops

– Septic shock

– Multiple organ system failure

– Death

• The number of sepsis cases per year has been on the rise:

– Aging population, the increased longevity of people with chronic diseases, the spread of antibiotic-resistant organisms, an upsurge in invasive procedures and broader use of immunosuppressive and chemotherapeutic agents.

How Do I Decide Who is Really Sick With an Infection?

Sepsis Biomarkers

Use in Diagnosis, Risk, and Response

Utility of Biomarkers

1. Diagnosis/differentiation

– Value of baseline

2. Prognostication

– Value of change over time

3. Following success/failure of therapy

Diagnosis of Sepsis

• Bacteria in the blood or other body fluids

– Source of the infection

– A high or low white blood cell count

– A low platelet count

– Low blood pressure

– Too much acid in the blood (acidosis)

– Altered kidney or liver function

• Biomarkers

• Diagnosis of sepsis and evaluation of its severity is complicated by the highly variable and non-specific nature of signs and symptoms.

Sepsis Biomarkers: Screening

Lever A, Mackenzie I. Br Med J. 2007;335:879–83.

• Distinguishing patients with localized infections or SIRS from those with sepsis is challenging.

• SIRS is not specific to sepsis and can result from other conditions such as acute pancreatitis and immunodeficiencies.

• Biomarkers of sepsis may improve diagnosis and therapeutic decision making.

Sepsis Biomarkers

• More than 170 biomarkers have been assessed for sepsis prognosis and diagnosis

Pierrakos C, Vincent JL. Crit Care. 2010,14:R15.

• Some common biomarkers include:

– White blood cell count

– Procalcitonin (PCT)

– Procoagulant factors– Lactate

– Interleukins and other cytokines

– C-reactive protein (CRP)

Procalcitonin and Accuracy of Diagnosis

Harbarth S, Holeckova K, Froidevaux C et al. Am J Respir Crit Care Med. 2001;164:396-402.

1 - Specificity

1.00

0.75

0.50

0.25

0.00

Sen

siti

vity

0.00 0.25 0.50 0.75 1.00

Clinical model with PCTAUC: 0.94

Clinical model without PCTAUC: 0.77

Procalcitonin Reference Range

Normal subjects < 0.5 pg/ml

Chronic inflammatory processes and autoimmune diseases

< 0.5 pg/ml

Viral infections < 0.5 pg/ml

Mild to moderate localized bacterial infections

< 0.5 pg/ml

SIRS, multiple trauma, burns 0.5 – 2 pg/ml

Severe bacterial infections, sepsis, multiple organ failure

> 2 pg/ml(often 10 – 100 pg/ml)

ACCP/ Society of Critical Care Medicine Consensus Conference. Crit Care Med. 1992;20:864-74. Harbarth S, Holeckova K, Froidevaux C et al. Am J Respir Crit Care Med. 2001;164:396-402. Christ-Crain M, Jaccard-Stolz D, Bingisser R et al. Lancet. 2004;363:600-7.

Annane D, Sebille V, Troche G et al. J Am Med Assoc. 2000;283:1038-45.

Survival Curves in Severe Sepsis and Septic Shock: Baseline Cortisol and Post-ACTH

Pro

bab

ility

of

Su

rviv

al

0

Basal Plasma Cortisol Level 34 g/dL, max > 9 g/dL

Basal Plasma Cortisol Level 34 g/dL, max 9 g/dL orBasal Plasma Cortisol Level > 34 g/dL, max > 9 g/dL

Basal Plasma Cortisol Level > 34 g/dL, max 9 g/dL

1.00

0.80

0.60

0.40

0.20

0 7 14 21 28

Time (Days)

Lobo SM, Lobo FR, Bota DP et al. Chest. 2003;123:2043-9.

CRP Levels Correlate With Mortality and Organ Failure in Sepsis

30

20

10

0

30

20

10

0

*

* p < 0.05

Number of Organ Failures

0 1 2 3 > 4(116/115) (111/110) (56/56) (20/19) (4/4)

Day 0 Day 2C

RP

mg

/dL

CR

P m

g/d

L

CRP Day 0

CRP Day 2 Non-Survivors

Survivors

p = 0.002

p = 0.001

Survivors vs. Non-Survivors

Lactic Acidosis

Mizock BA, Falk JL. Crit Care Med. 1992;20:80-95.

Glycogen

Glucose Pyruvate

Lactate

CitricAcidCycle

CO2

H2O

(Cytoplasm) (Mitochondria)

Anaerobic Glycolysis

1 Glu + 2 ADP + 2 Pi

2 Lactate + 2 ATP

1 Glu + 6 O2 + 38 ADP + 38 Pi

6 CO2 + 6 H20 + 38 ATP

O2

Aerobic Glycolysis

Diagnostic and Therapeutic Markers

SvO2

60-80% Normal

50% Lactic Acidosis (≥ 4 mmol/L)

80

60

40

38-40%

28 day in-hospital mortality Death within 3 days

Lactate1

30

25

20

15

10

5

00-2.4 2.5-3.9 > 4.0

% o

f M

ort

alit

y R

ate

% o

f M

ort

alit

y R

ate

0-2.4 2.5-3.9 > 4.0N = 827 N = 238 N = 112

Initial Lactate (mmol/L)2

50

40

30

20

10.0

0.0

Serum Lactate as a Predictor of Mortality

1 Trzeciak S, Dellinger RP, Chansky ME et al. Intensive Care Med. 2007;33:970-7.2 Shapiro NI, Howell MD, Talmor D et al. Ann Emerg Med. 2005; 45:524-8.

28%

Jansen TC, van Bommel J, Mulder PG et al. Crit Care. 2008,12:R160.

Prognostic Value of Serum Lactate


Serum Lactate as a Predictor of Mortality

Mea

n L

acta

te L

evel

(m

mo

l/L)

7

6

5

4

3

2

1

0

Arrival Scene (T1) Emergency Department (T2)

Non-survival

Survival

p = 0.001p < 0.001

Adapted from Jansen TC, van Bommel J, Mulder PG et al. Crit Care. 2008,12:R160.

8/66 (12%)

Mortality

24/58 (41%)

Mortalityp < 0.001

7 Missing (4 Died)

11 Missing (0 Died)

First Lactate Measurement

Second Lactate Measurement

N = 55

8/54 (15%)

Mortality

0/1(0%)

Mortality

p = 1.00

N = 51

2/14 (14%)

Mortality

18/37(49%)

Mortality

p = 0.025

N = 106

10/68 (15%)

Mortality

18/38 (47%)

Mortalityp < 0.001

N = 124

< 3.5 mmol/l ≥ 3.5 mmol/l

< 3.5 mmol/l ≥ 3.5 mmol/l < 3.5 mmol/l ≥ 3.5 mmol/l

< 3.5 mmol/l ≥ 3.5 mmol/l

Second Lactate Cumulative

Value of Blood Lactate Levels


Mo

rtal

ity

(%)

SBP (mmHg)

Lactate (mmol/l)< 100

> 100

> 3.5

< 3.5

60

50

40

30

20

10

0

Lactate, SBP, and Mortality

Serum Lactate and Mortality in Severe Sepsis

• Initial serum lactate evaluated in 839 adults admitted with severe sepsis.

Mikkelsen ME, Miltiades AN, Gaieski DF et al. Crit Care Med. 2009;37:1670-7.

Low Int High

ShockNon-Shock

28-D

ay M

ort

alit

y (%

)

50

45

40

35

30

25

20

15

10

5

0

p < 0.001

p = 0.001

p = 0.022

p = 0.024• High initial serum

lactate associated with ↑ mortality regardless of presence of shock or MODS.

Low Int High

Improving Lactate a Good Prognostic Sign

Bakker J, Gris P, Coffernils M et al. Am J Surg. 1996;171:221-6.

8

6

4

2

0

INITIAL +8h +16h +24h FINAL

Time

La

cta

te (

mm

ol/L

)

Survivors

Non-survivorsp < 0.05

p < 0.05p < 0.01

Sepsis is No Longer Just an ICU Disease

Levy MM, Dellinger RP, Townsend SR et al. Crit Care Med. 2010;38:367-74.

You have to go to the disease instead of waiting for it to come to you!

Hospital Origin and Mortality

Origin Mortality

Surviving Sepsis Campaign. http://ssc.sscm.org.

ED 52.4% 27.6%

ICU 12.8% 41.3%

Wards 34.8% 46.8%

Risk Stratification of Sepsis


Hypotension, vasopressors 36.7%

Lactate > 4 mmol/L only 30.0%

SBP < 90 mmHg and lactate > 4 mmol/L 46.1%

Sepsis Testing and Results

Guidelines, Algorithms, and Protocols

• Blood gases

Factors to Consider When Evaluating Sepsis

• Electrolytes

• Glucose

• Hematocrit

• Lactate

Sepsis Resuscitation Bundle

The Sepsis Resuscitation Bundle is published by the Surviving Sepsis Campaign and is used by multiple hospitals across the country.

The goal is to perform all indicated tasks 100% of the time within the first 6 hours of identification of severe sepsis.


Sepsis Resuscitation Bundle


3. Administer broad-spectrum antibiotic, within 3 hours of emergency department (ED) admission and within 1 hour of non-ED admission.

2. Obtain blood cultures prior to antibiotic administration.

1. Measure serum lactate.

4. In the event of hypotension and/or a serum lactate > 4 mmol/L:a. Deliver an initial minimum of 20 ml/kg of crystalloid or an equivalent.

b. Apply vasopressors for hypotension not responding to initial fluid resuscitationto maintain mean arterial pressure (MAP) > 65 mmHg.

5. In the event of persistent hypotension despite fluid resuscitation (septic shock) and/or lactate > 4 mmol/L:a. Achieve a central venous pressure (CVP) of > 8 mmHg.

b. Achieve a central venous oxygen saturation (ScvO2) > 70% or mixed venous oxygen saturation (SvO2) > 65%.

1. Administer low-dose steroids for septic shock in accordance with a standardized ICU policy. If not administered, document why the patient did not qualify for low-dose steroids based upon the standardized protocol.

Sepsis Management Bundle

Efforts to accomplish these goals should begin immediately, but these items may be completed within 24 hours of presentation for patients with severe sepsis or septic shock.

The tasks are:

2. Administer recombinant human activated protein C (rhAPC) in accordance with a standardized ICU policy. If not administered, document why the patient did not qualify for rhAPC.

3. Maintain glucose control > 70 mg/dL, but < 150 mg/dL.

4. Maintain a median inspiratory plateau pressure (IPP) < 30 cm H2O for mechanically ventilated patients.


Point-of-Care Analyte Benefits

• A 2010 study published in the Journal of Emergency Medicine found that point-of-care testing provided a reliable and feasible way to measure serum lactate at the bedside.1

1 Shapiro NI, Fisher C, Donnino M et al. J Emerg Med. 2010;39:89-94.2 Montassier E, Batard E, Segard J et al. Am J Emerg Med. 2010. Epub ahead of print.3 Martin MJ, FitzSullivan E, Salim A et al. Am J Surg. 2006;191:625-30.4 Moore CC, Jacob ST, Pinkerton R et al. Clin Infect Dis. 2008;46:215-22.

• Point-of-care lactate is useful in the diagnosis of sepsis at the bedside

– Recommended for institutions where clinical decisions are limited by lack of laboratory infrastructure or reliability.4

• Base excess (BE)

– Some studies suggest BE is an accurate marker for the prediction of elevated lactate in the emergency department (ED).2

– Some studies also show poor correlation due to effects of other conditions.3

• pH, pCO2, pO2, lactate, Na, K, iCa, Glu, Hct (plus calculated values TCO2, HCO3, BE, sO2, Hb)

• Single-use, self-calibrating, 100-150 uL WB sample

Point-of-Care Analyte Testing

*unique market features

• Requires only room temperature storage*

• Analytes on a single test card

• Bar-coded for patient safety

• Low-cost test cards

– Cant use expired cards*

– Smart card technology

– < $ than benchtop systems

Turnaround Time

• Serum lactate must be available with rapid turnaround time (within minutes) to effectively treat severely septic patients.

http://www.survivingsepsis.com/bundles/individual_changes/serum_lactate.www.emcrit.org/wp-content/uploads/lactate-faq.pdf.

• An arterial blood gas analyzer located in the clinical laboratories usually accomplishes this.

• Hospitals should invest in adequate equipment in to meet present standards of care for septic patients.

• If a central analyzer is not efficient in a particular hospital setting, point-of-care analyzers should be evaluated for faster turnaround time.

Time and Cost for Measuring Blood Lactate

Chiron Accusport® Central Laboratory

Time of transportation (min) -- -- 9.6 ± 3.8

Time for results (min) 1 1 85 ± 35

Time for results (range) 1-10 1 45-168

Hardware Electrodes: 4 x $134Total: $536 Device: $156 --

Reagents --Test strip: $1.22Quality Control Bottle: $11.10

--

Costs for 197 samples $536 $248 $493

Costs of transportation of one sample -- -- $3.61

Boldt J, Kumle B, Suttner S et al. Acta Anaesthesiol Scand. 2001;45:194–9.

Sepsis Treatment Guidelines

• Antibiotic therapy


– Begin intravenous antibiotics as early as possible

• Always within the first hour of recognizing severe sepsis (1D) and septic shock. (1B)

– Broad-spectrum

• One or more agents active against likely bacterial/fungal pathogens and with good penetration into presumed source. (1B)

– Reassess antimicrobial regimen daily to optimize efficacy, prevent resistance, avoid toxicity, & minimize costs. (1C)

– Consider combination therapy in Pseudomonas infections. (2D)

Sepsis Treatment Guidelines

• Antibiotic therapy


– Consider combination empiric therapy in neutropenic patients. (2D)

– Combination therapy no more than 3-5 days and de-escalation following susceptibilities. (2D)

– Duration of therapy typically limited to 7-10 days

• Longer if response slow, undrainable foci of infection, or immunologic deficiencies. (1D)

– Stop antimicrobial therapy if cause is found to be non-infectious. (1D)

Glycemia Control 80-110

Semi-recumbent

Position

Lactate POC (< 15’) Fluid Bolus

SIRS 2 Criteria• T > 38° or < 36°• HR > 90• RR > 20 or PaCO2 32 mmHg• WBC > 12 K or < 4 K; Bands > 10%

SepsisNo

Yes

CVP < 8

CVP > 15 + MAP > 110

MAP > 110

MAP < 65

No

NS 500 cc IVB until CVP > 8

NTG 10-60 mcg/min until CVP < 12 or MAP < 110

Norepinephrine 2-20 mcg/min or Dopamine 5-20 mcg/kg/min

NTG 10-60 mcg/min until MAP < 90 or Hydralazine 10-40 mg IV

Transfuse PRBC

Dobutamine 2.5-20 mcg/kg/min

ScvO2 < 70% Hgb < 10

ScvO2 < 70%

• CVP 8-12• MAP 65-110• ScvO2 > 70%• Lactate improved

Iden

tifi

cati

on

A

bs

Rap

id

CV

EG

DT

Bu

nd

led

Th

erap

ies

Preload

Afterload

Central Venous Oxygen

Content

Goals Achieved

?

APACHE III > 25

Activated Protein C

Organic Dysfunction

SBP < 90 p bolus Lactate > 4

Central Venous Arterial Line Access (< 2°)

Initiate Sepsis Bundle

Mechanical Ventilation

Labs Cultures

Antibiotics (< 4°)

Severe Sepsis/ Septic Shock

SIRS + Suspected Infection

ScvO2

Hgb

Rivers EP. N Engl J Med. 2001;345:1368-77.

CCF Sepsis Flowchart

Applications

Identification, Treatment, and Outcomes

Are any two of the following SIRS criteria present and new to the patient?

Heart rate > 90 beats/min Respiratory rate > 20/min

Temperature < 36.0 or > 38.3C Acutely altered mental state

Blood glucose > 7.7 mmol/L (in absence of diabetes) White cell count < 4 or > 12 x 109/L

Is there a clinical suspicion of new infection?

Cough/sputum/chest pain Dysuria

Abdominal pain/distension/diarrhea Headache with neck stiffness

Line infection Cellulitis/wound/joint infection

Endocarditis

Is there evidence of any organ dysfunction?

Systolic BP < 90/mean < 65 mmHg Urine output < 0.5 mL/kg/h for 2 h

Lactate > 2 mmol/L after initial fluids Creatinine > 177 umol/L

INR > 1.5 or aPTT > 60 s Platelets < 100 x 109/L

Bilirubin > 34 umol/L SpO2 > 90% unless O2 given

Identification of Sepsis

If YES, patient has SIRS

If YES, patient has Sepsis

If YES, patient has Severe Sepsis

Daniels R. J Antimicrob Chemother. 2011;66(Suppl 2):ii11–ii23.

Treatment of Patients With Sepsis

• Early goal-directed therapy: standard operating procedure– Apply with critical care/sepsis team if patient remains hypotensive

or lactate remains high following fluid challenges

Daniels R. J Antimicrob Chemother. 2011;66(Suppl 2):ii11–ii23.

1. Site central venous catheter using ultrasound guidance where practicable, according to proper procedures for infection control

2. If central venous pressure (CVP) < 8 mmHg, give further fluid challenges to achieve a target CVP of > 8 mmHg (> 12 mmHgif ventilated) unless the patient shows signs of fluid overload

3. If patient remains hypotensive, start a norepinephrine infusion to target SBP > 90 mmHg or MBP > 65 mmHg.

Improve Patient Outcomes

• Lactate clearance is associated with improved patient outcome.

Nguyen HB, Rivers EP, Knoblich BP et al. Crit Care Med. 2004;32(8):1637-42.Afessa B, Keegan MT, Schramm GE et al. Crit Care Med. 2011;15(Suppl 1): P286. Boldt J, Kumle B, Suttner S et al. Acta Anaesthesiol Scand. 2001;45:194–9.

• Point-of-care measurements of lactate are faster than central laboratories.

– May be beneficial for serial measurements.

• Lactate measurement is associated with increased risk of death independent of other aspects of sepsis bundle guidelines.

Conclusion

Download - Diagnosing & Managing Sepsis Syndrome: The Emerging Role of Bedside Analyte Testing

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