sepsis 2013: hot off the press kaplow, 2014 1. introduction > 750,000 cases/year > 500 - 1000...
TRANSCRIPT
![Page 1: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/1.jpg)
Sepsis 2013: Hot off the Press
Kaplow, 2014
1
![Page 2: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/2.jpg)
Introduction
• > 750,000 cases/year• > 500 - 1000 Americans die daily• Overall mortality rate 28-50%• Estimated cost of $5-10B/year
2
![Page 3: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/3.jpg)
SIRS Sepsis Severe Septic MODS Sepsis Shock
Sepsis: A Clinical Continuum
3
![Page 4: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/4.jpg)
4
![Page 5: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/5.jpg)
5
![Page 6: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/6.jpg)
Diagnostic Criteria for Sepsis
Physical Findings• Fever (> 38.3 ー C)
• Hypothermia (core < 36° C)
• Heart rate > 90/min
• Tachypnea
• Altered mental status
• Significant edema or positive fluid balance (> 20 mL/kg over 24 hr)
• Hemodynamic variables
• Hypotension (SBP < 90, MAP < 70, or SBP decrease > 40 mm Hg
Lab Findings
• Hyperglycemia (glucose > 140 mg/dL) in the absence of diabetes
• Leukocytosis (WBC count > 12,000)
• Leukopenia (WBC count < 4000)
• Normal WBC count with > 10% bands
• Elevated CRP
• Elevated procalcitonin level
6
![Page 7: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/7.jpg)
Diagnostic Criteria for Sepsis (cont’d)
Organ Dysfunction Variables
• Hypoxemia (PaO2/FiO2 < 300)
• Acute oliguria (urine output < 0.5 mL/kg/hr for at least 2 hrs despite adequate fluid resuscitation)
• Creatinine increase > 0.5 mg/dL
• Coagulation abnormalities (INR > 1.5 or aPTT > 60 s)
• Ileus (absent bowel sounds)
• Thrombocytopenia (PLT < 100,000)
• Total bilirubin > 4 mg/dL)
Tissue Perfusion Variables
• Hyperlactatemia (> 1 mmol/L)
• Decreased capillary refill or mottling
7
![Page 8: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/8.jpg)
Diagnostic Criteria for Severe Sepsis
• Sepsis-induced hypotension
• Lactate above ULN
• Urine output < 0.5 mL/kg/hr for more than 2 hrs despite adequate fluid resuscitation
• Acute lung injury with:– PaO2/FiO2 < 250 without pneumonia
– PaO2/FiO2 < 200 with pneumonia
• Creatinine > 2.0 mg/dL
• Bilirubin > 2 mg/dL
• Platelet count < 100,000 μL
• Coagulopathy (INR > 1.5)
8
![Page 9: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/9.jpg)
9
![Page 10: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/10.jpg)
CNS Acute change in MS (confusion, agitation, lethargy) or GCS < 15 (previously normal or decreased by 1)
Pulmonary Unexplained hypoxemia with suspected sepsis
(P/F < 200), bilateral infiltrates with PAOP < 18
Renal Oliguria, inc. serum creatinine from normal with urine Na < 40 mmol/L, rise in serum creatinine by 2 mg/dL in presence of preexisting renal insufficiency
Hepatobiliary Inc. LFTs to 2x normal, serum bilirubin > 2 mg/dL
GI Paralytic ileus, GI bleeding
Coagulation Confirmatory test for DIC (FDP > 1.4 or D-dimers > 2, thrombocytopenia or fall in platelets by 25%, inc. PT, PTT, clinical evidence of bleeding
10
![Page 11: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/11.jpg)
11
![Page 12: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/12.jpg)
12
![Page 13: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/13.jpg)
Cytokines
• Mediators of inflammation• Critical parts of the immune system• Increased levels during shock• TNF and IL-1: widespread effects released early in systemic inflammatory response
13
![Page 14: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/14.jpg)
Systems and Mediators AffectedIn Septic Shock
Complement System Coagulation CascadeFibrinolytic System CatecholaminesCachetin (TNF) HistamineIL-1 Circulating MDFPAF MacrophageLeukotrienes O2 free radicalsProstaglandins Inflammatory proteinsThromboxane A2
14
![Page 15: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/15.jpg)
Vascular Endothelium
Regulates:• Blood vessel tone• Vascular permeability• Coagulation• WBC and platelet activity• Phagocytosis of bacteria
15
![Page 16: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/16.jpg)
16
![Page 17: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/17.jpg)
17
![Page 18: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/18.jpg)
18
![Page 19: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/19.jpg)
Signs and Symptoms of Sepsis
General
• Fever• Chills• Fatigue• Malaise• Rigors• Warm, pink peripheries
19
![Page 20: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/20.jpg)
Signs and Symptoms of Sepsis
CNS
• Confusion• Anxiety• Disorientation• Apprehension • Agitation• Obtunded or comatose
20
![Page 21: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/21.jpg)
Signs and Symptoms of Sepsis
Cardiovascular
• Tachycardia• Increased pulse pressure• Hypotension• Cardiac output normal or increased• Normal capillary refill
21
![Page 22: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/22.jpg)
Signs and Symptoms of Sepsis
Pulmonary
• Hyperventilation• Respiratory alkalosis• SOB• Tachypnea
22
![Page 23: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/23.jpg)
Signs and Symptoms of Sepsis
GI/GU
• Nausea and vomiting• Decreased albumin• Jaundice• Oliguria
23
![Page 24: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/24.jpg)
Signs and Symptoms of Sepsis
Hematologic
• WBC increased or decreased• Increased INR, aPTT• DIC• Decreased platelets
24
![Page 25: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/25.jpg)
Signs and Symptoms of Sepsis
Metabolic • Increased base deficit• Increased lactate• Increased glucose
25
![Page 26: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/26.jpg)
Surviving Sepsis Campaign Bundles
To be completed within 3 hours:• Measure lactate level
• Obtain blood cultures prior to administration of antibiotics
• Administer broad spectrum antibiotics
• Administer 30 ml/kg crystalloid for hypotension or lactate ≥4mmol/L
*Targets are CVP of ≥8 mm Hg; ScvO2 of ≥70%, and normalization of lactate.
To be completed within 6 hours:•Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a MAP ≥65 mm Hg•In the event of persistent hypotension despite volume resuscitation or initial lactate ≥4 mmol/L (36 mg/dL):--Measure CVP* and central venous oxygen saturation (ScvO2)*Remeasure lactate if initial lactate was elevated*
26
![Page 27: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/27.jpg)
Management of Septic Shock
• ABCs, antimicrobials• Volume resuscitation• Vasopressor therapy• Inotropic support• ? Steroids• ? Bicarbonate therapy
• Blood products• Glucose control• Supportive therapies• Ventilator support• Sedation, analgesia, and
neuromuscular blockade
27
![Page 28: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/28.jpg)
Recommendations: Initial Resuscitation and Infection Issues: Initial Resuscitation
1. Resuscitation of patients with sepsis-induced tissue hypoperfusion (defined as hypotension persisting after initial fluid challenge or blood lactate ≥ 4 mmol/L). Goals during the first 6 hours of resuscitation:
a) Central venous pressure 8–12 mm Hg
b) MAP ≥ 65 mm Hg
c) U/O ≥ 0.5 mL/kg/hr
d) Central venous (superior vena cava) or mixed venous oxygen saturation 70% or 65%, respectively
2. In patients with elevated lactate levels targeting resuscitation to normalize lactate 28
![Page 29: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/29.jpg)
Recommendations: Initial Resuscitation and Infection Issues: Antimicrobial Therapy
1. Administration of effective intravenous antimicrobials within the first hour of recognition of septic shock and severe sepsis.
2a. Initial empiric anti-infective therapy of one or more drugs that have activity against all likely pathogens and that penetrate tissues presumed to be the source of sepsis.
2b. Antimicrobial regimen should be reassessed daily for potential de-escalation.
29
![Page 30: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/30.jpg)
Recommendations: Initial Resuscitation and Infection Issues: Antimicrobial Therapy
(cont’d)3. Use of low procalcitonin levels or biomarkers to assist in the discontinuation of empiric antibiotics in patients who initially appeared septic, but have no evidence of infection.
4a. Combination empirical therapy for neutropenic patients with severe sepsis and those with difficult-to-treat, MDR bacteria such as Acinetobacter and Pseudomonas.
4b. Empiric combination therapy should not be administered for more than 3–5 days. De-escalation to the most appropriate single therapy should be performed as soon as the susceptibility profile is known.
30
![Page 31: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/31.jpg)
Recommendations: Initial Resuscitation and Infection Issues: Antimicrobial
Therapy (cont’d)5. Duration of therapy typically 7–10 days; longer courses may
be appropriate in patients who have a slow clinical response, undrainable foci of infection, S. aureus; some fungal and viral infections or immunologic deficiencies, including neutropenia.
6. Antiviral therapy initiated as early as possible in patients with severe sepsis or septic shock of viral origin.
7. Antimicrobial agents should not be used in patients with severe inflammatory states determined to be of noninfectious cause.
31
![Page 32: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/32.jpg)
32
![Page 33: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/33.jpg)
33
![Page 34: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/34.jpg)
Volume Resuscitation
• Crystalloids for initial choice• No hydroxyethyl starches• Albumin in severe sepsis and septic shock if substantial amounts of crystalloids are required. • Titrate to clinical endpoints
urine output lactic acid decreased HR increased B/P improved mental status
34
![Page 35: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/35.jpg)
35
![Page 36: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/36.jpg)
Vasopressor Therapy
• Norepinephrine (NE)• Epinephrine (added or substitute for NE)• Vasopressin 0.03 units/min (may be added to supplement or decrease NE). Higher doses should be reserved for salvage therapy. Low dose vasopressin not recommended as a single agent.• Dopamine (only in highly selected patients) No renal dopamine.• Phenylephrine (not recommended except in serious arrhythmias, high CO and persistent hypotension, or salvage therapy).
(Titrate to MAP 65 mm Hg. All patients on pressors should have an arterial catheter placed ASAP.)
36
![Page 37: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/37.jpg)
37
![Page 38: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/38.jpg)
38
![Page 39: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/39.jpg)
39
![Page 40: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/40.jpg)
Inotropic Therapy
• Optimization of filling pressures• Tachyarrhythmias – undesirable s/e• Usually need in conjunction with vasopressor• Not used to increase CI to supra-normal levels
Dobutamine trial up to 20 mcg/kg/min if myocardial dysfunction is suspected by elevated PAOP
40
![Page 41: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/41.jpg)
Corticosteroid Therapy
• Do not use for sepsis– only septic shock.• Do not use if fluids and vasopressors keep MAP > 65.• If MAP not maintained, administer hydrocortisone 200 mg/day• Do not use ACTH stimulation test.• Don’t forget to taper.
41
![Page 42: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/42.jpg)
Bicarbonate Therapy
• Not routinely indicated• Doesn’t improve effectiveness of vasoactive agents• Doesn’t correct hemodynamics or decrease pressor requirements despite correction of acidemia• No longer given empirically.• May be used for pH < 7.15.
42
![Page 43: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/43.jpg)
Blood Product Administration
• Target hemoglobin 7-9 g/dL in adults.
• May be administered once hypoperfusion resolved, or• May be administered immediately if:
• Myocardial ischemia
• Severe hypoxemia
• Acute hemorrhage
• Ischemic CAD
• Do not use erythropoietin.
43
![Page 44: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/44.jpg)
Glucose Control
• Use arterial or serum blood sugar measurement; capillary blood may not be accurate.
• Treat after two consecutive blood glucose levels
> 180 mg/dL.
• Maintain blood glucose 110-180 mg/dL.
• Monitor every 1-2 hours until stable; then every 4 hours.
44
![Page 45: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/45.jpg)
Do Not Use
• Immunoglobulins
• Selenium
• rhAPC
45
![Page 46: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/46.jpg)
Supportive Therapies
• Renal replacement therapies
• VTE prophylaxis• Sepsis: LMWH
• Septic shock: LMWH + intermittent pneumatic compression
• Stress ulcer prophylaxis (H2 blocker or PPI for patients with severe sepsis factors who have bleeding risk factors
46
![Page 47: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/47.jpg)
Supportive Therapies (cont’d)
• Nutrition (oral or enteral as tolerated within the first 48 hours).
• TPN + enteral for first 7 days for severe sepsis or septic shock.
• Enteral up to 500 cal/day; advance only as tolerated.
47
![Page 48: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/48.jpg)
Ventilator Support
• Target tidal volume 6 mL/kg in patients with sepsis-induced ARDS.
• PEEP to avoid alveolar collapse (higher levels in patients with sepsis-induced moderate or severe ARDS.)
• Recruitment maneuvers in severe refractory hypoxemia.
48
![Page 49: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/49.jpg)
Sedation, Analgesia, and Neuromuscular Blockade
1. Sedation be minimized in ventilated sepsis patients, targeting specific titration endpoints.
2. NMBAs be avoided if possible in the septic patient without ARDS due to the risk of prolonged blockade after d/c’d. If NMBAs must be maintained, TOF monitoring should be used.
3. A short course of NMBA < 48 hours for patients with early sepsis-induced ARDS and a PaO2/FiO2 < 150.
49
![Page 50: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/50.jpg)
For more information:
Dellinger RP, Levy MM, Rhodes A, et al: Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012. Crit Care Med 2013; 41:580-637.
50
![Page 51: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/51.jpg)
Nursing Implications
• Identify patient at risk• Identify patient who may be developing sepsis• Recognition of subtle changes in condition• Proactive treatment• Emergent resuscitation
51
![Page 52: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/52.jpg)
Nursing’s role in identifying and helping in the treatment of sepsis is more important than ever before.
52
![Page 53: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/53.jpg)
53
![Page 54: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/54.jpg)
Nursing Implications
Methods to minimize host stress response
• Prevent infection• Avoid further tissue damage• Control hyper/hypothermia• Manage pain/anxiety/delirium
54
![Page 55: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/55.jpg)
55
![Page 56: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/56.jpg)
56
![Page 57: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/57.jpg)
57
![Page 58: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/58.jpg)
58
![Page 59: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/59.jpg)
59
![Page 60: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/60.jpg)
60
![Page 61: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/61.jpg)
61
![Page 62: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/62.jpg)
Infection Prevention
• Oral CHG for oropharnygeal decontamination.
• Selective digestive decontamination to prevent VAEs.
62
![Page 63: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/63.jpg)
Nursing Implications
• Source control• Preserve organ function• Prevent complications of nutritional support
prevent obstruction manage diarrhea prevent ileus
63
![Page 64: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/64.jpg)
64
![Page 65: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/65.jpg)
Prognosis: Factors to Consider
• Patient’s underlying health status• Development of organ failure• Prevention of complications• Infecting organism• Shock and low arterial pH during first days
65
![Page 66: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/66.jpg)
Sepsis Mortality
3
710
17 16
20
46
0
5
10
15
20
25
30
35
40
45
50
1
Severity of Disease
Mortality
No SIRS
SIRS2
SIRS3
SIRS4
Sepsis
Severe Sepsis
Shock
Rangel-Frausto, et al., 1995. JAMA 273: 117-2366
![Page 67: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/67.jpg)
Complications of Sepsis and SIRS
• CNS Dysfunction (19%)• ARDS (2-8%)• Liver Failure (12%)• Acute Renal Failure (9-23%)• DIC (8-19%)
67
![Page 68: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/68.jpg)
68
Patients admitted with septic shock to ED• Reduction in mortality: 70% vs. 52%• 5-day reduction in hospital LOS• Reduction in costs: $16,103 vs. $21,985
Schorr AF, Micek ST, Jackson WL, Kollef MH – CCM 2007;35:1257-1262
Implications of SSC Implementation
![Page 69: Sepsis 2013: Hot off the Press Kaplow, 2014 1. Introduction > 750,000 cases/year > 500 - 1000 Americans die daily Overall mortality rate 28-50% Estimated](https://reader036.vdocuments.mx/reader036/viewer/2022062519/5697bfb71a28abf838c9ef56/html5/thumbnails/69.jpg)
69