This webinar series is made possible with support from biomérieux, Inc.

This webinar series is made possible with support from biomérieux, Inc. 1

Sara McMannus, RN, BSN, MBA Sara Follin McMannus has been a nurse for 40 years. She earned her BSN from The University of Iowa and went on to earn a MBA from the University of Phoenix. In the course of her career, she has worked as a staff and charge nurse working in critical care. In addition, she has worked in staff development and the post anesthesia recovery unit. For the past 17 years, Sara has been the Clinical Program Manager for GE Healthcare. Her recent work in the field of education has been devoted to development of clinical education programs and new educational tools to help promote clinical excellence. Sara currently serves on the Advisory Board for Sepsis Alliance. 2

NURSES Suspect Sepsis: So more SURVIVE 3

Sharon L. Hansen, MN, RN, CCRN For more than 30 years, Sharon has been a critical care nurse in the Tacoma, WA area and a critical care nurse educator for the last 10 years. She received her Masters of Nursing from University of Washington Tacoma and currently lectures in the School of Nursing part-time. Sharon is also a clinical instructor for Green River Community College. She is a member of the Society of Critical Care Medicine and the American Association of Critical Care Nurses (AACN), as well as an active member of the Mountain to Sound AACN Chapter. Sharon is all too familiar with sepsis in both her personal and professional life after her husband, Mark, developed sepsis in 2003 and experienced post-sepsis syndrome symptoms. Her clinical focus centers on sepsis identification, early and effective resuscitation, hemodynamics, oxygenation, optimizing hemodynamic support, and post sepsis syndrome. 4

COI Disclosures I have no financial disclosures

Thank You Sepsis Alliance Carl Flatley Surviving Sepsis Campaign My husband Mark, a survivor of septic shock, and my daughter Kristen, a survivor of childhood sepsis MultiCare Health System The health care teams who I have had the honor and privilege to work with, in particular the intensive care nurses and the critical care and infectious disease specialists Sepsis survivors and their families who have shared their stories with me Nurses across the continuum

Objectives Discuss the national incidence of sepsis Define sepsis Recognize early warning signs of sepsis Describe current interventions and therapies 7

Source: Sepsis Alliance 8

Global Incidence of Sepsis 9 Source: World Sepsis day, 2015

Sepsis contributes to 1 in every 2 to 3 deaths in hospitals Majority had sepsis on presentation to the hospital 10 Source: Liu,V., et al., 2014

258,000 deaths a year in the US Deaths from Breast cancer AIDS + Prostate Cancer TOTAL < Deaths from Sepsis 27 Deaths* every ~55 min *2010-2014 US air traffic deaths 11 Source: Liu,V., et al., 2014

The Disconnect. Sepsis Myths Only affects the elderly Only patients with comorbidities Won t happen to me or my family 12

Faces of Sepsis My name is Carl Flatley, founder of Sepsis Alliance My daughter Erin died of sepsis at age 23 Too many daughters and sons die every day Suspect Sepsis 13

Faces of Sepsis My name is Doreen I am a Registered Nurse I am fortunate. I am a SEPSIS Survivor Suspect Sepsis 14

Challenges.. Symptoms are subtle May delay arrival to ED triage call for rapid response or medical emergency teams Symptoms mimic other, and potentially less severe, conditions Condition escalates quickly No one specialty/department owns sepsis Limited sepsis identification and management resources 15

Sepsis Alliance Resource 16

Symptoms of Sepsis in Children 17

What is Sepsis? Sepsis is the body s overwhelming and life-threatening response to infection, which can lead to tissue damage, organ failure, and death. Bacteria Other INFECTION Fungi Parasites Viruses Sepsis SIRS or SOFA criteria Trauma Burns Other Pancreatitis 18 Sourece Singer, M., et.al., 2016 Diagram modified from Bone, R. C., et.al., 1992

Sources of Infection Sepsis can be caused by any type of infection: Bacterial Viral Fungal Parasitic 19

Recognizing Response to Infection Two methods are available to help in identifying systemic response to infection SIRS criteria SOFA criteria A simpler version of SOFA is called qsofa 20

What is SIRS? Systemic Inflammatory Response Syndrome This syndrome may occur as the body responds to infection or injury. It is important to remember non-infectious disorders may also cause SIRS. 21 Source: Bone, R. C., et.al., 1992

SIRS Criteria Hyperthermia >38.3 C/ 101F Hypothermia <36 C/ 96.8 F Tachycardia >90 beats per minute Tachypnea >20 breaths per minute Leukocytosis (WBC >12,000) Leukopenia (WBC <4,000) Bands 10% 2 or more SIRS criteria plus infection equals SEPSIS 22 Source: Bone, R. C., et.al., 1992

Sepsis Identification using SOFA criteria 23 Source: Singer, M., et.al., 2016

qsofa quick Sequential Organ Failure Assessment Modification of the SOFA Score range 0-3. Score of 2 or higher predictive of mortality rate of at least 10% (study revealed 24%) Can be assessed immediately upon presentation Does not require any supplemental investigation (WBC or Lactate) 24 Source: Singer, M., et.al., 2016

qsofa Patients with suspected infection who are likely to have a prolonged ICU stay or to die in the hospital can be promptly identified at the bedside with qsofa qsofa CRITERIA SCORE Respiratory Rate 22/min 1 Altered Mental Status 1 Systolic BP 100 mmhg 1 Total Score 3 25

Recognizing Sepsis in Pregnancy S.O.S > 6 have been associated with ICU or telemetry unit admit, positive blood cultures, fetal tachycardia, and longer hospital stay Source: Albright,C.M., et al 2014 26

Sepsis The presence of infection (suspected or confirmed) with systemic manifestations of response to infection Using SIRS or SOFA or qsofa criteria 27 Source: Surviving Sepsis Campaign

Sepsis Septic Shock Sepsis induced hypotension that persists despite adequate fluid resuscitation (30 ml/kg) and/or lactate > 4 is Septic Shock 28 Source: Surviving Sepsis Campaign

How Does Infection Cause Shock? Organism Systemic inflammation or inflammatory response Diffuse endothelial disruption and microcirculation defects SEPTIC SHOCK Subset of sepsis with circulatory and cellular/metabolic dysfunction associated with higher risk of mortality Global tissue hypoxia and organ dysfunction 29 Source: Surviving Sepsis Campaign

Time is Tissue 3-Hour Bundle To be completed within 3 hours of time of presentation: Measure lactate level Obtain blood cultures prior to administration of antibiotics Administer broad spectrum antibiotics Administer 30mL/kg crystalloid for hypotension or lactate 4mmol/L Early recognition and treatment of sepsis may prevent development septic shock 30 Source: Surviving Sepsis Campaign

Lactate The body's energy needs are mainly met by aerobic metabolism, which requires oxygen. If there is a lack of oxygen in the body, it reverts to anaerobic metabolism, of which lactic acid is a byproduct. This may, in turn, lead to lactic acidosis, or a decreased physiological ph. This is an emergency and requires immediate medical attention. Elevated lactate levels tell you that there are tissue beds in your body that are having to function without oxygen. As perfusion is improved, lactate levels usually decrease. 31

Timely and Appropriate Antibiotics 32 Source: Kumar et.al., 2006

Fluid Administration Administer 30mL/kg crystalloid for hypotension or lactate 4mmol/L Examples: Lactated Ringers Normal Saline 33 Source: Surviving Sepsis Campaign

Reassessment is NOT Optional Document reassessment of volume status and tissue perfusion Either Repeat focused exam (after initial fluid resuscitation) by licensed independent practitioner including vital signs, cardiopulmonary, capillary refill, pulse, and skin findings. Or two of the following: Measure CVP Measure ScvO 2 Bedside cardiovascular ultrasound Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge 34 Source: Surviving Sepsis Campaign

Dynamic Assessment of Fluid Responsiveness using Stroke Volume (SV) SV 57 SV 55 Frank- Starling Curve SV 47 SV 35 500 ml bolus 500 ml bolus Preload: Fluid bolus, Passive leg raise

Stroke Volume Assessment using Passive Leg Raise (PLR) Obtain Stroke Volume This is a measured valve obtained invasively or noninvasively 1. Place patient in a 45 semi-recumbant position for 2 minutes SCD s should be turned off, pillows removed and foot of bed flat 2. Lay patient flat in supine position and elevate legs to 45 without allowing feet to drop 3. Observe and obtain SV/SVI for 60-90 sec. Fluid responsive: SV/SVI increases by 10% 4. Reposition patient 36

Relationship of Stroke Volume to Extravascular Lung Water (Extravascular Lung Water) Source: Marik, 2017

Source Control What is putting this individual at risk for infection? Invasive lines Implanted devices Congenital abnormalities such as valve disease Exposure Wounds Recent childbirth Do not underestimate the power of your nursing assessment. 38 Source: Surviving Sepsis Campaign

Time is Tissue 6-Hour Bundle To be completed within 6 hours of time of presentation: Apply vasopressors for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure (MAP) 65mmHg In the event of persistent hypotension after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was 4 mmol/l, reassess volume status and tissue perfusion and document findings Re-measure lactate if initial lactate elevated 39 Source: Surviving Sepsis Campaign

Vasopressors in Sepsis (Dellinger et. al, 2017) 40 (Dellinger et. al, 2017)

Reassessment is NOT Optional Document reassessment of volume status and tissue perfusion Either Repeat focused exam (after initial fluid resuscitation) by licensed independent practitioner including vital signs, cardiopulmonary, capillary refill, pulse, and skin findings. Or two of the following: Measure CVP Measure ScvO 2 Bedside cardiovascular ultrasound Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge 41 Source: Surviving Sepsis Campaign

Additional Laboratory Tests 42

Procalcitonin (PCT) PCT is a prohormone of calcitonin Secreted by many cell types and organs after bacterial pro-inflammatory stimulation Elevated PCT levels indicate bacterial infection accompanied by a systemic inflammatory reaction. Localized infection generally dose does not increase circulating PCT. Slightly elevated levels Bacterial infection with mild systemic inflammatory response Very elevated levels Acute disease with severe systemic reaction, such as severe sepsis and septic shock. 43

Procalcitonin (PCT) A useful tool for optimization, treatment duration, and de-escalation of antibiotic therapy in a bacterial infection Increases early, 3-6 hours, after an infectious challenge and has highly a specific rise in response to severe systemic bacterial infections Levels are usually low in viral infections, chronic inflammatory, and autoimmune disorders Procalcitonin levels in sepsis are usually >.5-2 ng/ml May reach levels of 10 to 100 ng/ml or more. 44

C-Reactive Protein (CRP) An additional inflammatory marker available for sepsis screening A rise in the plasma concentration of CRP in the absence of other non-infectious causes of inflammation (ex: trauma, surgery, etc) may be suggestive of infection Severe liver disease may reduce the elevation of CRP. In these individuals, diagnosis of sepsis should not be excluded based on lower CRP 45 Pieri,G., et.al (2014)

Paranoia takes over U s e d w i t h p e r m i s s i o n G a r y B l a c k 46 Source: Black, 2011

Why Do Septic Patients Become Confused? 47 (Zampieri, 2011)

The Great Unknown. Sepsis Survivors Number of disabilities Amputation Thinking Memory Calculations Post traumatic stress disorder Many carry the scars of sepsis for the rest of their lives 48

Sepsis Survivors and Families 49

Empowering Nurses Suspect Sepsis SAVE LIVES Advocate for patients Bring the Right Care to the Right Patient AT the Right Time KNOW SEPSIS 50

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Sepsis Alliance Mission Save lives and reduce suffering by raising awareness of sepsis as a medical emergency Follow us on For more information visit us at www.sepsis.org 52

Sepsis Alliance Our Special thanks in the development of the initial presentation to: Tom Ahrens PhD, RN, FAAN Lisa Barlett (Davis) Lisa Brandt Doreen Bettencourt, BSN, RN Joan Buckley, BS, MS, AAS Scott Carr Zach Doubek Marnie Doubek, MD Carl Flatley, DDS, MSD Sharon Hansen, MN, RN, CCRN Sara McMannus, BSN, RN, MBA Laura Messineo, RN, MHA Maria Teresa Palleschi, DNP, APRN-BC, CCRN Sue Sirianni, DNP, APRN-BC, CCRN Marijke Vroomen-Durning, RN 53

Questions? 54

This webinar series is made possible with support from biomérieux, Inc. 55

References Albright C. M., Ali TN, Lopes V, et al. The Sepsis in Obstetrics Score: a model to identify risk of morbidity from sepsis in pregnancy. Am J Obstet Gynecol 2014;211:39.e1-8. Black, G. (2011). Gyroscope: A Survival of Sepsis. West Conshohocken: Infinity Publishing. Bone, R.C., et.al. (1992). American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: The definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Critical Care Medicine, 20(6), 864-874. Dellinger, R. P., Schorr, C. A., & Levy, M. M. (2017). A users guide to the 2016 surviving sepsis guidelines. Critical Care Medicine, 381-385. DOI: 10.1097/CCM.0000000000002257 Liu, V., Escobar, G.J., Greene, J.D., Soule, J., Whippy, A., Angus, D.C., Iwashyna, T.J., Hospital deaths in patients with sepsis from two independent cohorts. JAMA. 2014;312(1):90-92. doi:10.1001/jama.2014.5804 Marik, P. E. (2012). Noninvasive cardiac output monitors: a state-of the-art review. Journal of Cardiothoracic and Vascular Anesthesia. doi:10.1053/j.jvca.2012.03.022 Pieri, G., Agarwal,B., Burroughs, A.K., (2014). C-reactive protein and bacterial infection in cirrhosis. Annals of Gastroenterology 27(2): 113 120. PMCID: PMC3982625 Singer, M., Deutschman, C.S., Seymour, C.W., Shankar-Hari, M., Annane, D., Bauer, M., Bellomo, R., Angus, D.C., The third International Consensus definitions for sepsis and septic shock (Sepsis- 3). JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287 Stinson, D. (2017). RN. (S.Hansen, Interviewer) Surviving Sepsis Campaign. (2016). Updated Bundles in Response to New Evidence. Retrieved from Surviving Sepsis.org: http://www.survivingsepsis.org/sitecollectiondocuments/ssc_bundle.pdf World Sepsis day (2015) Retrieved from World Sepsis Day.org: http://www.world-sepsis-day.org Zampieri,F.G., Park,M., Machado, F.S., Azevedo,L.S.P., Sepsis-associated encephalopathy: not just delirium Clinics, (2011) October; 66(10): 1825 1831, doi: 10.1590/S1807-59322011001000024 56